Physical Examination of the Eyes and Ears - PowerPoint Presentation

Slide1

Physical Examination of the Eyes and Ears

Slide2

Specific Objectives

Slide3

Lacrimal glands of the eye.

Slide4

Lacrimal glands of the eye.

Slide5

Subjective Data - Health History Questions

Slide6

Testing Central Visual Acuity

Snellen Eye Chart

Slide7

The Snellen chart is the most commonly used and accurate measure of visual acuity.

It has lines of letters arranged in decreasing size.

Normal visual acuity is 20/20.

Steps:

Place the Snellen chart in a well-lit spot at eye level. (The client may be standing or seated).

Position the client on a mark 20 feet from the chart.

Hand the client an opaque card (eye cover) with which to shield one eye a time during the test.

Tell the client to read, left to right, from the top of the chart to the smallest line of letters that the client can see.

Ask the client to cover the other eye and to read from top of the chart to the smallest line of letters that the client can see.

Ask the client to read from the chart down to the smallest line of letters that the client can see

with both eyes uncovered

.

If the client uses corrective lenses for distance vision, test first with eyeglasses or contact lenses. Then test without glasses or contact lenses.

Slide8

If the client is unable to read more than half of the letters on a line, record the number of the line above.

If visual acuity is even lower, assess whether the client can count your fingers when they are spread in front of the eyes or distinguish light perception from your penlight.

Document the results as a fraction.

The numerator indicates the distance from the chart.

The denominator indicates the distance at which a client with normal vision can read the last time.

Thus “20/30” means, “you can read at 20 feet what the normal eye could have read at 30 feet.”

Indicate whether the client missed any letters or if corrective lenses were worn

Report any abnormal findings.

Slide9

Confrontation Test

This is a gross measure of peripheral vision.

It compares the client’s peripheral vision with your own, assuming yours is normal.

Steps:

Position yourself at the eye level with the client at about 2 feet away.

Ask the client to hold the head steady.

Ask the client to cover one eye with an opaque card.

Ask the client to look by the other eye directly straight at you.

Close your eye opposite to the client's covered one.

Slide10

Ask the client to say “Now” or “Yes” as a pencil or your flicking finger is first seen in the midline between you and the client.

Slowly advance it from periphery in several directions (superior, inferior, nasal, and temporal).

Slide11

Estimate the angle between the anteroposterior axis of the eyes and the peripheral axis where the object is first seen. Compare it with normal peripheral vision angles, assuming yours is normal.Apply the test to the other eye.Document the findings.Report any abnormal findings.

Slide12

Inspect Extraocular Muscle Function

1.

Corneal Light Reflex (The Hirschberg test)

This test assesses the parallel alignment of the eye axes by shining a light toward the client’s eyes.

Steps:

Ask the client to stare straight ahead.

Hold the light about 30 cm away.

Note the reflection of the light (i.e., the bright white dots) on the corneas.

Document the reflection of the light on the corneas. Normally, the reflection of the light on the corneas is on exactly the same spot on each eye.

Report any abnormal findings.

Slide13

3.

The Six Cardinal Fields of Gaze (also known as Diagnostic Positions Test)Leading the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement.Steps:Ask the patient to hold the head steady and follow the movement of your finger, pen, or penlight only with the eyes.Hold the target (e.g. pen) back about 30 centimeters so the client can focus on it comfortably.Move the target through the six positions, hold it momentarily, then back to center. Progress clockwise.To the right and upward.To the right.Down to the right.Down to the left.To the left.To the left and upward

Slide14

Note parallel tracking of the target with both eyes.

Note the upper eyelid continues to overlap the superior part of the iris, even during downward movement.

Note any nystagmus (i.e., rapid fluttering of the eyeball). Mild nystagmus at extreme lateral gaze is normal. Nystagmus at any other position is not.

Note any white rim of sclera between the lid and the iris. If noted, it is termed "lid lag".

Document the findings.

Report any abnormal findings.

Slide15

INSPECT EXTERNAL OCULAR STRUCTURES

Begin with the most external points, and logically work your way inward.

1.

General

Already you will have noted the client’s ability to move around the room, with vision functioning well enough to avoid obstacles and to respond to your directions.

Also note the facial expression; a relaxed expression accompanies adequate vision.

Slide16

2.

Eyebrows

Normally the eyebrows are present bilaterally, move symmetrically as the facial expression changes, and have no scaling or lesions.

3.

Eyelids and Lashes

 

The upper lids normally overlap the superior part of the iris, and approximate completely with the lower lids when closed. The skin is intact without redness, swelling, discharge, or lesions.

The palpebral fissures are horizontal in non-Asians, whereas Asians normally have an upward slant.

Note that the eyelashes are evenly distributed along the lid margins and curve upward.

 

Slide17

4.

Eyeballs

The eyeballs are aligned normally in their sockets with no protrusion or sunken

appearance.

.

Conjunctiva and Sclera

Ask the client to look up.

Using your thumbs, slide the lower lids down along the bony orbital rim. Take care not to push against the eyeball.

Inspect the exposed area.

The eyeball looks moist and glossy.

Numerous small blood vessels normally show through the transparent conjunctiva. Otherwise, the conjuctivae are clear and show normal color of the structure below – pink over the lower lids and white over the sclera.

Note any color change, swelling, or lesions.

The sclera is china white.

Slide18

6.

Eversion of the Upper Lid

This maneuver is not part of the normal examination, but it is useful when you must inspect the conjunctiva of eth upper lid, as with eye pain or suspicion of a foreign body.

Most people are apprehensive of any eye manipulation. Enhance their cooperation by using a calm and gentle, yet deliberate approach.

Slide19

Steps:Ask the client to keep both eyes open and look down. This relaxes the eyelid, whereas closing it would tense the orbicularis muscle.Slide the upper lid up along the bony orbit to lift up the eyelashes.Grasp the eyelashes between your thumb and forefinger and gently pull down and outward.With your other hand, place the tip on an applicator stick on the upper lid above the level of the internal tarsal plates.

Slide20

Gently push down with the stick as you lift the eyelashes up. This uses the edge of the tarsal plate as a fulcrum and flips the lid inside out. Take special care not to push in on the eyeball.

Secure the everted position by holding the eyelashes against the bony orbital rim.

Inspect for any color change, swelling, lesion, or foreign body.

To return to normal position, gently pull the eyelashes outward as the client look up.

Slide21

7. Lacrimal ApparatusAsk the client to look down.With your thumbs, slide the outer part of the upper lid up along the bony orbit to expose under the lid.Inspect for any redness or swelling.Normally, the puncta drain the tears into the lacrimal sac.Presence of excessive tearing may indicate blockage of the nasolacrimal duct.Check this by pressing the index finger against the sac, just inside the lower orbital rim, not against the side of the nose.Pressure will slightly evert the lower lid, but there should be no other response to pressure.

Slide22

Inspect Anterior Eyeball Structures

1.

Cornea and Lens

Shine a light from the side across the cornea, and check for smoothness and clarity.

This oblique view highlights any abnormal irregularities in the corneal surface.

There should be no opacities (cloudiness) in the cornea, the anterior chamber, or the lens behind the pupil.

Slide23

2.

Iris and Pupil

The 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 the adult, resting size is from 3 to 5 mm.

Although they may be normal (at 5%), all unequally sized pupils (called anisocoria) call for a consideration of central nervous system injury.

Slide24

3a.

Pupillary Light Reflex Test

Pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina.

Steps:

Darken the room.

Ask the client to gaze into the distance. (This dilates the pupils.)

Advance a light in from the side. Note the response.

Normally, you will see (1) constriction of the same-sided pupil (a direct light reflex), and (2) simultaneous constriction of the other pupil (a consensual light reflex). The resting size is 3, 4, or 5 mm (yet equal-sized pupils) and decreases equally in response to light.

Gauge the pupil size in millimeters, both before and after the light reflex.

Record the findings. An Example: R 3/1 = 3/1 L. This indicates that both pupils measure 3 mm in the resting state and that both constrict to 1 mm in response to light.

Slide25

3b. Accommodation Test Ask the client to focus on a distant object. This process dilates the pupils.Have the client shift the gaze to a near object, such as your finger held about 7 to 8 cm from the nose. A normal response includes (1) pupillary constriction and (2) convergence of the axes of the eyes.

Record the response to all of these maneuvers. An Example:

PERRLA

, or Pupils Equal, Round, React to Light, and Accommodation.

Report any abnormal findings.

Slide26

Inspect the Ocular Fundus

The ophthalmoscope enlarges your view of the eye so you can inspect the media (anterior chamber, lens, vitreous) and the ocular fundus (the internal surface of the retina).

It accomplishes this by directing a beam of light through the pupil to illuminate the inner structures. Thus, using the ophthalmoscope is like peering through a keyhole (the pupil) into an interesting room beyond.

Slide27

The ophthalmoscope should function as an appendage of your own eye. This takes some practice.

Practice holding the instrument and focusing at objects around the room before you approach a “real” client.

Hold the ophthalmoscope right up to your eye, braced firmly against the cheek and brow.

Extend your index finger onto the lens selector dial so that you can refocus as needed during the procedure without taking your head away from the ophthalmoscope to look.

Now look about the room, moving your head and the instrument together as one unit.

Keep both your eyes open; just view the field through the ophthalmoscope.

Slide28

Recall that the ophthalmoscope contains a set of lenses that control the focus. The unit of strength of each lens is the diopter.

The black numbers indicate a positive diopter; they focus on objects nearer in space to the ophthalmoscope.

The red numbers show a negative diopter and are for focusing on objects farther away.

To examine a client, darken the room to help dilate the pupils. Remove eyeglasses for yourself or the client.

Set the large round aperture with the light on. The light must have maximum brightness.

Tell the client, “Please keep looking at that light switch (or mark) on the wall across the room, even though my head will get in the way.”

Starting at a distant fixed object helps to dilate the pupils and to hold retinal structures still.

Slide29

Place your free hand on the client’s shoulder or forehead. This helps orient you in the space, because once you have the ophthalmoscope in position, you only have a very narrow range of vision. Also, your thumb can anchor the upper lid and help prevent blinking. Match sides with the client. That is, hold the ophthalmoscope in tour right hand up to your right eye to view the client’s right eye. You must do this to avoid bombing noses during the procedure.

Slide30

Begin about 25 cm away from the client at an angle about 15 degrees lateral to the client’s line of vision. Note the red glow filling the client’s pupil. This is the

red reflex

, caused by the reflection of your ophthalmoscope light off the inner retina.

Keep sight of the red reflex, and steadily move closer to the eye.

If you lose the red reflex, the light has wandered off the pupil and onto the iris or sclera. Adjust your angle to find it again.

As you advance, adjust the lens to +6 and note any opacity in the media. These appear as dark shadows or black dots interrupting the red reflex. Normally none is present.

Slide31

Progress toward the client until your foreheads almost touch.

Adjust the diopter setting to bring the ocular into sharp focus.

If you and the client have normal vision, this should be at 0.

Moving the diopters compensates for nearsightedness or farsightedness.

Use red lenses for nearsighted eyes, and the black for farsighted eyes.

Slide32

The retinal structures viewed with an ophthalmoscope are the optic disc, the retinal vessels, the general background, and the macula.

The most prominent landmark is the

optic disc

, located on the nasal side of the retina. Explore these characteristics:

Color: creamy yellow-orange to pink.

Shape: round to oval.

Margins: distinct and sharply demarcated, although the nasal edge may be slightly fuzzy.

Slide33

Retinal Vessels

Follow a paired artery and vein out to the periphery in the four quadrants.

 

The General Background of the Fundus

The color normally varies from light red to dark brown-red.

Macula

A bright light on it causes some watering and discomfort and pupillary constriction.

Its normal color is somewhat darker than the rest of the fundus but is even and homogenous.

Slide34

Assessment of the Ears

Slide35

Specific Objectives

By the end of this presentation, each student should:

Identify the anatomic landmarks of the ear.

Describe the tympanic membrane and its anatomic landmarks.

Collect subjective and objective data to the ears and hearing.

Identify health history questions for assessment of the ears.

Differentiate between normal and abnormal assessment findings when assessing the ears.

Slide36

The Anatomical Landmarks of the External Ear

The external ear, called the auricle or pinna, has six anatomical landmarks: the helix, antihelix, external auditory meatus, tragus, antitragus, and lobule.

The landmarks are used as reference points when one is documenting findings.

Slide37

The Tympanic Membrane and its Anatomical Landmarks

The tympanic membrane, or eardrum, separates the external and middle ear.

It is translucent with a pearly gray color.

On inspection with an otoscope, a prominent cone of light is visible—a reflection of the otoscope light.

The malleus pulls at the center of the ear, causing it to appear oval and slightly concave

.

The umbo, almost in the center, the most depressed point, is the location of the attachment of the first ossicle; the pars flaccid is the small, slack, superior section of the membrane, and the remainder of the drum, which is thicker and more taut, is the pars tensa.

The thickened border is the annulus.

Slide38

The Functions of the Middle Ear

The middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear and protects the inner ear by reducing the amplitude of loud sounds.

The Eustachian tube allows equalization of air pressure on each side of the tympanic membrane.

The Functions of the Inner Ear that can be Assessed

The ear transmits sound and converts its vibrations into electrical impulses, which can be analyzed by the brain.

The inner ear contains the bony labyrinths

, which hold the sensory organs for equilibrium and hearing.

Although the inner ear is not accessible to direct examination, its function can be assessed

.

Slide39

The Types of Hearing Loss

Anything that obstructs the transmission of sound impairs hearing.

Hearing loss may be (1) conductive, (2) sensorineural, or (3) mixed (conductive and sensorineural).

Conductive hearing loss involves a mechanical dysfunction of the external or middle ear.

If the sound amplitude is increased enough, the person is able to hear.

Cerumen buildup and otosclerosis

are two possible causes of this type of hearing loss.

Sensorineural

or

perceptive

hearing loss indicates a pathological condition of cranial nerve VIII.

Presbycusis

a gradual degeneration of the nerve that occurs with aging, may be the cause.

When hearing loss is the result of both conductive and sensorineural causes, the loss is referred to as mixed.

Slide40

Subjective Data - Health History Questions

Earaches

Infections

Discharge

Hearing loss (Any degree of impairment of the ability to apprehend sound.)

Environmental noise

Tinnitus

طنين

(Ringing or buzzing in the ears.)

Vertigo

دوار

(A sensation of whirling

التفاف

and loss of balance.)

Self-care behaviors

Slide41

Step 1: Position the client

The client should be in a sitting position.

Lighting must be adequate to detect skin color changes, discharge, and lesions.

Step 2: Instruct the client

Explain that you will be carrying out a variety of assessments of the ear.

Tell the client you will be touching the ear areas, and it should cause no discomfort, and that no pain or discomfort should be reported.

Slide42

Step 3: Inspect the External Ear

Size and Shape:

The ears are of equal size bilaterally with no swelling or thickening.

Skin Condition:

The skin color is consistent with the person’s facial skin color.

The skin is intact, with no lumps or lesions.

The External Auditory Meatus:

Note the size of the opening to direct your choice of speculum for the otoscope.

No swelling, redness, or discharge should be present.

Some cerumen is usually present. The color varies from gray-yellow to light brown and black, and the texture varies from moist and waxy to dry and desiccated.

A large amount of cerumen obscures visualization of the canal and drum.

Slide43

Step 5:

Inspect with the Otoscope

As you inspect the external ear, note the size of the auditory meatus. Then choose the largest speculum that will fit comfortably in the ear canal and attach it to the otoscope. Tilt the person’s head slightly away from you toward the opposite shoulder. This method brings the obliquely sloping eardrum into better view.

Pull the pinna up and back on an adult or older child. This helps straighten the S-shape of the canal.

Hold the pinna gently but firmly.

Do not release traction on the ear until you have finished on the examination and the otoscope is removed.

Slide44

Hold the otoscope “upside down” along your fingers and have the dorsa (back) of your hand along the person’s cheek braced to steady the otoscope. Insert the speculum slowly and carefully along eh axis of the canal. Watch the insertion; then put your eye up to the otoscope. The inner two thirds of the ear are very sensitive and pressing the speculum against either side of the auditory canal will cause pain.

Slide45

Sometimes you cannot see anything but canal wall. If so, try to re-position the person’s head, apply more traction on the pinna, and re-angle the otoscope to look forward toward the person’s nose.

Once it is in place, you may need to rotate the otoscope slightly to visualize the entire eardrum; do this gently.

Lastly, perform the otoscope examination before you test hearing; ear canals with impacted cerumen give the erroneous impression of pathologic hearing loss.

Slide46

Structure 1. The External Canal

Note any redness and swelling, lesions, foreign bodies, or discharge.

If any discharge is present, note the color and odor.

Structure 2. The Tympanic Membrane

2A.

Color and Characteristics.

Systematically explore its landmarks. The normal eardrum is shiny and translucent, with a pearl-gray color. The cone-shaped light reflex is prominent in the anteroinferior quadrant (at 5 o’clock in the right drum and 7 o’clock in the left drum). This is the reflection of your otoscope light. Sections of the malleus are visible through the translucent drum: the umbo, manubrium, and short process.

At the periphery the annulus looks whiter and denser.

Slide47

2B.

Position.

The eardrum is flat, slightly pulled in at the center and flutters when the person performs the Valsalva maneuver or holds the nose and swallows (insufflation).

You may elicit these maneuvers to assess drum mobility.

2C. Integrity of Membrane.

Inspect the eardrum and the entire circumference of the annulus for perforations. The normal tympanic membrane is intact.

Some adults may show scarring, which is a dense white patch on the drum. This is a sequela of repeated ear infection.

Slide48

Step 6: Test Hearing Acuity

1.

Whispered Voice Test

This test evaluates hearing acuity of high-frequency sounds.

It evaluates one ear at a time while masking hearing in the other ear to prevent sound transmission around the head.

Steps:

Ask the client to occlude the left ear or the ear may be occluded by the nurse. This is done by placing one finger on the tragus and rapidly pushing it in and out of the auditory meatus.

Cover your mouth so that the client cannot see your lips.

Standing at the client’s side at a distance of 30 to 60 cm from the person’s ear, whisper a simple two-syllable word, such as Tuesday, armchair, baseball, or fourteen. Normally, the person repeats each word correctly after you say it.

Then do the same procedure to test the right ear using a different two-syllable word.

The client should be able to repeat the words correctly. Inability to repeat the words may indicate a loss of the ability to hear high-frequency sounds.

Document the findings.

Report any abnormal findings.

Slide49

2.

Tuning Fork Tests

Tuning forks are used to evaluate auditory acuity.

The tines of the fork, when activated, produce sound waves. The frequency, or cycles per second (cps), is the expression used to describe the action of the instrument.

A fork with 512 cps vibrates 512 times per second and is the size of choice for auditory evaluations.

The tines are set into motion by squeezing, stroking, or lightly tapping it against your hand. The fork must be held at the handle to prevent interference with the vibration of the tines.

Air conduction (AC) is the transmission of sound through the tympanic membrane to the cochlea and auditory nerve.

Bone conduction (BC) is the transmission of sound through the bones of the skull to the cochlea and auditory nerve.

The AC is usually the more sensitive route.

Slide50

2A. Perform the Weber test

The Weber test uses bone conduction to evaluate hearing in a person who hears better in one ear than in the other.

Steps:

Hold the tuning fork by the handle and strike the fork on the palm of the hand.

Place the base of the vibrating fork against the client’s skull.

The midline of the anterior portion of the frontal bone is used. The midline of the forehead is an alternative choice.

Ask the client is the sound is heard equally on both sides, or better in one ear than the other.

The normal response is bilaterally equal sound, which is recorded as “no lateralization” or “negative Weber test”.

If the sound is lateralized, ask the client to tell you which ear hears the sound better. As an example, the abnormal findings are recorded as “sound lateralizes to right ear”, or “sound lateralizes to left ear”, as applicable.

Document the findings.

Report any abnormal findings.

Slide51

2B. Perform the Rinne test

The Rinne test compares air conduction and bone conduction sound.

Steps:

Hold the tuning fork by the handle and gently strike the fork on the palm of your hand to set it vibrating.

Place the base of the fork on the client’s mastoid process

Ask the client to tell you (or do a signal by a finger) when the sound is no longer heard.

Note the number of seconds.

Then immediately move the tines of the still-vibrating fork in front of the external auditory meatus. It should be 1 to 2 cm from the meatus.

Ask the client to tell you again when the sound is no longer heard.

Slide52

Again note the number of seconds.

Normally, the sound is heard twice as long by air conduction than by bone conduction after bone conduction stops. For example, a normal finding is AC 30 seconds, BC 15 seconds. A normal response is called positive Rinne test.

Repeat with the other ear.

Document the findings.

Report any abnormal findings.

Slide53

Review Questions

1.

Peripheral vision is evaluated by the nurse using the:

Corneal light test.

Cover test.

Confrontation test.

Cardinal fields of gaze test.

2.

The nurse assesses the response of the eye to light and documents normal findings as:

A. PEERLA.

B. PERRLA.

C. PERLLA.

D. PERLAA.

Slide54

Tinnitus is described as:

I

nability

to hear well.

Dizziness.

Ringing in the ear.

Ear pain.

Slide55