King Saud University

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• King Saud University
• College of Nursing
• Health Assessment (NUR 224)
• Eyes, Ears, Mouth, Nose

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Objectives

• After completion of this presentation, the nurse
  will be able to
• Conduct a basic adult eyes, ears, mouth, and nose
  assessment.
• Distinguish normal from abnormal findings

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Techniques

• Inspection
• Palpation

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Eye
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Anatomy

• Eyes are protected by orbital cavity.
• Eyelids protect the eyes from injury, strong
  light, and dust.
• Eyelashes filter the dust and dirt.
• Conjunctiva is a thin mucus membrane between the
  eyelid and the eye ball.
• Cornea protects and covers the iris and pupils.
• Lacriminal Apparatus cover the eye and secrets
  tears to keep the conjunctiva and cornea moist
  and lubricated.

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Anatomy (cont.)

• Extraocular muscle, are six muscles to orbit
  eyes.
• Each muscle is coordinated with the other muscle
  in the other eye.
• Three cranial nerves (CN) control the eye
  movements.
• Cornea is bending the incoming light rays so and
  make them focused on retina.
• Cornea sensitive to light and blink when
  contacted with an object (CN V, VII)

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Eyes - Inspection

• Cornea and lens
• Iris
• Pupils size, shape, symmetry, reaction to light

• Position and alignment of eyes
• Eyebrows
• Quantity, distribution
• Eyelids
• Edema, color, lesions
• Conjunctiva and sclera
• color, vascular pattern

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Eyes

• Are there 2
• Loss of vision
• Pain
• Disorders
• Strabismus, diplopia
• Discharges / Redness / Swelling
• Prosthesis
• Past history
• Glasses / contact lens

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ABNORMALITITES

• Ptosis
• drooping of the eye lid
• Blepharitis
• inflammation of eyelids
• Sty or Hordeolum
• Staphylococcal infection of hair follicles at lid
  margin

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Abnormal Facial Features

• Tics
• Abnormal facial movements
• Exopthalomus
• Prominent eyes
• Acromegaly
• Gradual enlargement of the bones of the face
  jaws

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Eyes
Trauma
Conjunctivitis
Cyst
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Eye Ptosis
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Sty
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Inspect Conjunctiva Sclera

• Ask the person to look up.
• Using your thumbs, slides the lower lids down
  along the bony orbital rim.
• Both should be clear

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Visual Acuity

• Snellen Eye Chart
• Distance/Central vision position patient 20 feet
  (6 meters) from the chart
• Patient may wear glasses and contact lens, but
  remove the reading glasses.
• Test one eye at a time.
• Start from the biggest lines to the smallest
  lines.

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Visual Acuity
Jaeger chart

• Near vision
• Used for people over 40 years of age or for those
  who report difficulty reading.
• You can use Jaeger or Rosenbaum chart (hand-held
  card).
• Can also use to test visual acuity at the
  bedside.
• Hold 14 inches (about 30 cm) from patients eyes.

Rosenbaum chart
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Confrontation Test

• Range of peripheral vision
• The client should be sitting 60-90 cm from you
  and at eye level
• Test one eye at a time
• The clients peripheral visual fields are
  compared to that of the examiner.
• This test assumes the examiner has normal
  peripheral vision.
• Ask the person to say now when see the object.

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Extraocular movements

• The client must keep the head still while
  following a pen that you will move in several
  directions to form a star in front of the
  clients eyes.
• Always return the pen to the center before
  changing direction.
• Note for
• Strabismus (deviation)
• Nystagmus involuntary eye movement
• Diplopia 2 images for a single objet.

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Developmental Considerations

• Aging Adult
• Have changes in eye structure
• Skin looses elasticity
• Decreased tear production
• Pupil size decreases
• Lens looses elasticity
• With older people
• Increase cataract formation
• Glaucoma or increased ocular pressure
• Macular degeneration

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Tips for Using the Ophthalmoscope

• It use to look into the inner deep part of the
  eye (fundus)
• Darken the room and have the patient look off in
  the distance
• Switch the ophthalmoscope light and turn the lens
  disc to the large round beam of white light
• Turn lens disc to the 0 diopter
• Hold the ophthalmoscope in your right hand to
  examine the patients right eye with your right
  eye hold it in your left hand to examine the
  patients left eye with your left eye
• Stand directly in front of the patient, 15 inches
  away, and start at an angle of 15 degrees lateral
  to the patients line of vision
• Shine the beam of light onto the pupil and look
  for an orange glow this is the red reflex
• Follow the red reflex and move inward towards the
  nasal aspect of the visual field

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Tips for Using the Ophthalmoscope

• It use to look into the inner deep part of the
  eye (fundus)
• Darken the room and have the patient look off in
  the distance
• Switch the ophthalmoscope light and turn the lens
  disc to the large round beam of white light
• Turn lens disc to the 0 diopter
• Hold the ophthalmoscope in your right hand to
  examine the patients right eye with your right
  eye hold it in your left hand to examine the
  patients left eye with your left eye
• Stand directly in front of the patient, 15 inches
  away, and start at an angle of 15 degrees lateral
  to the patients line of vision
• Shine the beam of light onto the pupil and look
  for an orange glow this is the red reflex
• Follow the red reflex and move inward towards the
  nasal aspect of the visual field

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Ears
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Ears

• Earaches
• Discharge/odor
• Hearing Loss
• Tinnitus
• Vertigo
• Microtia
• Macrotia

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Ears Inspection

• Inspection
• Auricle for redness, lesions
• Ear canal
• Discharge, foreign bodies, redness, swelling
• Tympanic membrane (by Use otoscope )
• Color, contour
• Palpation
• Auricle for lumps, tenderness

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Straightening the Ear Canal and Inserting the
Speculum
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Ear
Tophi
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Ears Hearing acuity

• Test one ear at a time
• Whisper test
• Ask the client to occlude the other ear or the
  ear may be occluded by the nurse.
• Cover your mouth so the client cannot see your
  lips
• Standing 30-60cm behind patient, softly say
  nine-four, baseball
• Ask the client to repeat the phrase.

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Ears Hearing acuity

• Rinne
• Compare time of air vs. bone conduction
• Place the base of the tuning fork on the clients
  mastoid process- and note the number of seconds.
• Then move the fork in front the external auditory
  meatus (1-2 cm)
• If bone conduction is equal or greater than air
  conduction, then suspect conductive hearing loss

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Ears Hearing acuity

• Weber
• Lateralization of sound to impaired ear suspect
  unilateral conductive hearing loss

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Ears

• Romberg test
• Ask the patient to remain still and close their
  eyes (for about 20 seconds).
• If the patient loses their balance, the test is
  positive.

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Nose Inspection/Palpation

• Inspection
• Size, shape
• Symmetry
• Lesions/signs of infection
• Patency test
• Septum (by use nasal speculum)-deviation,
  inflammation or perforation
• Palpate for tenderness, swelling

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Assess Nose for Symmetry, Edema, and Air Passage
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Mouth / Tongue/ Teeth / Throat

• Mucous membranes
• Sores / Lesion
• Tonsils
• Sore throat
• Gums
• Teeth

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Mouth and Pharynx - Inspection

• Lips
• Note color, moisture, lumps, ulcers, cracking
• Gums and teeth
• Note color, presence and position of teeth
• Roof of mouth
• Note color

• Tongue and floor of mouth
• Note color and texture, ulcers
• uvula, tonsils, pharynx
• Note color, symmetry, presence of exudate,
  swelling, ulceration or tonsillar enlargement

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Gums
Gingivitis
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Tongue
Glossitis
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The Mouth and Gums
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Under the Tongue
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Above and behind the tongue
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Say AAHHH
Abnormal
Normal CN X
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Peritonsilar Abscess
Tonsillitis
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Is the tongue moist and pink?
Assess both top and.
.underneath
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Oral Herpes Simplex
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Assess Outside of Mouth and Lips for Color,
Moisture, and Abnormalities
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• Place your hands on both sides of the lower jaw
  and ask the patient to clench his teeth. Should
  be able to feel same muscle tension bilaterally

CN V
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• Ask the patient to stick his tongue straight out
  of his mouth.

CN XII
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Summary
Abnormalities
Eyes Visual disturbances, use of corrective lenses, pain, redness, excessive tearing, double vision (diplopia)
Ears Hearing loss, ringing (tinnitus), vertigo, pain, discharge
Nose Drainage (rhinorrhea), congestion, sneezing, nose bleeds (epistaxis)
Mouth Swelling, ulceration or tonsillar enlargement
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• Question?