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King Saud University

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King Saud University College of Nursing Health Assessment (NUR 224) Eyes, Ears, Mouth, & Nose * – PowerPoint PPT presentation

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Title: King Saud University


1
  • King Saud University
  • College of Nursing
  • Health Assessment (NUR 224)
  • Eyes, Ears, Mouth, Nose

2
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

3
Techniques
  • Inspection
  • Palpation

4
Eye
5
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.

6
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)

7
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

8
Eyes
  • Are there 2
  • Loss of vision
  • Pain
  • Disorders
  • Strabismus, diplopia
  • Discharges / Redness / Swelling
  • Prosthesis
  • Past history
  • Glasses / contact lens

9
ABNORMALITITES
  • Ptosis
  • drooping of the eye lid
  • Blepharitis
  • inflammation of eyelids
  • Sty or Hordeolum
  • Staphylococcal infection of hair follicles at lid
    margin

10
Abnormal Facial Features
  • Tics
  • Abnormal facial movements
  • Exopthalomus
  • Prominent eyes
  • Acromegaly
  • Gradual enlargement of the bones of the face
    jaws

11
Eyes
Trauma
Conjunctivitis
Cyst
12
Eye Ptosis
13
Sty
14
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

15
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.

16
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
17
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.

18
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.

19
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

20
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

21
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

22
Ears
23
Ears
  • Earaches
  • Discharge/odor
  • Hearing Loss
  • Tinnitus
  • Vertigo
  • Microtia
  • Macrotia

24
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

25
Straightening the Ear Canal and Inserting the
Speculum
26
Ear
Tophi
27
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.

28
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

29
Ears Hearing acuity
  • Weber
  • Lateralization of sound to impaired ear suspect
    unilateral conductive hearing loss

30
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.

31
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

32
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33
Assess Nose for Symmetry, Edema, and Air Passage
34
Mouth / Tongue/ Teeth / Throat
  • Mucous membranes
  • Sores / Lesion
  • Tonsils
  • Sore throat
  • Gums
  • Teeth

35
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

36
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37
Gums
Gingivitis
38
Tongue
Glossitis
39
The Mouth and Gums
40
Under the Tongue
41
Above and behind the tongue
42
Say AAHHH
Abnormal
Normal CN X
43
Peritonsilar Abscess
Tonsillitis
44
Is the tongue moist and pink?
Assess both top and.
.underneath
45
Oral Herpes Simplex
46
Assess Outside of Mouth and Lips for Color,
Moisture, and Abnormalities
47
  • 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
48
  • Ask the patient to stick his tongue straight out
    of his mouth.

CN XII
49
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
50
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