Eyes and Ears Flashcards
Inspect and Palpate the external ear
Size and Shape
● Should be equal bilaterally with no swelling and thickening
Skin Condition
● Skin color consistent with pt’s face.
● Skin is intact with no bumps or lesions.
● Some patients may have Darwin’s Tubercle, a small painless nodule at the helix.
Tenderness
● Move the pinna and push on the tragus.
● Should feel firm, and movement should not produce pain.
● Palpating the mastoid process should also produce no pain.
The external Auditory Meatus
● Note the size of the opening to direct the choice of the speculum of the otoscope
● There should be no swelling, redness, or discharge present
● Some cerumen is usually present varying from grey-yellow to light brown and black, and the texture can vary from moist and waxy to dry and flaky
Inspection of Tympanic Membrane
Check for the color and characteristic
● Should be shiny and translucent with pearl grey coloration
● A cone-shaped light reflex is prominent in the anteroinferior quadrant
- at the 5:00 position in the right eardrum and at the 7:00 position in the left eardrum
● Sections of the malleus should be visible through the translucent eardrum (Umbo, manubrium, short process)
● The annulus should look shiny whiter and denser at the peripheral
Inspect using the Otoscope
● Note for the size of the auditory meatus
● Tilt the pt’s head slightly away and toward the opposite shoulder
● Hold the pinna gently and firmly (Adults pull up & back) (Children pull down age 3 years below)
● Hold the otoscope upside down along your fingers, and have the dorsa (back) along the pt’s cheek braced to steady the otoscope
Inspect using the Otoscope (External Canal)
● Note any redness, swelling, lesions, and foreign bodies or discharge
- If any discharge is present note the color and odor
● For a patient with a hearing aid, note any irritation on the canal wall from poorly fitting ear moulds
Test Hearing Acuity
Whispered Voice test
● Will test one ear at a time, must mask(cover) hearing in the other ear to prevent sound transmission
● Place the finger on the tragus and rapidly push it in and out of the auditory meatus
● Shield your lips so that the patient can’t compensate for hearing loss by lip reading or using a good ear
● With your head 30-60 cm away from the patient’s ear, exhale and whisper 2 syllable words such as “Tuesday” “baseball” and “fourteen”
Normal findings
● Patients can repeat each word correctly after the I say it
Test Vestibular Apparatus
Romberg Test
● Have the pt stand with feet together and arm at their sides
● Ask the pt to close their eyes and hold the position for 20 seconds
● Stand close to catch the pt in case they fall
Normal Findings
● Normally a person can maintain posture and balance even with visual orienting information blocked, although slight swaying may occur
Inspect External ocular structure
General
● Note for facial expression
● A relaxed expression accompanies adequate vision
Eyebrows
● Should be bilateral, move symmetrically as the facial expression changes
● Should not have any scaling or lesions
Eyelids and Lashes
● The upper eyelids normally overlap the superior part of the iris and approximate completely with lower eyelids when it is closed
● Note eyelashes are evenly distributed along the eyelid margins and curve outward
Eyeballs
● Should be aligned normally with their socket with no protrusion or sunken appearance
● Some people of African descent normally have a slight protrusion of the eyeball beyond the supraorbital ridge
Conjunctiva and Sclera
● Ask the pt to look up and use your thumbs to slide the pt lower eyelids down along the bony orbital rim
● The eyeball should be moist and glossy
● Small blood vessels normally show through the transparent conjunctiva
- Otherwise, conjunctiva are clear and show the normal color of structure: pink over the lower eyelids and white over the sclera
● Note any color change, swelling, or lesions
● The sclera is china white
● Ask pt to look down and use your thumbs to
slide the outer part of the upper eyelid up along the
bony orbit to expose under the eyelid.
● Inspect for any redness or swelling
● Normally, the puncta drain the tears into the lacrimal sac.
- Check this by pressing your index finger against the sac, just inside the lower orbital rim, not against the side of the nose.
- Pressure causes the lower eyelid to revert slightly, but no other response to pressure should occur.
Inspect the Anterior Eyeball structure
Cornea and Lens
● Shine a light from the side across the pt cornea, and check for smoothness and clarity
● No opacities (cloudiness) should appear in the cornea, the anterior chamber, or the lens behind the pupil
Iris and Pupil
● Iris normally appears flat, with a round regular shape and even coloration.
● Note the size, shape, and equality of the pupils
● Normally the pupils appear round, regular, and of equal size in both eyes.
- In adults, resting size is from 3 to 5 mm
Test the Anterior eyeball
Papillary light reflex
● Go to a dark room and ask the pt to gaze into the distance (this will dilate the pupils)
● Move the light in from the side and note the response:
- Constriction of the same side pupil (Direct light reflex)
- Simultaneous constriction of the other pupil (Consensual light reflex)
Accommodation
● Asking the pt to focus on a distant object (this dilates the pupils)
● Have the pt shift the gaze to a near object, such as your finger held about 7-8 cm
● Normal response includes a pupillary constriction and convergence of the axes of the eys
● Record normal responses and compare them to PERRLA (pupils equal, round, react to light, and accommodation)
Inspecting the Ocular Fundus
● Inspecting the inner deep part of the eye
● An ophthalmoscope enlarges your view of the eyes so you can inspect the media and the ocular fundus
Instructions:
● Instruct the pt to stare at a fixed point and to maintain the fixed gaze even if you enter the path of vision
● To examine the right eye, hold the ophthalmoscope in your right hand with the index finger on the lens wheel
● Begin with the lens on the 0 dioptres. With the light on and with the large round aperture place the ophthalmoscope over the right eye
● Place your left hand on the patient’s shoulder or head – your thumb can hold open the patient’s eyelid
● Stand at a slight angle lateral to the patient’s line of sight about 25 cm away from the patient
● Hold the ophthalmoscope against your head, directing the light into the patient’s pupil.
● As you look into the patient’s pupil you will see the red-light reflex.
● At this point you will need to adjust the lens wheel (dioptre) to bring the ocular structures into focus.
● Keep advancing toward the patient until the ophthalmoscope almost touches the patient’s eyelashes.
● Begin to look for the optic disc by following the path of blood vessels – as they grow larger they lead to the
optic disc.
Test Central Visual Acuity
Snellen Eye Chart
● Place the Snellen chart in a well-lit spot in the room at eye level
● Position the pt 20 feet away from the chart
● Give the pt a card to cover/shield one side of the eye during the test
● Remove reading glasses because it blurs distance vision
● Ask the pt to read through the chart to the smallest line of letters (encourage the patient to try the next smallest line in addition).
● Record results with -1 and -2 (indicates letters missed)
● Normal visual acuity is 20/20
- Top number indicates the distance the pt is standing from the chart
- Bottom number indicates the distance at which a normal eye could have read that particular line
Test Visual Fields
Confrontation Test
● This measures peripheral vision
● Position yourself at eye level wt the pt about 60 cm away.
● Direct the patient to cover one eye with an
opaque card and look straight at you with the
other eye.
● Cover your own eye opposite to the patient’s
covered one.
● Hold a pencil or flick a finger as a target midline between you and the pt and slowly advance it inward from the periphery in several directions
● Have the patient say ‘now’ when they see the target at 500 upwards, 900 temporal, 700 down, and 600 nasal
Extraocular muscle function
Corneal light reflex
● Assess the parallel alignment of the eye axes by shining a light toward the pt’s eye
● Direct the pt to stare straight ahead as you hold the light about 30 cm away
● Note the reflection of the light on the corneas it should be in the exact same spot in each eye
