eye assessment
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Eye Eye AssessmeAssessmentnt
Edwin B. Malic RN
External eye structureExternal eye structureEyelidsEyelashesConjunctivaLacrimal apparatusExtraocular muscleeyeball
Internal structureInternal structureIrisLensRetinaOptic discRetinal vessel
visionvision
Visual fields and visual pathwayUpper temporalLower temporalUpper nasalLower nasal
Visual reflexesVisual reflexesPupillary light reflex- Direct- Indirect or consensual
accommodation
Anatomy of the eyeAnatomy of the eye
Anatomy of the eyeAnatomy of the eye
Anatomy of the eyeAnatomy of the eye
Collecting subjective dataCollecting subjective dataDo you see spots or floaters in
front of your eyes?Do you experience blind spots?
Are they constant or intermittent?Do you see halos or rings around
lights?Do you have trouble seeing at
night?Do you experience double vision?
Collecting subjective dataCollecting subjective dataDo you have any eye pain or
itching? DescribeDo you have any redness or
swelling in your eyes?Do you experience excessive
watering or tearing of the eye? One eye or both eyes?
Have you had any eye discharge? describe
Collecting subjective dataCollecting subjective dataHave you ever had problems with
your eyes or vision?Have you ever had eye surgery?Describe any past treatments
you have received for eye problems (medication, surgery, laser treatments, corrective lenses). Were these successful? Were you satisfied?
Family historyFamily historyIs there a history
of eye problems or vision loss in your family?
Lifestyle and health Lifestyle and health practicespracticesAre you exposed to conditions or
substance In work place or home that may harm your eyes or vision? Do you wear safety glasses during exposure to harmful substances?
Do you wear sunglasses during exposure to the sun?
What types of medications do you take?
Lifestyle and health Lifestyle and health practicespracticesWhen was your last eye
examination?Do you have a prescription for
corrective lenses? Do you wear them regularly? If you wear contacts, how long do you wear them? How do you clean them?
Collecting objective dataCollecting objective data
Preparing the clientExplain each vision test
EquipmentSnellen or E chartHand-held snellen card or near
vision screenerpenlight
Collecting objective dataCollecting objective data
EquipmentOpaque cardsOphthalmoscopeDisposable gloves
Physical assessmentPhysical assessment
While performing examination, remember these key points
Administer vision test competently and record the results
Use the ophthalmoscope correctly and confidently
Recognize and distinguish normal variation from abnormal findings
Evaluating visionEvaluating vision
Test distant visual acuity
o Position the client 20 feet from the snellen or e chart
o Ask her to read each line until she cannot decipler the letters or their direction
o Document results
Evaluating visionEvaluating vision
Test distant visual acuity
Normal visual acuity is 20/20
Deviation from normal
Myopia20/200 is considered
legally blindAny client with vision
worse than 20/30 should be referred for further evaluation
Evaluating visionEvaluating vision
Test near visual acuityo Use for middle aged clients and
others who complain difficulty in reading
o Give the client a hand-held vision chart
o Have the client cover one eye with an opaque card before reading from top to bottom
Evaluating visionEvaluating vision
Test near visual acuity
Normal near visual acuity is 14/14
Deviation from normal
Presbyopia (impaired near vision)
Evaluating visionEvaluating vision
Test visual fields for gross peripheral vision
The client should see the examiner’s finger at the same time the examiner sees it
Deviation from normal
A delayed or absent perception of the examiner’s finger indicates reduced peripheral vision
Testing extraocular muscle Testing extraocular muscle functionfunctionPerform corneal light reflexHold the penlight approximately
12 inches from the client’s faceShine the light toward the bridge
of the nose while the client stares ahead.
Testing extraocular muscle Testing extraocular muscle functionfunctionPerform corneal
light reflex
The reflection of light on the corneas should be in the exact same spot on each eye, which indicate parallel alignment
Deviation from normal
Asymmetric position of the light reflex indicates deviated alignment of the eyes due to muscle weakness or paralysis
Testing extraocular muscle Testing extraocular muscle functionfunctionPerform cover testAsk the client to stare straight
ahead and focus on a distant object. Cover one eye with an opaque card.
As you cover the eye, observe the uncovered eye for movement.
Now remove the card and observe the previously covered eye for any movement
Testing extraocular muscle Testing extraocular muscle functionfunction
Perform cover test
The uncovered eye should remain fixed straight ahead. The uncovered eye should remain fixed straight ahead after being uncovered
Deviation from normal
The uncovered eye will move to establish focus when the opposite eye is covered. When covered eye is uncovered, movement to reestablish focus occurs
Phoria, strabismus, tropia
Testing extraocular muscle Testing extraocular muscle functionfunctionPerform the positions testo Instruct the client to focus on an
object you are holding (approximately 12 inches from the client’s face)
o Move the object through the six cardinal positions of gaze in clockwise direction, and observe the client’s eye movement
Cardinal Positions of Gaze
The six positions in which the eyes can be turned where each eye is controlled primarily by one muscle: up/right, right, down/right, down/left, left, and up/left.
Testing extraocular muscle Testing extraocular muscle functionfunctionPerform the
positions test assesses eye muscle strength and cranial nerve function
o Eye movement should be smooth and symmetric throughout all six direction
Deviation from normal
Failure of eyes to follow movement symmetrically indicates weakness
Nystagmus, an oscillating (shaking movement)
External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashes
Note width and position of palpebral fissures
Upper lid margin should be between the upper margin of the pupil
The lower lid rest on the lower border of the iris. No white sclera is seen above or below the iris
Palpebral fissures may be horizontal
Deviation from normal
o Drooping of the eyelid(ptosis) oculomotor damage
o Retracted lid margins
External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashesAssess the ability
of eyelids to close
o The upper and lower lids close easily and meet completely when closed
Deviation from normal
Failure of lids to close completely puts client at risk for corneal damage
External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashes
Note the position of eyelids in comparison with the eyeballs. Note any unusual turnings, color, swelling, lesion, discharge
Deviation from normal
External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashesLower eyelid is upright with no inward or outward turning
Eyelashes are evenly distributed and curve along the lid margins
Xanthelasma, raised yellow plaques located most often near the inner canthus, are normal with increasing age and high lipid levels
Inverted lower lid(entropion) may cause pain and injure the cornea
Ectropion an evertted lower eyelid, results in exposure and drying of the conjunctiva
External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashesObserve for
redness, swelling, discharge, or lesion
o Skin on both eyelids is without redness, swelling, or lesion
Deviation from normal
Redness and crusting along the lid margins suggest seborrhea or blepharitis
External eye structureExternal eye structure
Observe the position and alignment of the eyeball in the eye socket
o Eyeballs are symmetrically aligned in sockets without protruding or sinking
Deviation from normal
Protrusion of the eyeballs accompanied by retracted eyelid margins is termed exophthalmus
Sunken eyes may be seen with severe dehydration
External eye structureExternal eye structure
Inspect the bulbar conjunctivao Have the client keep her head
straight while looking from side to side then up toward the ceiling
o Observe clarity, color, and textureo This procedure is stressful and
uncomfortable for the client. It is usually only done if the client complain of pain “something in the eye”
External eye structureExternal eye structure
Inspect the bulbar conjunctivaAssess the areas over the
lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid)
External eye structureExternal eye structure
Inspect the bulbar conjunctiva
o Bulbar conjunctiva is clear, moist, and smooth.
o Sclera is white
Deviation from normal
o Generalized redness of conjunctiva (conjuctivitis)
o Areas of dryness are associated with allergies/ trauma
o Episcleritis is a local, noninfectious inflammation of sclera
External eye structureExternal eye structure
inspect the palpebral conjunctivao Put on gloves, first inspect the
palpebral conjunctiva of the lower eyelid by placing your thumbs bilaterally at the level of the lower bony orbital rim and gently pulling down to expose palpebral conjunctiva
o Ask the client to look up as you observe the exposed area
Inspect the palpebral conjunctivaEvert the upper eyelidAsk the client to look down with
his eyes slightly openPlace a cotton applicator
approximately 1 cm above the eyelid margin and push down while still holding the eyelashes
External eye structureExternal eye structure
Inspect the palpebral conjunctiva
Clear and free of swelling or lesion
Free of foreign bodies, or trauma
Deviation from normal
Cyanosis of the lower lid (lung heart disorder)
Foreign body or lesion may cause irritation, burning, pain
External eye structureExternal eye structure
Inspect the lacrimal apparatus
o No swelling/redness
Deviation from normal
Swelling of the lacrimal gland may be visible in the lateral aspect of the upper eyelid. May be cause by blockage, infection, or an inflammation
External eye structureExternal eye structure
palpate the lacrimal apparatuso Put on disposable gloves to
palpate the nasolacrimal duct to assess for blockage
o Use one finger and palpate just inside the orbital rim
External eye structureExternal eye structure
Palpate the lacrimal apparatus
No drainage should be noted from the puncta when palpating the nasolacrimal gland
Deviation from normal
Expressed drainage from the puncta on palpation occurs with duct blockage
External eye structureExternal eye structure
Inspect the cornea and lenso Shine a light from the side of the
eye for n oblique viewo Look through the pupil to inspect
the lens
External eye structureExternal eye structure
Inspect the cornea and lens
The cornea is transparent with no opacities. The oblique view shows a smooth and overall moist surface; the lens is free of opacities
Deviation from normal
Areas of roughness, dryness on the cornea are often associated with injury or allergic responses.
Opacities of the lens are seen with cataracts
External eye structureExternal eye structure
Inspect the iris and pupil
o Iris is typically round, flat, and evenly colored. The pupil, round with a regular border, is centered in the iris. Pupils are normally equal in size (3-5mm)
o anisocoria
Deviation from normal
o Irregularly shape irises, miosis, mydriasis, and anisocoria
External eye structureExternal eye structure
Test pupillary reaction to light
o Normal reaction is constriction
Deviation from normal
o Monocular blindness can be detected when light directed results no response
o When light is directed into the unaffected eye, both pupils constrict
External eye structureExternal eye structure
Test accommodation of pupils
o The normal pupillary response is constriction and convergence of the eyes when focusing on a near object
Deviation from normal
o Pupils do not constrict; eyes do not converge
Abnormal findingsAbnormal findings
Pseudostrabismus Ptosis
Abnormal findingsAbnormal findingsentropion ectropion
Abnormal findingsAbnormal findingsConjunctivitis
Ear Ear AssessmentAssessment
Structure and functionStructure and functionExternal
earMiddle earInner ear
HEARING
Collecting subjective dataCollecting subjective dataHistory of present health concern
o Changes in hearing- describe any recent changes in
your hearing- Are all sounds affected with this
change or just some sounds
Collecting subjective dataCollecting subjective dataHistory of present health concern
o Other symptoms- Do you have any ear drainage?
Describe the amount and any odor
- do you have any ear pain? If so, do you have an accompanying sore throat. Sinus infection, or problem with your teeth or gums?
- Do you experience any ringing or crackling in your ears?
- Do you ever feel like you are spinning or that the room is spinning? Do you ever feel dizzy or unbalanced?
Past health historyPast health historyHave you ever had any problems
with your ears such as infection, trauma or earaches?
Describe any past treatments you have received for ear problems (medication, surgery, hearing aids). Were these successful? Were you satisfied?
Family HistoryFamily HistoryIs there a
history of hearing loss in your family?
Lifestyle and health Lifestyle and health practicespracticesDo you work or live in an area with
frequent or continuous loud noise? How do you protect your ears from the noise?
Do you spend a lot of time swimming or in water? How do you protect your ears?
Has your hearing loss affect your ability to care for yourself? To work?
Has your hearing loss affect socializing with others?
Lifestyle and Health Lifestyle and Health PracticesPracticesWhen was your last hearing
examination?How do you care for your ears?
Collecting objective dataCollecting objective data
Preparing the cliento Make sure client is seated
comfortablyo Test should explained thoroughly
to guarantee accurate results.
Collecting objective dataCollecting objective data
EquipmentWatch with a second-hand for
romberg testTuning forkOtoscope
Collecting objective dataCollecting objective data
Physical assessmentRecognize the role of hearing in
communication and adaptationKnow how to use the otoscope
effectivelyUnderstand the usefulness and
significance of basic hearing tests
External ear structuresExternal ear structures
Inspect the auricle, tragus, and lobule
Ears are equal in size bilaterally (4-10cm)
Skin is smooth with no lesion, lumps, or nodules
No discharge should be present
Darwin’s tubercle
Deviation from normal
Ears are smaller than 4cm
Malaligned or low set ears may be seen with genitourinary disorder
Enlarged preauricular and posturicular lymph nodes-infection
External ear structuresExternal ear structures
Palpate the auricle and mastoid process
o Auricle, tragus, and mastoid process are not tender.
Deviation from normal
Painful auricle/tragus associated with postauricular cyst
Tenderness over the mastoid process (mastoiditis)
Tenderness behind the ear may occur with otitis media
Internal ear: otoscopic Internal ear: otoscopic examinationexamination
Inspect the external auditory
Small amount of odorless cerumen (earwax) is the only discharge normally present
Deviation from normal
o Foul smelling, sticky, yellow discharge
o Bloody purulent discharge
o Blood or watery drainage
o Impacted cerumen bloking the view of ear canal
Internal ear: otoscopic Internal ear: otoscopic examinationexaminationObserve the color
and consistency of the ear canal walls
o The canal walls should be pink and smooth without nodules
Deviation from normal
o Reddened, swollen canals
o Exostoses (nonmalignat nodular swellings)
o Polyps
Inspect the tympanic membrane
o Should be pearly, gray, shiny, and translucent with no bulging or retraction
o slightly concave, smooth and
Deviation from normal
o Red, bulging eardrum and distorted, diminished or absent light reflex
o Yellowish, bulging membrane with bubbles behind
o Bluish or dark red color
o White spotso perforations
Perform the weber’s testo Helps to evaluate the conduction of
sound waveso Strike a tuning fork softly with the
back of your hand and place it in the center of the client’s head or forehead.
o Ask whether the client hears the sound better in one ear or the same in both ears
A tuning fork is an acoustic resonator in the form of a two-pronged fork with the prongs (tines) formed from a U-shaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when set vibrating by striking it against a surface or with an object, and emits a pure musical tone after waiting a moment to allow some high overtones to die out
Perform the weber’s test if the client reports diminished or lost hearing in one ear
o Vibrations are heard equally well in both ears
o No lateralization of sound to either ear
Deviation from normal
o With conductive hearing loss, client reports lateralization of sound to the poor ear
o With sensorineural hearing loss, client reports lateralization in good ear
Perform the rinne testPerform the rinne testStrike a tuning fork and place the
base of the fork on client’s mastoid process
Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal
Ask the client to tell you if the sound is audible after the fork is moved
Perform the rinne test
o Air conduction sound is normally heard longer than bone conduction sound
Deviation from normal
o With conductive hearing loss, bone conduction sound is heard longer than or equally s long as air conduction side.
o With sensorineural hearing loss, air conduction sound is heard longer than bone conduction sound
Perform romberg test
o Client maintains position for 20 sec without swaying or with minimal swaying
Deviation from normal
o Clients moves feet apart to prevent falls or starts to fall from loss of balance. This may indicate vestibular disorder
Mouth, throat, nose, and Mouth, throat, nose, and sinussinus
Structure and functionStructure and functionMouthThroatNoseSinuses
Collecting subjective dataCollecting subjective dataTongue and mouth- do you experience tongue or mouth
sores or lesions? Are they painful? How long have you had them? Do they recur? Is it single or do you have many?
- do you experience redness, swelling, bleeding, or pain of the gums or mouth? How long has this been happening? Have you lost any permanent teeth?
Collecting subjective dataCollecting subjective data nose and sinuses- Do you have pain over your sinuses?- do you experience nosebleeds? How
much bleeding? What color?- Do you experience frequent clear or
mucous drainage from your nose?- Can you breath through both of your
nostrils? Do you have a stuffy nose at times during the day or night?
Collecting subjective dataCollecting subjective data nose and sinuses- Do you have seasonal allergies,
had fever? Describe the timing of the allergies and symptoms
- have you experienced a change in your ability to smell or taste?
Collecting subjective dataCollecting subjective data throat- Do you have difficulty chewing or
swallowing food? How long have you had this? Do you have any pain?
- Do you have a sore throat? How long have you had it? Describe. How often do you get sore throats?
- Do you experience hoarseness? How long?
Past health historyPast health historyHave you ever had any oral,
nasal, or sinus surgery? Do you have a history of sinus infections? Describe your symptoms. Do you use nasal sprays?
Family historyFamily historyIs there a
history of mouth, throat, nose, or sinus cancer in your family
Lifestyle and health Lifestyle and health practicespracticesDo you smoke or use smokeless
tobacco? If so, how much? Are you interested in quitting this habit?
Do you drink alcohol? How much and how often?
Do you grind your teeth?
Lifestyle and health Lifestyle and health practicespractices
o Describe how you care for your teeth or dentures., how often do you brush and use dental floss? When was your last dental examination?
o If the client wear braces: how do you care for your braces? Do you avoid any specific types of foods? Describe your usual dietary intake for a day
o Do you brush your tongue?o How often are you in the sun? do you
use lip sunscreen products?
Preparing the clientPreparing the clientPlace on sitting positionExplain the procedureA gentle, yet confident and
matter of fact approach may help the client to feel more at ease
EquipmentEquipmentGloves4x4 gauze padPenlightShort, wide- tipped speculum
attached to the head of an otoscope
Tongue depressorNasal speculum
Physical assessmentPhysical assessment
When preparing to examine the nose and mouth
o Be able to identify and understand the relationship among the structures of the mouth and throat, nose, and sinuses
o Know age related changes of the oral cavity and nasal and sinus
o Refine examination techniques
mouthmouth
Inspect the lips (observe for lip consistency and color)
o Lips are smooth and smooth without lesions or swelling
Deviation from normal
o Pallor around the lips
o Reddish lipso swelling
mouthmouth
Inspect the teeth and gumso Ask the client to open the moutho Note the number, color,
condition, and alignment of the teeth
o Put on gloves and retract the client’s lips and cheeks to check gums for color and consistency
Inspect the teeth and gums
o Thirty two pearly whitish teeth with smooth surface and edges
o Some clients normally have only 28 teeth if the four wisdom teeth do not erupt
Deviation from normal
o Yellow or brownish teeth
o Missing teeth can affect chewing as well as self image
o White spot on teeth may result from antibiotic therapy
Gums are pink, moist, and firm with tight margins to the tooth.
No lesion or masses
Deviation from normal
Red, swollen gums that bleed easily, scurvy (vitamin c deficiency), and leukemia.
Enlarged reddened gums (hyperplasia)
Inspect the buccal mucosao Use a penlight and tongue
depressor to retract the lips and cheeks to check the color and consistency
o Also note the stenson’s ducts (parotid ducts) located on the buccal mucosa across from the second upper molars
Inspect the buccal mucosa
o It should be appear pink, tissue is smooth and moist without lesions
o Stenson’s duct are visible with flow of saliva and with no redness, swelling, pain, or moistness
Deviation from normal
o Leukoplakia may be seen in chronic irritation and smoking
o Leukoplakia is a percancerous lesion and client should be referred for evaluation
Inspect and palpate the tongueo Ask the client to stick out the
tongueo Inspect the color, moisture, size,
and textureo Observe for fasciculation's (fine
tremors), and check for midline protrusion
o Palpate any lesions present for induration (hardness)
Inspect and palpate the tongue
o Tongue should be pink, moist a moderate size with papillae (little protuberances) present
o No lesion are present
Deviation from normal
o Deep longitudinal fissures seen in dehydration
o Black tongue (bismuth toxicity)
o Black, hairy tongue; smooth reddish, shiny tongue w/o papillae indicative of niacin or vit. B12 deficiencies
Assess the ventral surface of the tongue
o Ask the client to touch the tongue to the roof of the mouth, and use a penlight to inspect ventral surface of tongue, frenulum
o Palpate the area if you see lesion
o It should be smooth, shiny, pink or slightly pale with no lesion
o Older client may have varicose veins on the ventral surface
Deviation from normal
o Leokoplakia, persistent lesions, ulcers or nodules may indicate cancer
Inspect for the wharton’s duct
o The frenulum is mdline; wharton’s ducts are visible with salivary glands
Dviation from normal
o Lesions, ulcers, nodules, or hypertrophied duct
Observe the sides of the tongueo use a square gauze pad to hold
the client’s tongue to each sideo Palpate any lesion, ulcers, or
nodules
No lesion, ulcers or nodules are apparent
Deviation from normal
Canker sore may be seen on the sides of the tongue in clients receiving certain kinds of chemotherapy
Leukoplakia, persistent lesion nodules may indicate cancer
Check the strength of the tonguePlace your fingers on the external
surface of the cheekAsk the client to press the
tongue’s tip against the inside of the cheek to resist pressure
Repeat from other side
The tongue offers strong resistance
Deviation from normal
o Decreased tongue strength may occur with 12 cranial nerve defect
Check the anterior tongue’s ability to taste
o By placing the drops of sugar and salty water on the tip and sides of tongue depressor
The client can distinguish between sweet and salty
Deviation from normal
o Loss of taste discrimination occurs with zinc deficiency, seven cranial nerve defect and certain medication use
Inspect the hard (anterior) and soft palate (posterior) and uvula
Ask the client to open the mouth wide while you use penlight to look at roof. Observe color and integrity
The hard palate is pale or whitish with firm, transverse rugae (wrinkle like folds)
Deviation from normal
Yellow tint to the hard palate may indicate jaundice
An opening in the hard palate are called cleft palate
Note the odor
o No unusual or foul odor is noted
Deviation from normal
o Fruity or acetone breath is associated with diabetic ketoacidosis
o Foul odors may indicate oral or respiratory infection
Assess the uvula
o Apply tongue depressor to the tongue and shine a penlight into client’s wide-open mouth
o Ask the client to say “ahhhhhhh”
No redness of or exudate from uvula or soft palate
Midline elevation of the uvula and symmetric elevation of the soft palate
Deviation from normal
o Bifid uvula looks like a split in two/ (submucous cleft palate)
o Asymmetric movement or loss of movement (CVA)
Inspect the tonsilso Using the tongue depressor to
keep the mouth open wide, inspect the tonsils for color, size, and presence of exudate or lesions
They are normally pink and symmetric and may be enlarged to 1+ in healthy clients
No exudate, swelling or lesions should be present
Deviation from normal
Tonsil are red, enlarge and covered with exudate
Maybe indurated with pathches of white or yellow exudates
Inspect the posterior pharyngeal wall
o Keeping the tongue depressor in place, shine the penlight on the back of the throat
o Observe the color of the throat, and note any exudate or lesions
Throat is normally pink without exudate or lesion
Deviation from normal
o A bright red throat with white or yellow exudate indicates pharyngitis
o Yellowish mucus on throat may be seen with postnasal sinus drainage
nosenose
inspect and palpate the external nose
Color is the same as the rest of the face; nasal structure is smooth and symmetric; clients report no tenderness
Deviation from normal
o Nasal tenderness on palpation may accompanies a local infection
Check the patency of air flow through the nostril
By occluding one nostril at a time and asking the client to sniff
Client is able to sniff through each nostril while other is occluded
Deviation from normal
o Client cannot sniff through a nostril
o This maybe a sign of swelling, rhinitis, or a foreign object obstruction
Inspect the internal nose
Dark pink, moist and free of exudate
Nasal septum is intact and free of ulcers and perforation
Deviation from normal
Nasal mucosa is swollen and pale or bluish gray in clients with allergies
sinusessinuses
Palpate the sinusPalpate the frontal sinuses using
thumb to press up on the brow on each side of the nose
Palpate the maxillary sinuses by pressing with thumbs up
Sinuses are not tender
Deviation from normal
The frontal and maxillary sinuses are tender in clients with allergies or sinus infection
Transilluminate the sinus (frontal and maxillary)
a red glow
Deviation from normal
Absence of red glow usually indicates a sinus filled with fluid, pus thick mucus
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