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 Eyebrows Quantity, distribution Eyelids Edema, color, lesions Conjunctiva and sclera color, vascular pattern Cornea and lens Iris 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 Conjunctivitis Trauma 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.

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 Jaeger chart

Confrontation Test Range of peripheral vision: o The client should be sitting 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

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

Mucous membranes Sores / Lesion Tonsils Sore throat Gums Teeth Mouth / Tongue/ Teeth / Throat

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

Abnormal Normal CN X Say “AAHHH”

Tonsillitis Peritonsilar Abscess

Is the tongue moist and pink? ….underneath Assess both top and….

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 Visual disturbances, use of corrective lenses, pain, redness, excessive tearing, double vision (diplopia) EarsHearing loss, ringing (tinnitus), vertigo, pain, discharge Nose Drainage (rhinorrhea), congestion, sneezing, nose bleeds (epistaxis) Mouth Swelling, ulceration or tonsillar enlargement

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