King Saud University
College of Nursing
Health Assessment (NUR 224)
Eyes, Ears, Mouth, & Nose
1
ObjectivesAfter completion of this presentation, the nurse will be able to:
Conduct a basic adult eyes, ears, mouth, and nose assessment.
Distinguish normal from abnormal findings
Techniques Inspection
Palpation
Eye
Anatomy Eyes are protected by orbital cavity.
Eyelids protect the eyes from injury, strong light, and
dust.
Eyelashes filter the dust and dirt.
Conjunctiva is a thin mucus membrane between the
eyelid and the eye ball.
Cornea protects and covers the iris and pupils.
Lacriminal Apparatus cover the eye and secrets tears to
keep the conjunctiva and cornea moist and lubricated.
Anatomy (cont.)
Extraocular muscle, are six muscles to orbit eyes.
Each muscle is coordinated with the other muscle in
the other eye.
Three cranial nerves (CN) control the eye movements.
Cornea is bending the incoming light rays so and
make them focused on retina.
Cornea sensitive to light and blink when contacted
with an object (CN V, VII)
Eyes - Inspection Position and alignment of eyes
Eyebrows Quantity, distribution
Eyelids Edema, color, lesions
Conjunctiva and sclera color, vascular pattern
Cornea and lens
Iris
Pupils – size, shape, symmetry, reaction to light
Eyes Are there 2Loss of visionPainDisorders
Strabismus, diplopia
Discharges / Redness / SwellingProsthesisPast historyGlasses / contact lens
ABNORMALITITESPtosis
drooping of the eye lid
Blepharitis
inflammation of eyelids
Sty or Hordeolum
Staphylococcal infection of hair follicles at lid
margin
Abnormal Facial Features
Tics
Abnormal facial movements
Exopthalomus
Prominent eyes
Acromegaly
Gradual enlargement of the bones of the face &
jaws
Conjunctivitis
Trauma
Cyst
Inspect Conjunctiva & ScleraAsk the person to look up.Using your thumbs, slides the lower lids down along
the bony orbital rim.Both should be clear
Visual Acuity
Snellen Eye Chart Distance/Central vision: position patient 20
feet (6 meters) from the charto Patient may wear glasses and contact lens,
but remove the reading glasses.o Test one eye at a time.o Start from the biggest lines to the smallest
lines.
Visual Acuity Near vision
Used for people over 40 years of age or for those
who report difficulty reading.
You can use Jaeger or Rosenbaum chart (hand-
held card).
Can also use to test visual acuity at the bedside.
Hold 14 inches (about 30 cm) from patient’s eyes.
Rosenbaum chart
Jaeger chart
Confrontation Test
Range of peripheral vision:
o The client should be sitting 60-90 cm from you and at eye level
o Test one eye at a time
o The client’s peripheral visual fields are compared to that of the examiner.
o This test assumes the examiner has normal peripheral vision.
o Ask the person to say “now” when see the object.
Extraocular movements
• The client must keep the head still while following a pen that you will move in several directions to form a star in front of the client’s eyes.
• Always return the pen to the center before changing direction.
• Note for:
Strabismus (deviation)
Nystagmus: involuntary eye movement
Diplopia: 2 images for a single objet.
Developmental ConsiderationsAging Adult
Have changes in eye structureSkin looses elasticityDecreased tear productionPupil size decreasesLens looses elasticityWith older people
Increase cataract formationGlaucoma or increased ocular pressureMacular degeneration
Tips for Using the Ophthalmoscope
It use to look into the inner deep part of the eye (fundus)Darken the room and have the patient look off in the distanceSwitch the ophthalmoscope light and turn the lens disc to the large
round beam of white lightTurn lens disc to the 0 diopterHold the ophthalmoscope in your right hand to examine the patient’s
right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye
Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision
Shine the beam of light onto the pupil and look for an orange glow; this is the red reflex
Follow the red reflex and move inward towards the nasal aspect of the visual field
Tips for Using the Ophthalmoscope
It use to look into the inner deep part of the eye (fundus)Darken the room and have the patient look off in the distanceSwitch the ophthalmoscope light and turn the lens disc to the large
round beam of white lightTurn lens disc to the 0 diopterHold the ophthalmoscope in your right hand to examine the patient’s
right eye with your right eye; hold it in your left hand to examine the patient’s left eye with your left eye
Stand directly in front of the patient, 15 inches away, and start at an angle of 15 degrees lateral to the patient’s line of vision
Shine the beam of light onto the pupil and look for an orange glow; this is the red reflex
Follow the red reflex and move inward towards the nasal aspect of the visual field
Ears
EarsEaraches Discharge/odor Hearing LossTinnitusVertigo
MicrotiaMacrotia
Ears – InspectionInspection
Auricle for redness, lesions
Ear canal
o Discharge, foreign bodies, redness, swelling
Tympanic membrane (by Use otoscope )
o Color, contour
Palpation
Auricle for lumps, tenderness
Straightening the Ear Canal and Inserting the Speculum
Tophi
Ears – Hearing acuityTest one ear at a time
Whisper test
Ask the client to occlude the other ear or the ear may be
occluded by the nurse.
Cover your mouth so the client cannot see your lips
Standing 30-60cm behind patient, softly say “nine-four,”
“baseball”
Ask the client to repeat the phrase.
Ears – Hearing acuity
Rinneo Compare time of air vs. bone conduction
o Place the base of the tuning fork on the client’s mastoid process- and note the number of seconds.
o Then move the fork in front the external auditory meatus (1-2 cm)
o If bone conduction is equal or greater than air conduction, then suspect conductive hearing loss
Ears – Hearing acuity
Weber
o Lateralization of sound to impaired ear;
suspect unilateral conductive hearing loss
Ears –
Romberg test:
Ask the patient to remain still and close their eyes (for about 20 seconds).
If the patient loses their balance, the test is positive.
Nose – Inspection/PalpationInspectionSize, shapeSymmetry Lesions/signs of infectionPatency testSeptum (by use nasal speculum)-deviation, inflammation or perforation
Palpate for tenderness, swelling
Assess Nose for Symmetry, Edema, and Air Passage
Mucous membranes
Sores / Lesion
Tonsils
Sore throat
Gums
Teeth
Mouth / Tongue/ Teeth / Throat
Mouth and Pharynx - Inspection
Lips Note color, moisture,
lumps, ulcers, cracking
Gums and teethNote color, presence and
position of teeth
Roof of mouthNote color
Tongue and floor of mouth Note color and texture,
ulcers
uvula, tonsils, pharynxNote color, symmetry,
presence of exudate, swelling, ulceration or tonsillar enlargement
Gingivitis
Glossitis
The Mouth and Gums
Under the Tongue
Above and behind the tongue
Abnormal
Normal CN X
Say “AAHHH”
Tonsillitis Peritonsilar Abscess
Is the tongue moist and pink?
….underneath
Assess both top and….
Oral Herpes Simplex
Assess Outside of Mouth and Lips for Color, Moisture, and Abnormalities
Place your hands on both sides of the lower jaw and ask the patient to clench his teeth. Should be able to feel same muscle tension bilaterally
CN V
Ask the patient to stick his tongue straight out of his mouth.
CN XII
Summary Abnormalities
Eyes Visual disturbances, use of corrective lenses, pain, redness, excessive tearing, double vision (diplopia)
Ears Hearing loss, ringing (tinnitus), vertigo, pain, discharge
Nose Drainage (rhinorrhea), congestion, sneezing, nose bleeds (epistaxis)
Mouth Swelling, ulceration or tonsillar enlargement
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Question?