Transcript ASSESSING THE EYES

Nur330
Geiman
Identify pertinent history questions to the eyes
Obtain a history and perform a physical assessment
on the eyes
 Differentiate between normal and abnormal system
findings related to the eyes
 Identify actual/potential health problems related to
the eyes
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External Structures
 Sclera: gives shape and structure to eye
 Iris: controls amount of light entering eye; provides
eye color
 Extraocular muscles: control eye movement –
Cranial nerves III, IV and VI
External Structures
 Eyelids and lashes: protect the eyes from injury
 Lacrimal glands and ducts: produce tears
 Conjunctiva: provide lubrication
External Structures
 Cornea: transparent, avascular outer layer of the
eyeball
 Anterior chamber: filled with aqueous humor
 Pupil: the aperture of the iris, controls the amount
of light allowed into the retina
 Lens: an elastic biconvex disc that bends the light
wave entering the eye by either flattening or
increasing the lens curvature.
Internal Structures
 Optic disc and physiological cup: area where the
optic nerve and the blood vessels enter the eye
 Retinal blood vessels: blood supply to eye
Internal Structures
 Retina: inner layer; receives light waves that are
sent to brain and converted into visible perceptions
 Macula: an indistinct, darker, avscular area on the
retina responsible for night, color, and central vision
and motion detection
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The optic fundus is the only area in the body
where the blood vessels can be directly
observed
Can reveal systemic problems with circulation
as in with chronic HTN and diabetes
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Extraocular muscles (CN: III, IV, and VI)
Eyelids
Constriction and relaxation of the muscular
tissue of the iris and ciliary body allows for
visual adaption
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CN control eye movements, muscles of the
eye lids, opening and closing of eyes
Vision from the time the image is transmitted
on the retina
What developmental variations of the eyes
might be seen with:
 Children
 By the age of 5 to 6, children should have 20/20 vision
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Older adults
 Presbyopia – farsightedness begins to occur by the 4th or
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5th decade
Cataracts – the clouding of the lens
Night vision impaired – degeneration of rods
Age-related macular degeneration (AMD) – loss of central
vision
Diabetic retinopathy
What cultural variations of the eyes might
be seen with:
 Dark-skinned African Americans
 Asians
What symptoms would signal a problem with the eyes?
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Vision loss/acuity
Eye tearing
Eye drainage
Eye appearance changes
Redness/swelling
History of ocular
problems?
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Pain
Blurred vision
Dry eyes
Strasbismus/diplopia
Patient-centered care
Glasses/contact lenses
Glaucoma
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Anatomical Landmarks: visual fields (superior, inferior,
nasal, temporal)
Approach: inspection, palpation, ophthalmoscopy
Position: sitting
Tools: visual acuity charts (Snellen), penlight,
ophthalmoscope, cotton ball, cotton swab
General survey and head-to-toe scan
Far vision: Snellen eye chart
Near vision: read newsprint 13 to 15” from eyes
Color vision: identify color bars on Snellen or use
color plates
 Peripheral vision: Confrontation test: come in from
the periphery in all fields and note field cuts
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Test corneal light reflex
Test six cardinal fields of gaze
Testing Extra Occular
Movements
Cranial
Nerves
tested:
•CN III
•CNIV
•CN VI
Lids and lashes: color, lesions, edema, symmetry,
position and distribution of lashes
 Lacrimal glands and ducts: color, edema, excessive
tearing or drainage
 Conjunctiva: color, cyanosis, moisture, lesions, and
foreign bodies
 Sclera: color, jaundice, moisture, lesions, or tears
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Cornea: clarity and abrasions, corneal reflex
Anterior chamber: clarity, bulging iris, and blood
Iris: color, size, shape, and symmetry
Pupils: size, shape, reaction to light–direct and
consensual, test accommodation
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Eye ball: consistency and tenderness
Lacrimal glands and ducts: tenderness and
excessive tearing
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Red reflex: presence, opacities
Optic disc and physiologic cup: color, size, shape,
borders, cup-disc ratio
Retinal vessels: size ratio of arteries and veins, color,
arteriole light reflex, crossings
Retina: color, texture, exudates, lesions, hemorrhages,
and aneurysms
Macula and fovea: color, size, location, lesions
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Red reflex is the
reflection of light off
the retina
Absence or red reflex
could indicate
cataracts or opacities
in lens or vitreous
humor
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Abnormally, progressive opacity of the lens
Pupil may appear cloudy
Red reflex may be absent or darkened
Years of exposure to ultraviolet light are a risk
factor for cataracts
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Separation of the retinal layer and choroid
layer in the back of the eye
Initial symptoms start with seeing floaters,
flashing lights, and a slowing expanding
shadow in the lateral fields of gaze
Untreated retinal detachment results in
irreversible blindness
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Characterized by increased pressure within
the eyeball; can cause progressive damage to
the optic nerve.
Open-angle (chronic) glaucoma is by far the
most common type of glaucoma.
Regardless of race, adults starting at age 40
should be checked every 2 to 4 years and
then every year starting at age 65
Person with diabetes should be checked
annually
What are the functions of auricle and external ear
canal:
 collect and transmit sound waves
 Connects the auricle to the Tympanic Membrane (TM)
 Contains fine hairs and glands
 Protects the TM from external environmental factors
What are the functions of the middle ear:
Tympanic membrane (TM): divides external ear
from middle ear; transmits sound waves
 Ossicles: three smallest bones in body, transmit
sound waves
 Eustachian tube: equalizes pressure on both sides
of TM
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What are the functions of the inner ear:
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Structures of inner ear: transmit sound
waves to CN VIII and affect equilibrium
Carrying sound waves through the external auditory canal to the TM. The sound vibrations cause the
TM and the malleus, anvil and stapes bones to move, thus transmitting the vibrations to the inner
ear structures
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An additional pathway whereby the sound
waves vibrate the skull bones and transmit
the vibrations to the inner ear structure.
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Hearing by both air conduction and bone
conduction rely on intact skeletal structures
What developmental variations of the ears
might be seen with:
 Children – more prone to ear infections
 Older adults
 Presbycusis – usually high pitched sounds and consonants
 Excess accumulation of cerumen
What symptoms would signal a problems
with the ears?
 Earache
 Hearing loss (conductive vs. sensorineural loss)
 Vertigo
 Ringing in the ears (tinnitus)
 Ear drainage (otorrhea)
 Earache (otalgia)
 Infections
 Patient-centered nursing
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History of ear infections?
Severe head injury or stroke?
History of tinnitus? Vertigo?
Medications?
Exposure to loud noises?
Smoker or exposure to second hand smoke
History of hearing loss in the family?
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Anatomical landmarks: angle of attachment of the
ears
Approach: inspection and palpation
Position: sitting
Tools: tuning fork, otoscope, thermometer, watch
General survey and head-to-toe scan
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Angle of attachment and position
Size, shape, and symmetry
Drainage: clear, blood, or purulent
Consistency and tenderness
Palpate tragus, mastoid, and helix for tenderness
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Preauricle
tag
Hold the otoscope upside down like a pencil.
Pull the pinna of the ear up and back for adults, ear
down and back for children
 Brace you insertion hand on the patient’s head for
stabilization
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OR
 Hold the otoscope handle upright and slowly and
gently insert the scope along the axis of the external
auditory canal (1/2 inch in adult)
 Put your eye up to the viewing lens
 Do not insert further, gently apply more traction on
the ear
External ear canal: patency, color, drainage,
lesions, and foreign objects
 Tympanic membrane:
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 Color – normal TM should be shiny, pearl gray, intact and
mobile
Whispered voice test (for low pitch)
 Stand 1-2 feet behind client so they can not read your lips.
 Instruct client to place one finger on tragus of left ear to obscure sound.
 Whisper word with 2 distinct syllables towards client's right ear.
 Ask client to repeat word back.
 Repeat test for left ear.
 Client should correctly repeat 2 syllable word.
Weber test – assess lateralization of sound
through both BC and AC
 Hold tuning fork by stem and tap with palm of hand
 Place vibrating tuning fork in the middle of the
patient’s forehead or top of the head
 NORMAL FINDING: The sound is heard in the center
of the head or equally in both ears.
 Abnormal: If there is a conductive hearing loss
present, the vibration will be louder on the side with
the conductive hearing loss.
 If the patient doesn't hear the vibration at all, attempt
again, but press the butt harder on the patient's head.
Rinne test - Test compares air and bone conduction
hearing.
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Strike the tuning fork softly.
Place the vibrating tuning fork on the base of the
mastoid bone.
Ask client to tell you when the sound is no longer
heard.
Note the time interval and immediately move the
tuning fork to in front of the ear
Ask the client to tell you when the sound is no longer
heard..
Note the time interval and findings
Rinne Test Results
 Normal hearing clients will note air conduction
twice as long as bone conduction (ie, bone
conduction is less than air conduction)
 With conductive hearing loss, bone conduction
sound is heard longer than or equally as long as air
conduction
 With sensorineural hearing loss, air conduction is
heard longer than bone conduction in affected
ear, but less than 2:1 ratio
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The Vestibular apparatus – test the inner ear’s
vestibular apparatus by performing the
Romberg test.
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Meniere’s Disease
 Chronic, progressive disease of the inner ear that
leads to permanent hearing loss
 Affects proprioception
 Sensation of fullness or pressure in the ears and
recurrent episodes of vertigo, tinnitus, and
hearing loss
 Disturbance of balance and gait
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Presbycusis
 Diminished hearing acuity in older adults
specifically for high-pitched sounds
 Hearing acuity decreased