Eyes and Ears Special Senses. Eyes Review the function and structure of the eye

Eyes and Ears

Special Senses

Eyes

Review the function and structure of the eye.

A & P - External Eye

Lacrimal Apparatus

6 Extraocular Muscles

A & P - Internal Eye

Internal StructureOuter Layer

transparent cornea covers the iris sclera - protects and site for attachment of extraocular muscles

Middle Layer pupil - SNS =dilates. PNS= constricts, vitreous humor maintains shape,

Inner Layer retina- extension of optic nerve, receives light impulses to be transmitted to

occipital lobe Optic disc: vessels converge at center, yellow-orange in colour, round or oval,

physiologic cup within the disc (smaller lighter circle). Retinal vessels: paired artery &vein Fovea centralis -Macula: slightly darker pigment at center has the sharpest and

keenest vision due to cones and rods.

Visual Pathways

EYE

Health History

Subjective information

Health History

AgeInfant/Child

Peripheral vision intact in newborn Most neonates (80%) are born farsighted (gradually

decreases after 7 to 8 years) Macula (area of keenest vision) begins development by

4 months and is mature by 8 months. Decreased eye cordination at birth, eye movement

sometime sluggish to eyes

Health HistoryAge

Middle agePresbyopia(difficulty with near vision)Hypertensive RetinopathyVisual acuity diminished gradually after 50 yrs

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Health History

Age (cont’d) Elderly

Develop cataracts (lens opacity), glaucoma (increased ocular pressure) and macular degeneration (loss of central vision)Entropion, ectropionExternal eye changes: wrinkling and droopingDry eyes- Lacrimal glands involute: decreased

tear production, dryness and burning

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Health History

Gender- Female - dry eyesRace- Glaucoma (African Americans), melanona of

eye (Caucasians)Common chief complaints

Changes in visual acuity Pain Drainage Itching Dryness

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Health History

Characteristics of chief complaints Location Quality Associated manifestations Aggravating and alleviating factors Setting Timing

Past Health History

Medical: eye-specificSurgical: eye-specificMedicationsAllergiesInjuries and accidentsSpecial needsChildhood illnesses

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Past Health History

FamilySocial

Work environment

Health maintenance activities Diet Use of safety devices Health check-ups

Assessment of the EyeEquipment

Ophthalmoscope Penlight Vision charts Vision occluder

General approach Lighting Environment

Preparation for Physical Exam of the Eye

Position the client sitting up with the head at your eye level

Use orderly approach moving from the extraocular structures to the intraocular structure(1-6 p 348)

Visual Acuity

Assessment of Cranial nerve IIDistance vision - Use Snellen Chart N= 20/20

Myopia (nearsightedness) Amblyopia (loss of visual acuity due to uncorrected

strabismus= crossed eyed or DM,alcoholism, uremia)

Near vision - use Rosebaum or snellen card N = reading is possible at 14 inches until late 30-40s Hyperopia (farsightedness)

Color vision N = can id primary colors on snellen chart

Visual Fields

Confrontation technique

Assess all fields N= pt covers 1 eye,

use own visual field as control, can see stimulus at 90°temporally, 60°nasally, 50°superiority, 70°inferiority

Visual Fields

Types of defects (p352 image)

Hemianopsia Circumferential

blindness Unilateral blindness

External Eye and Lacrimal Apparatus

Eyelids- inspect N = symmetrical eyelids, can raise eyelids

symmetrically (CN 3) Abnormal findings

Ptosis (drooping of lid) Exophthalmos (protrusion of eyes out of orbit) Entropion(turning inward or inversion of lower lid) ectropion (outward turning of lower eyelid) hordeolum (acute localized inflammation- internal =

conjunctival side of lid, & external =sty)

External Eye and Lacrimal Apparatus

Lacrimal apparatus- inspect, palpate N = no enlgmt, no swelling or no redness, no

exudate and minimal tearing. No dischrg from punctum apon palpation.

Abnormal findings dacryoadenitis (acute inflammation of lacrimal gland) dacryocystitis - obstruction of lacrimal duct dt

inflammation

Extraocular Muscle Function CN III, IV, VI

Corneal light reflex (Hirschberg test)Cover/uncover testCardinal fields of gaze

Extraocular Muscle Function CN III, IV, VI

Corneal light reflex (Hirschberg test)

N= light reflex seen symmetrically in center of each eye Abnormal findings

due extraocular muscle weakness

• extropia (outward turning of eye

• esotropia (inward turning or eye)

Extraocular Muscle Function CN III, IV, VI

Cover/uncover test N= eyes are aligned,

no movement of either eye

Abnormal findings phoria =latent

misalignment of eye exists

Extraocular Muscle Function CN III, IV, VI

6 Cardinal fields of gaze N=both eyes move smoothly

and symmetrically in 6 fields of gaze & converge on the object as it converges on then nose

note : nystagmus= involuntary movement

Abnormal findings deviations from N

Anterior Segment StructuresConjunctiva- inspect

N= transparent, sm bld vessels, white Abnormal findings

conjunctiva, edema, lesions, foreign bodies,

Sclera -inspect N= white , sm bld vessels Abnormal findings

jaundice, blue (osteogenesis imperfecta-thinning of sclera)

Cornea- inspect with penlight N= corneal surface is moist, shiny Abnormal findings

presence of discharge, cloudiness, opacities, irregularities

Anterior Chamber

Iris Inspect the iris for color, nodules, vascularity

N=even color or mosaic, smooth no vascularity Shine light obliquely through the anterior chamber

from lateral side towards nasal chamber N=the entire iris will be illuminated Abnormal findings

hyphema (bleeding into iris dt trama)

Anterior Chamber

Pupil (CN III) darken room & note size and shape of pupil,

move penlight from side to front of eye, observe pupillary reaction

N=PERRLA N= direct light flex (pupil constrict with light) N= Consensual light reflex (move penlight in

front of one eye and observe other eye for pupillary constriction)

N = Accommodation (pupils constrict as converge onto closer object)

Abnormal findings anisocoria - sm diff in pupil size oculomotor nerve damage- a fixed and

dilated pupil is seen (see pg 363)

Anterior Chamber

Lens shine penlight directly into

pupil , note color of lens

N= transparent in color

Abnormal findings cataract- cloudiness or

opacity in the lens

Posterior Segment Structures

Assessment techniques

use of ophthalmoscope

Posterior Segment Structures

Retinal structures instruct pt to look at distant object use ophthalmoscope, shine into each eye

N= Red Reflex present (pupil appears red through ophthalmoscope)

N= observe intact optic disc (on nasal side of retina by following any retina vessel centrally)

Abnormal findings absent red reflex - dt cataract

Posterior Segment Structures

Macula move ophthalmoscope

towards ear (temporal lobe) and observe for black circle around fovea.

N= macula is darker, avascular area with a pinpoint reflective center known as the fovea centralis

Gerontological Variations

Changes in visual acuityPresbyopiaCataractsMacular degenerationGlaucoma

Review of Normal Findings

Visual acuity 20/20Near vision acuity at 14 inchesAble to identify all six colorsVisual fields intact

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Review of Normal Findings

Eyelids symmetrical; no drooping, infections, or tumors

No enlargement, swelling, or redness of the lacrimal apparatus

Light reflex is symmetrical in the center of each cornea

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Review of Normal Findings

Eyes aligned on cover/uncover testExtraocular eye movements intact in all

six fieldsBulbar conjunctiva is transparentPalpebral conjunctiva is pink and moist

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Review of Normal Findings

Sclera are white, without exudate, lesions, or foreign bodies

Cornea is moist, shiny, without discharge, cloudiness, or opacities

Entire iris is illuminatedColor of iris is evenly distributed

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Review of Normal Findings

Pupils are deep, black, round, and of equal diameter

Pupil size is 2–6 mmLens is transparentRed reflex is presentOptic disc is pinkish orangeMacula is darker, avascular

Ears

Review the function and structure of the Ear

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Anatomy and Physiology of the Ear

Three sections External ear Middle ear Inner ear

External ear Auricle or pinna

External, Middle, Inner Ear Structure

External Ear Structure

Middle Sar Structures

Air filled cavity Tympanic membrane Ossicles ( 3 tiny bones - malleus,

incus, stapes)

2 muscles involved in movement of ossicles- tensor tympani- pulls inward, stapedius - pulls outwards

Eustachian tube - connected to nasopharynx by the auditory canal (relieves air pressure within the middle cavity) see next slide

Inner Ear Structures

Controls hearing and equilibrium/balance closed fluid-filled system of

interconnecting tubes called the Labyrinth cochlea (snail shape structure containing

perilymph & endolymph which vibrate and stimulate vestibulocochlear nerve CNVIII)

semicircular canals (provide balance and equilibrium for the body)

vestibule (btwn cochlea & semicircular canals)

Frequency range of 20–20,000 Hz Decibel range 0–140

Pathways of Hearing

1. Air Conduction (AC): most efficient.

AC>BC

2. Bone Conduction (BC)

3. See OH

Ears

Health History

Subjective Data

Ears-Subjective Data**Note the following**

EaracheInfectionsDischarge (otorrhea)Hearing lossEnvironmental noise TinnitusVertigo Self care behaviours

What further information would you gather if the client is an infant and children?

Ear infections (how many, 1st one?)

Parent = 1. Does the child seem to have hearing loss?

2. Does the child put objects in the ears?

Ears – Physical Examination

Objective Data

Equipment

OtoscopeTuning fork

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Assessment of the Ear

Consists of three parts Auditory screening(CN VIII) Inspection and palpation of external ear Otoscopic assessment

Auditory Screening

Voice-whisper test instruct pt to occlude 1 ear with finger stand 2 feet behind the other ear and whisper ask pt to repeat whispered words

N= able to repeat words whispered at a distance of 2 feet

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Auditory Screening- Tuning fork tests

Weber test N= able to hear sound

equally in both ears

Abnormality Determines whether

hearing loss is conductive or sensorineural

Auditory Screening- Tuning fork tests

Rinne test Normal finding: air

conduction > bone conduction

Abnormality Determines whether

hearing loss is conductive or sensorineural

Hearing Loss

1. Central deafness: occurs with pathologic conditions above the junction of the acoustic nerve and the brain stem. E.G. brain tumor, vascular changes which deprive the inner ear of blood supply, CVA.

2. Conduction deafness: mechanical dysfunction of the external or middle ear. Partial loss (must increase amplitude). E.G. impacted cerumen, foreign bodies, perforated tympanic membrane, pus in middle ear.

3. Sensorineural deafness: pathology of the inner ear, CN VIII or auditory areas of the cerebral cortex. E.G. presbycusis (gradual nerve deterioration), ototoxic drugs (affect the hair cells in the cochlea)

External Ear

Inspection & Palpate Note position, size, color, and shape

N= flesh color, top of ear = to outer canthus of eye, cerumen is moist & does not obscure the tympanic membrane, no foreign bodies, redness, drainage, deformities, nodules, or lesions

Abnormal findings Pale, red, cyanotic Small-size or large-size ears Purulent drainage Clear or bloody drainage Hematoma behind ear over mastoid Pain or tenderness on palpation

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Otoscopic Assessment Inspect both external ear canal using

otoscope N= No redness, swelling, tenderness, lesions, drainage,

foreign bodies Tympanic membrane is pearly gray with well-defined landmarks Light reflex present at 5 o’clock in right ear and 7 o’clock in left

ear Tympanic membrane moves when patient blows against

resistance

Abnormal findings Chalky patches on tympanic membrane Severe pain Redness, swelling, narrowing, pain Drainage Hard, dry, very dark yellow cerumen Reddened tympanic membrane

Ear Abnormalities

Acute Otitis Media tympanic membrane is red

with decreased motility,and possible bulging due inflammation of middle ear

Chronic & Acute Otitis Externa redness, swelling, narrowing

and pain of external ear, drainage present due to inflammation of external ear

Risk Factors for Otitis Media

Less than 2 years of age Frequent upper respiratory infections Cold weather Male gender Caucasians, Native Americans, Alaska natives Family history Smoky environment Bottle fed Down syndrome

Ear Abnormalities

Tympanic Membrane Perforation due to untreated ear

infection secondary to increasing pressure or trama to the ear canal.

Equilibrium Abnormalities

Labyrinth becomes inflammed and sends the wrong information to the brain.

Which develops into what we call…..

Vertigo: staggering gait, strong spinning, whirling sensation.

Developmental Considerations

Infants/Children Rubella in 1st trimester can damage the organ of

Corti and impair hearing Eustachian tube is shorter and wider, position is

more horizontal than the adult’s Greater risk for ear infection External auditory canal is shorter and sloped is

opposite to the adult’s

Developmental Considerations

Aging Adult Cilia becomes coarse and stiff Cerumen is dryer and impaction is a common

reversible cause of hearing loss. Presbycusis occurs with aging “50s” (nerve

degeneration in the inner ear or auditory nerve) “70s” takes longer to process sensory input and

to respond to it.

Transcultural Considerations

Otitis Media (OM) incidence and severity increased in Native Americans, Alaskan and Canadian Inuits & Hispanics.

Also increased in premature infants and those with Down Syndrome, and bottle fed babies in supine position.