What are the external structures of the eye?
Eyelids Lateral and medial canthus Eyelashes, conjunctiva Lacrimal apparatus Extraocular muscles
What are the internal structures of the eye?
Sclera, cornea, iris, ciliary body Pupil (3 to 5 mm) lens, choroid, retina, optic disc Physiologic cup, retinal vessels Anterior chamber, posterior chamber
What are risk factors for Cataracts?
Increasing age – developing at 30 years of age Exposure to ultraviolet B light Diabetes mellitus Cigarette smoking Alcohol use Diet low in antioxidant vitamins High blood pressure Eye injuries/surgery Steroid use Female gender Persistent diarrhea Gout Abdominal obesity Beta blocker use
What can you due to reduce risk for Cataracts?
Wear sunglasses Quit smoking Limit alcohol intake Avoid eye injuries Regular eye examinations
What is Cataracts?
clouding of the usually clear lens of the eye, causing a person to see as though looking through a frosty or foggy window.
What is Glaucoma?
an acute or chronic condition in which there is an increase of IOP which leads to damage of the retina and optic nerve, with resulting visual field loss.
What is referred to as the “silent thief of sight”
What is Macular Degeneration?
age-related macular degeneration is the primary cause of vision loss in older adults. Does not affect peripheral vision. Affects ventral vision, color perception and fine detail which affects reading, driving and seeing faces.
What is Diabetic Retinopathy?
occurs in both type 1 & type 2 diabetes. Caused by changes in the small blood vessels in the retina. Changes in the microvasculature include microaneurysms, intraretinal hemorrhage, hard exudates, and focal capillary closure. Is painless
What are sign and symptoms of Glaucoma?
gradual loss of peripheral vision, blurred vision, “halos” around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes and/or headaches
What are sign and symptoms of Macular Degeneration?
blurred vision, straight lines which appear crooked
What are sign and symptoms of Diabetic Retinopathy?
floaters or cobwebs in the visual field, sudden visual changes including spotty or hazy vision or complete loss of vision. Many patients are asymptomatic
What is the leading cause of blindness worldwide?
What equipment will you need for a physical assessment of the eyes?
Snellen or E chart Hand-held Snellen card or near-vision screener Penlight Opaque cards Ophthalmoscope
What score is normal for distant acuity with or without corrective lenses?
How do you get the top number of a visual acuity score?
By how many feet the client is from the chart ex. 20/20 is 20 ft from the eye chat
How do you get the bottom number of a visual acuity score?
It is the number found on the chart row of the smallest print that the patient can read.
What score is normal for near acuity with or without corrective lenses?
What is associated with optic atrophy, glaucoma, or Vitamin A deficiency?
What is diplopia?
Double vision which may indicate increased ICP due to an injury or tumor.
While assessing extraocular muscle function how would you conduct the corneal light reflex test?
use penlight to observe parallel alignment of light reflection on corneas. Asymmetric position of the light reflex indicated deviated alignment of the eyes, possibly due to muscle weakness or paralysis.
While assessing extraocular muscle function how would you conduct the Cover test?
use opaque card to cover an eye to observe for eye movement. Tests for deviations in alignment or strength or slight deviations in eye movement
While assessing extraocular muscle function how would you conduct the Positions test (6 Cardinal Fields of Gaze)?
observe for eyes to follow movement symmetrically. Assesses eye muscle strength and cranial nerve function.
During physical inspection of the eyelids and eyelashes you notice drooping of the upper lid may be due to oculomotor nerve (CN II) damage, myasthenia gravis, weakened muscle tissue or damage, or congenital disorder what is it?
while you observe the position and alignment of the eyeball in the eye socket you notice protrusion of the eyeballs accompanied by retracted eyelid marginsIs this characteristic of Graves’ disease and recognize it as what?
Redness or swelling around the puncta may indicate what?
an infectious or inflammatory condition
while palpate the lacrimal apparatus you expressed drainage from the puncta this indicates what?
blockage of the duct
Unequal size in the iris and pupil is always what kind of finding?
What test pupillary reaction to light?
Direct -shine a light on the pupil and watch for it to constrict Indirect –shine a light on the left pupil and watch for the right pupil to constrict
How do you test accommodation of pupils?
Accommodation of pupils occurs when the client moves focus of vision from far to near, causing the pupils to constrict. Normally, pupils constrict when they focus on a near object and dilate on a distant object.
How do you test test convergence ?
ask the client to maintain focus on your finger as you move it from 6 inches in front of her face to the tip of her nose. Watch for eyes to converge, or “cross” medially.
Pupillary constriction in response to indirect light is known as what?
list abnormalities of the external eye
Ptosis Exopthalmos Entropion Ectropion Chalazion Blepharitis Conjunctivitis Diffuse episcleritis Hordeolum
Optic nerve discs are larger in what nationality?
blacks, Asians, and Native Americans
what are common Nursing Diagnoses for an eye assessment?
Ineffective Health Maintenance R/T a lack of knowledge of necessity for eye examinations Self-care Deficit (must specify the deficit) related to poor vision Acute Pain R/T injury from eye trauma, abrasion, or exposure to chemical irritant Social Isolation R/T inability to interact effectively with others secondary to vision loss
Though usually abnormal, entropion and ectropion are common in who?
any reports of blind spots require what?
Immediate medical attention
when testing pupillary reaction to light what should you expect?
pupils are 3mm and equal in size
Presbyopia is common in who?
adults over 45
what are external structure of the ear?
external auditory canal-the external auditory canal is S-shaped in the adult
Tympanic membrane-has a translucent pearly gray appearance.
To examine the external auditory canal you must do what?
pull the auricale upward and back
what do the modified sweat glads in the external auditory cannal serete and what is purpose?
cermen and to keep the tympanic membrane soft which also has bacteriostatic properties that serves as as defense against foreign bodies
what are the structures of the middle ear?
Round and oval windows
Three auditory ossicles – the malleus, the incus, and the stapes
Eustachian tube – equalizes air pressure on either side of the tympanic membrane. Connects middle ear to the nasopharynx
What is the middle ear?
air filled chamber where sound waves are transmitted from the tympanic membrane to the inner ear.
What are the structures of the inner ear?
Labyrinth: bony and inner membranous labyrinth
Bony labyrinth: cochlea, vestibule, and semicircular canals
Spiral organ of Corti –sensory organ for hearing. Sensory receptors, located in the vestibule and in the membranous semicircular canals, sense position and head movements and help maintain both static and dynamic equilibrium.
Vestibular nerve and cochlear nerve: 8th cranial nerve
the inner ear is what?
What is Conductive hearing?
transmission of sound waves through the external and middle ear
What causes conductive hearing loss?
something blocks or impairs the passage of vibrations from getting to the inner ear. E.g. impacted cerumen, otitis media, foreign body, perforated tympanic membrane, drainage in the middle ear, or otosclerosis.
What is Sensorineural or perceptive hearing?
transmission of sound wave in the inner ear
What causes Sensorineural or perceptive hearing loss?
damage is located in the inner ear. E.g. organ of Corti, CN VIII (Vestibulocochlear/acoustic), or temporal lobe of the brain.
What are risk factors for hearing loss?
Aging, especially due to many years of exposure to sounds that can damage inner ear cells
Heredity, with genetics that are related to susceptibility to ear damage
Occupational loud noises as regular part of the working environment
Recreational noises and exposure to explosive noises
Ototoxic medications – can cause tinnitus or hearing loss
Illnesses, especially with fever
Cardiovascular risk factors
Genetic and family susceptibility
Hypoxia during birth
Rubella, syphilis or certain other infections in pregnant mother
Inappropriate use of ototoxic drugs during pregnancy
Neonatal jaundice, which can damage the otic nerve in a newborn baby
Infectious diseases such as meningitis, measles, mumps, and chronic ear infections in childhood as well as in later life
Head injury or injury to the ear
Wax or foreign bodies blocking the ear canal – can cause tinnitus
how do you conduct the whisper test?
Stand 1 to 2 feet behind the client
Have client occlude one ear canal
Whisper a two-syllable word such as "baseball" and ask client to identify the word
Repeat on the other ear, using a different word
Expected report – identifies whispered words
how do you conduct the webers test?
Activate a tuning fork and place it on top of the patient’s head or on the patient’s forehead
Ask patient, "Please tell me if you hear the sound better in one ear than the other or if you hear it equally in both ears."
what are the expected outcomes of the webers test?
hears sound equally in both ears
Conductive hearing loss – client hears the sound in the "poor" ear
Sensorineural hearing loss – sound is louder in the "good" ear
What does the Rinne test do?
compares air and bone conduction
How do you conduct the Rinne test?
Activate a tuning fork, and place the handle tip on the mastoid bone, just behind the auricle of one ear
Ask patient, "please tell me when you stop hearing the sound" and note the time interval
After patient stops hearing the sound, hold the tuning fork in front of the auricle of the ear, and say, "Tell me when the sounds stops" while noting the time interval
What is the expected outcome of the Rinne test?
air conduction is approximately twice as long as bone conduction. Cranial nerve VIII, Acoustic, hearing component intact
What is the Romberg test used for?
test of equilibrium
what do you have the client do durning a romberg test?
Ask the client to stand with feet together, arms at sides and eyes open, then with the eyes closed
durning a romberg test if the client moves the feet apart to prevent falling from a loss of balance it can indicate what?
a vestibular (inner ear) problem
what is Otitis media?
An ear infection is usually caused by bacteria or viruses
Presbycusis is common at what age?
What is Presbycusis
Presbycusis is the loss of hearing that gradually occurs in most individuals as they grow older.
What is postauricular cyst?
a blocked sbaceous gland
what is a Darwin tubercle?
it is clinically insignificant projection seen on the auricle, that should produce no discharge
when collecting data what question would you ask durning the lifestyle and health practices to determine if a clients is at risk for otitis externa?
do you spend a lot of time swimming or in the water?
How should you remove ear wax?
you should never insert anything it to the ear including cotton tipped swabs due to the chance of impacting it futher. you can use a moist washcloth to clean the outside of the ear 0r see a professional to remove wax only if there is an issue
What are structures of the mouth and oral cavity?
Hard and soft palates
Tongue and its muscles
Openings of the salivary glands
What are the structure of the throat?
what are the structures of the nose?
External portion covered with skin and an internal nasal cavity
External nose – bridge, tip, and two oval openings called nares
Internal nose –
superior, middle, and inferior turbinates
what are structures of the sinus?
frontal, maxillary, ethmoidal, and sphenoidal
what decreases the weight of the skull?
what equipment is needed for assessment of mouth, nose, throat, and sinuses?
Cotton gauze pads
Nasal speculum attached to otoscope
What is halitosis?
fruity or acetone breath is what?
Ammonia order is caused by what?
foul oder is caused by what?
oral or respiratory infection or tooth decay
fecal breath is cause by what?
a bowel obstruction
sulfur oder is caused by what?
end stage of liver disease
When assessing the lip you do what?
inspect and palpate for color, moistness, craking, lesions
When assessing the buccal mucosa what do you do?
inspect for color, intactness, lesions
while assessing the gums what should you inspect for?
inspect for color, lesions, erosion, bleeding
What is Gingivitis?
gums that are swollen, puffy, receding, sometimes tender, or that bleed easily.
what shoud you look for while inspecting and palpating the tongue?
dorsal,lateral and ventral surfuces for moistness, texture and consistency, size, symmentry,lesions, coating
while inspecting the salivary glands (Parotid, submandibular and sublingual glands) you are inspecting for what?
swelling and tumors
while inspecting the pharynx you are looking for what?
intactness,color, potnasal drainage, lesions
what are the gradings for the tonsils?
1+ tonsils are visible (normal)
2+ midway between the tonsillar pillars and uvula
3+ tonsils touch the uvula
4+ tonsils touch each other
how many teath do adults have?
28 teeth, but if the wisdom teeth are present 32
what is Herpes simplex type I?
also referred to as cold sores or fever blisters. Rash noted by a red base on which small blisters cluster. Is viral.
what is Cheilosis of lips?
painful inflammation and cracking of the corners of the mouth. Can occur on one or both sides of the mouth. Caused by yeast (Candida) infection
What is Leukoplakia
white patches or spots on the mucous membrane of the tongue or cheek. The spots are smooth, irregular in shape and size, hard, and occasionally fissured. Considered precancerous and require evaluation
what is Hairy leukoplakia?
patches that appear, usually on the side of the tongue, which are fuzzy
what causes a Smooth, reddish, shiny tongue without papillae?
vitamin B12 deficiency
What is thrush?
Candida albicans infection –white, raised, creamy, easily removable patches on the tongue and other oral mucosal surfaces
Fissures on the tongue are caused by what?
seen with dehydration
what is Black, hairy tongue?
benign medical condition characterized by elongated filiform lingual papillae with typical carpet-like appearance of the dorsum of the tongue.
What is Kaposi’s sarcoma lesions?
a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs. The patches are usually red or purple and are made of cancer cells and blood cells. See in HIV/AIDS patients.
what causes Nasal polyp?
Causes are chronic inflammation due to infection, allergies, drug sensitivity, or immune disorders
what is Perforated septum?
is a medical condition in which the nasal septum, the cartilaginous membrane dividing the nostrils, develops a hole or fissure.
when would you transillumnste the sinuses?
if tenderness was detected during palpation and precussion
How do you transillumnate the maxillary sinuses and the frontal sinus?
frontal sinus- hold a strong, narrow light source snugly under the eyebrows
maxillary sinus-hold a strong, narrow light source snuglyover the maxillary sinus and ask the client to open their mouth
absences of red glow indicates the sinus is filled with pus or fluid
what is crepitus?
a grating sound or sensation produced by friction between bone and cartilage or the fractured parts of a bone
what are common signs and symptoms of Sinusitis?
Drainage of a thick, yellow or greenish discharge from the nose or down the back of the throat
Nasal obstruction or congestion, causing difficulty breathing through your nose
Pain, tenderness and swelling around your eyes, cheeks, nose or forehead
Reduced sense of smell and taste
Aching in your upper jaw and teeth
Cough, which may be worse at night
Bad breath (halitosis)
Fatigue or irritability
when collecting health history data why would you ask if the client ever experiences nosebleeds ?
nosebleeds are most commonly due to dry nasal membranes and nose picking. Other causes may include acute and chronic sinusitis, allergies, anticoagulsnts, cocaine use, common colds, devisted septums, foreign body in the nose, nasal sprays
refer a cleint who experiences ferquent nosebleeds for futher evaluation
when useing an ophthalmscope for an eye examine what should you remeber?
always use the same eye of the one you are viewing so not to bump noses ex.your right eye to examine clients right eye
when the client moves the eye chart futher awy during a near visual acuity test this would indicate what?
presbyopia ( impaired near sided vision) caused by decreased accomodation