Health Assessment (NUR 230)

Eyes, Ears, Mouth, & Nose

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 Objectives
After 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  Cornea and lens

 Eyebrows
 Iris
 Quantity, distribution

 Eyelids  Pupils – size, shape, symmetry,

 Edema, color, lesions
reaction to light
 Conjunctiva and sclera
 color, vascular pattern
 Eyes
 Are there 2
Loss of vision
Pain
Disorders
Strabismus, diplopia
Discharges / Redness / Swelling
Prosthesis
Past history
Glasses / contact lens
ABNORMALITITES
Ptosis

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
 Trauma
Conjunctivitis

Cyst
 Inspect Conjunctiva & Sclera
 Ask 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 chart
o 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.
 Jaeger chart
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
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 Considerations
Aging Adult
Have changes in eye structure
Skin looses elasticity
Decreased tear production
Pupil size decreases
Lens looses elasticity
With older people
 Increasecataract formation
 Glaucoma or increased ocular pressure

 Macular 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 distance
 Switch the ophthalmoscope light and turn the lens disc to the large round beam of
white light
 Turn lens disc to the 0 diopter
 Hold 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 distance 
Switch the ophthalmoscope light and turn the lens disc to the large round beam of 
white light
Turn lens disc to the 0 diopter 
Hold 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
Ears
Earaches
 Discharge/odor
 Hearing Loss
Tinnitus
Vertigo

Microtia
Macrotia
 Ears – Inspection
Inspection
 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 acuity
Test 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

Rinne
o 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/Palpation
Inspection
Size, shape
Symmetry
Lesions/signs of infection
Patency test
Septum (by use nasal speculum)-deviation, inflammation or
perforation

Palpate for tenderness, swelling

Assess Nose for Symmetry, Edema, and Air
Passage
Mouth / Tongue/ Teeth / Throat
Mucous membranes

Sores / Lesion

Tonsils

Sore throat

Gums

Teeth
Mouth and Pharynx - Inspection
Lips Tongue and floor of mouth
Note color, moisture, Note color and texture,
lumps, ulcers, cracking ulcers
Gums and teeth
Note color, presence and uvula, tonsils, pharynx
position of teeth Note color, symmetry,
presence of exudate,
Roof of mouth
Note color
swelling, ulceration or
tonsillar enlargement
Gingivitis
Glossitis
The Mouth and Gums
Under the Tongue
Above and behind the tongue
 Say “AAHHH”

Abnormal

Normal CN X
Tonsillitis Peritonsilar Abscess
Is the tongue moist and pink?

Assess both top and….

….underneath
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
Question?

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