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Assessment: Eyes and Ears

Assessment: Eyes and Ears. Health Assessment Nu 325 Su 2010. Examination of the Eyes. Preparation Client sitting up with head at your eye level Equipment Snellen eye chart Jaeger card Opaque card or occluder Penlight. Subjective Data. Vision difficulty ↓ Acuity Night blindness

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Assessment: Eyes and Ears

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  1. Assessment: Eyes and Ears Health Assessment Nu 325 Su 2010

  2. Examination of the Eyes • Preparation • Client sitting up with head at your eye level • Equipment • Snellen eye chart • Jaeger card • Opaque card or occluder • Penlight

  3. Subjective Data • Vision difficulty • ↓ Acuity • Night blindness • Blurring • Blind spots • Floaters • Halos or rainbows around objects

  4. Subjective Data • Pain • Strabismus, diplopia • Redness, swelling • Watering, discharge • Past hx ocular problems • Surgery, allergies • Glaucoma • Testing, family hx

  5. Subjective Data • Use of glasses or contact lenses • Effectiveness • Last prescription • Problems • Contact care • Self-care behaviors • Last eye exam • Home & work environment

  6. Subjective Data • Current medications • Systemic or topical • Eye medications

  7. Subjective Data: Infants & Children • Maternal vaginal infections at delivery • Developmental milestones of vision • Routine vision testing at school? • Safety measures from eye trauma

  8. Subjective Data: Elderly • Visual difficulty • Stair climbing • Driving • Night vision • Last glaucoma test • Hx cataracts, visual loss, progressive blurring • Drying or burning of eyes • Trouble reading or sewing

  9. Objective Data:Test Central Visual Acuity • Snellen eye chart: Distance vision • 20 feet • Use an opaque card • Leave on glasses or contacts • Remove reading glasses • Ask to read smallest line of print possible • Encourage to read next line also • Normal: 20/20 both eyes • Numerator – distance from chart • Denominator – distance normal eye could have read chart

  10. Snellen Eye Chart

  11. Objective Data:Test Central Visual Acuity • Snellen Eye Chart: Distance vision • If unable to see largest letters, shorten distance, e.g., 10/200 • If acuity is <, ask to count your fingers or distinguish light perception with penlight • Jaeger Card: Near vision (> 40 y/o or problems reading) • 14 inches • Test eyes separately with glasses on • Normal: Jaeger 14/14 in each eye • If no card, use newsprint or magazine

  12. Jaeger Card

  13. Visual Pathways & Visual Fields

  14. Objective Data: Test Visual Fields • Confrontation Test • Gross measure of peripheral vision • Compares client’s with yours • Eye level, 2 feet from client • Client covers one eye with card & stares straight • You cover your opposite eye • Penlight or flicking finger advancing from periphery, slightly behind client • Client says, “Now” when target seen • Normal:500 upward, 900 temporal, 700 down, 600 nasal • Document: Visual fields intact & WNL by confrontation

  15. Confrontation Test

  16. Range of Peripheral Fields

  17. Objective Data: Test Extraocular Muscle Function • Corneal Light Reflex • Assess parallel alignment of eyes • Shine light directly into eyes • Client stares straight ahead • Note reflection of light on corneas • Normal: Symmetric • If asymmetry, perform cover test • Document: Corneal light reflex symmetric bilaterally

  18. Objective Data: Test Extraocular Muscle Function • Cover Test • Tests small degrees of deviated alignment • Client stares straight ahead • Cover one eye with opaque card • Note uncovered eye • Normal: Fixed steady gaze • Uncover eye • Observe previously covered eye • Normal: Stays straight • Repeat with other eye

  19. Cover Test

  20. Objective Data: Test Extraocular Muscle Function • 6 Cardinal Positions of Gaze • AKA Diagnostic Positions Test • Client holds head steady & follows finger or penlight with eyes only • Hold target 12 inches back • Move to 6 positions • Hold momentarily, then back to center, progress clockwise • Can also use “H” • Normal: Parallel tracking with both eyes

  21. Objective Data: Test Extraocular Muscle Function • 6 Cardinal Positions of Gaze • Note any nystagmus • Mild: Normal at extreme lateral gaze • Abnormal any other position – denotes weakness of EOM or dysfunction of the CN innervating it • Note upper lid overlaps superior iris • Even with downward movement • Lid lag occurs with hyperthyroidism

  22. Extraocular Muscles

  23. Extraocular Muscles & Direction of Movement

  24. Six Cardinal Positions of Gaze

  25. Objective Data:Inspect External Ocular Structures • General • Gross visual ability • Facial expression • Eyebrows • Present bilaterally & move symmetrically • No scaling or lesions • Eyelids & lashes • Upper lids overlap superior iris • Approximate completely when closed • Intact; no redness, discharge, swelling or lesions • Palpebral fissures horizontal • Asians upward slant • Lashes evenly distributed & curve outward

  26. Anatomy of the External Eye

  27. Objective Data:Inspect External Ocular Structures • Eyeballs • Aligned, not protruding or sunken • Blacks: Slight protrusion normal • Conjunctiva & sclera • Client looks up • Slide lower lids down with thumbs • Do not push eyeball • Eyeball should be moist, glossy, small blood vessels visible but otherwise conjunctivae clear • Palpebral conjunctiva pink • Sclera china white • Dark-skin: Gray-blue or muddy, freckles, yellow fat deposits under lids • Abnormal: Jaundice – scleral icterus

  28. Examination of Conjunctiva & Sclera

  29. Objective Data:Inspect External Ocular Structures • Lacrimal apparatus • Client looks down • Use thumbs to slide outer upper lid along bony orbit • Inspect for redness, swelling, tenderness • Check puncta & lacrimal gland • Press index finger against sac just inside lower orbital rim (not nose) • Assess for tenderness, redness, discharge

  30. Lacrimal Apparatus

  31. Inspection of Nasolacrimal Duct

  32. Objective Data: Inspect Anterior Eyeball Structures • Cornea & Lens • Shine light from side • Check smoothness, clarity • Arcus senilus normal in elderly (see p.325) • Iris & Pupil • Iris flat, round, even color • Note pupil size, shape, equality • 5% people have anisocoria

  33. Anterior Eye Structures

  34. Internal Anatomy of the Eye

  35. Objective Data: Inspect Anterior Eyeball Structures • Pupillary Light Reflex • Darken room, client gazes into distance • Advance light from side • Note direct & consensual response • Can gauge in mm (Normal 3-5mm) • R 3/1= 3/1 L • Test Accommodation & Convergence • Client focuses on distant object • Shift gaze to object 3 inches from eyes • Normal: Pupils constrict & converge • Document: PERRLA

  36. Pupillary Light Reflex

  37. Testing Accommodation & Convergence

  38. Actual Nursing Diagnosis • Disturbed visual perception related to improper use of contact lenses as evidenced by excessive tearing and inflammation

  39. Examination of the Ears • Preparation • Client sitting straight up, head at eye level • If ear canal obstructed with cerumen, may need to irrigate (eardrum intact) • Soften w/ warm mineral oil & H2O2 • Irrigate with warm water & bulb syringe • Equipment • Otoscope with bright light • Tuning fork

  40. Subjective Data • Earaches • Describe sx • Accompanying cold sx or sore throat • Hx trauma • Infections • Adult, child, treatment • Discharge • Appearance, odor, relation to pain • Hearing loss • Actual • Family hx

  41. Subjective Data • Environmental noise • Tinnitus • Vertigo • Self-care behaviors • Infants & children • Ear infections • Hearing • Trauma, injury

  42. Objective Data:Inspect & Palpate External Ear • Size & shape • Skin condition • Tenderness • External auditory meatus

  43. External Ear Structures

  44. Objective Data:Inspect Using the Otoscope • Use largest speculum that fits comfortably • Tilt head toward opposite shoulder • Pull pinna up & back for adult or older child • Pull pinna down if infant to < 3 yrs • Pull gently but firmly until done with otoscopic exam

  45. Infant vs. Adult Eustachian Tube

  46. Positioning Pinna

  47. Objective Data:Inspect Using the Otoscope • Hold otoscope upside down • Dorsa of your hand against cheek • Insert speculum gently along axis of canal • Avoid touchy bony section of canal wall • If see only wall, reposition • Rotate otoscope gently to visualize tympanic membrane

  48. Objective Data:Inspect Using the Otoscope • External Canal • Note redness, lesions, or discharge (color & odor) • Tympanic membrane • Shiny, translucent, pearly gray • Cone-shaped light reflex • 5 o’clock right drum; 7 o’clock left drum • Visualize umbo, manubrium & short process • Note position • Flat, bulging, retracted? • Check integrity of membrane

  49. Internal Anatomy of the Ear

  50. Use of Otoscope

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