Title: King Saud University
1- King Saud University
- College of Nursing
- Health Assessment (NUR 224)
- Eyes, Ears, Mouth, Nose
2Objectives
- 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
3Techniques
4Eye
5Anatomy
- 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.
6Anatomy (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)
7Eyes - 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
8Eyes
- Are there 2
- Loss of vision
- Pain
- Disorders
- Strabismus, diplopia
- Discharges / Redness / Swelling
- Prosthesis
- Past history
- Glasses / contact lens
9ABNORMALITITES
- Ptosis
- drooping of the eye lid
- Blepharitis
- inflammation of eyelids
- Sty or Hordeolum
- Staphylococcal infection of hair follicles at lid
margin
10Abnormal Facial Features
- Tics
- Abnormal facial movements
- Exopthalomus
- Prominent eyes
- Acromegaly
- Gradual enlargement of the bones of the face
jaws
11Eyes
Trauma
Conjunctivitis
Cyst
12Eye Ptosis
13Sty
14Inspect 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
15Visual 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.
16Visual 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
17Confrontation 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.
18Extraocular 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.
19Developmental 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
20Tips 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
21Tips 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
22Ears
23Ears
- Earaches
- Discharge/odor
- Hearing Loss
- Tinnitus
- Vertigo
- Microtia
- Macrotia
24Ears 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
25Straightening the Ear Canal and Inserting the
Speculum
26Ear
Tophi
27Ears 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.
28Ears 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
29Ears Hearing acuity
- Weber
- Lateralization of sound to impaired ear suspect
unilateral conductive hearing loss
30Ears
- 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.
31Nose 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(No Transcript)
33Assess Nose for Symmetry, Edema, and Air Passage
34Mouth / Tongue/ Teeth / Throat
- Mucous membranes
- Sores / Lesion
- Tonsils
- Sore throat
- Gums
- Teeth
35Mouth 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(No Transcript)
37Gums
Gingivitis
38Tongue
Glossitis
39The Mouth and Gums
40Under the Tongue
41Above and behind the tongue
42Say AAHHH
Abnormal
Normal CN X
43Peritonsilar Abscess
Tonsillitis
44Is the tongue moist and pink?
Assess both top and.
.underneath
45Oral Herpes Simplex
46Assess 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
49Summary
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