Transcript nur_224-eyes_ears_mouth_nose.ppt

King Saud University
College of Nursing
Health Assessment (NUR 224)
Eyes, Ears, Mouth, & Nose
1
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
Techniques
 Inspection

Palpation
Eye
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.
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)
Eyes - Inspection
 Position and alignment of eyes
 Cornea and lens
 Eyebrows
 Iris
 Quantity, distribution
 Eyelids
 Edema, color, lesions
 Conjunctiva and sclera
 color, vascular pattern
 Pupils – size, shape, symmetry,
reaction to light
Eyes
 Are there 2
 Loss of vision
 Pain
 Disorders
 Strabismus, diplopia
 Discharges / Redness / Swelling
 Prosthesis
 Past history
 Glasses / contact lens
ABNORMALITITES
 Ptosis
 drooping of the eye lid
 Blepharitis
 inflammation of eyelids
 Sty or Hordeolum
 Staphylococcal infection of hair follicles at lid
margin
Abnormal Facial Features
 Tics
 Abnormal facial movements
 Exopthalomus
 Prominent eyes
 Acromegaly
 Gradual enlargement of the bones of the face &
jaws
Eyes
Trauma
Conjunctivitis
Cyst
Eye Ptosis
Sty
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
Visual Acuity
 Snellen Eye Chart
 Distance/Central vision: position patient 20
feet (6 meters) from the chart
o Patient may wear glasses and contact lens,
but remove the reading glasses.
o Test one eye at a time.
o Start from the biggest lines to the smallest
lines.
Jaeger chart
Visual Acuity
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
patient’s eyes.
Rosenbaum chart
Confrontation Test
 Range of peripheral vision:
o
The client should be sitting 60-90 cm from you and at eye
level
o
Test one eye at a time
o
The client’s peripheral visual fields are compared to that of
the examiner.
o
This test assumes the examiner has normal peripheral
vision.
o
Ask the person to say “now” when see the object.
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 client’s
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.
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
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 patient’s right eye with 
your right eye; hold it in your left hand to examine the patient’s 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 patient’s 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 
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 patient’s right eye with 
your right eye; hold it in your left hand to examine the patient’s 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 patient’s 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 
Ears
Ears
 Earaches
 Discharge/odor
 Hearing Loss
 Tinnitus
 Vertigo
 Microtia
 Macrotia
Ears – Inspection
 Inspection
 Auricle for redness, lesions
 Ear canal
o
Discharge, foreign bodies,
redness, swelling
 Tympanic membrane (by Use
otoscope )
o
Color, contour
 Palpation
 Auricle for lumps, tenderness
Straightening the Ear Canal and
Inserting the Speculum
Ear
Tophi
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.
Ears – Hearing acuity
Rinne
o
Compare time of air vs. bone conduction
o
Place the base of the tuning fork on the client’s
mastoid process- and note the number of
seconds.
o
Then move the fork in front the external
auditory meatus (1-2 cm)
o
If bone conduction is equal or greater than air
conduction, then suspect conductive hearing
loss
Ears – Hearing acuity
 Weber
o
Lateralization of sound to impaired ear;
suspect unilateral conductive hearing loss
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.
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
Assess Nose for Symmetry, Edema, and
Air Passage
Mouth / Tongue/ Teeth / Throat
 Mucous membranes
 Sores / Lesion
 Tonsils
 Sore throat
 Gums
 Teeth
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
Gums
Gingivitis
Tongue
Glossitis
The Mouth and Gums
Under the Tongue
Above and behind the tongue
Say “AAHHH”
Abnormal
Normal CN X
Tonsillitis
Peritonsilar Abscess
Is the tongue moist and pink?
Assess both top and….
….underneath
Oral Herpes Simplex
Assess Outside of Mouth and Lips for
Color, Moisture, and Abnormalities
 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
 Ask the patient to stick
his tongue straight out
of his mouth.
CN XII
Summary
Abnormalities
Eyes
Ears
Visual disturbances, use of corrective lenses,
pain, redness, excessive tearing, double vision
(diplopia)
Hearing loss, ringing (tinnitus), vertigo, pain,
discharge
Nose
Drainage (rhinorrhea), congestion, sneezing,
nose bleeds (epistaxis)
Mouth
Swelling, ulceration or tonsillar enlargement
Question?
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