Eye Assessme nt

Edwin B. Malic RN

External eye structure

Eyelids Eyelashes Conjunctiva Lacrimal apparatus Extraocular muscle eyeball

Internal structure
Iris Lens Retina Optic disc Retinal vessel

vision
Visual fields and visual pathway Upper temporal Lower temporal Upper nasal Lower nasal

Visual reflexes
Pupillary

light reflex

Direct Indirect or consensual

accommodation

Anatomy of the eye

Anatomy of the eye

Anatomy of the eye

Collecting subjective data

Do you see spots or floaters in front of your eyes? Do you experience blind spots? Are they constant or intermittent? Do you see halos or rings around lights? Do you have trouble seeing at night? Do you experience double vision?

Collecting subjective data

Do you have any eye pain or itching? Describe Do you have any redness or swelling in your eyes? Do you experience excessive watering or tearing of the eye? One eye or both eyes? Have you had any eye discharge? describe

Collecting subjective data

Have you ever had problems with your eyes or vision? Have you ever had eye surgery? Describe any past treatments you have received for eye problems (medication, surgery, laser treatments, corrective lenses). Were these successful? Were you satisfied?

Family history

Is there a history of eye problems or vision loss in your family?

Lifestyle and health practices

Are you exposed to conditions or substance In work place or home that may harm your eyes or vision? Do you wear safety glasses during exposure to harmful substances? Do you wear sunglasses during exposure to the sun? What types of medications do you take?

Lifestyle and health practices

When was your last eye examination? Do you have a prescription for corrective lenses? Do you wear them regularly? If you wear contacts, how long do you wear them? How do you clean them?

Collecting objective data

Preparing the client Explain each vision test Equipment Snellen or E chart Hand-held snellen card or near vision screener penlight

Collecting objective data

Equipment Opaque cards Ophthalmoscope Disposable gloves

Physical assessment
While performing examination, remember these key points Administer vision test competently and record the results Use the ophthalmoscope correctly and confidently Recognize and distinguish normal variation from abnormal findings

Evaluating vision
Test distant visual acuity o Position the client 20 feet from the snellen or e chart o Ask her to read each line until she cannot decipler the letters or their direction o Document results

Evaluating vision
Test distant visual acuity Deviation from normal

Normal visual acuity is 20/20

Myopia 20/200 is considered legally blind Any client with vision worse than 20/30 should be

Evaluating vision
Test near visual acuity o Use for middle aged clients and others who complain difficulty in reading o Give the client a hand-held vision chart o Have the client cover one eye with an opaque card before reading from top to bottom

Evaluating vision
Test near visual acuity Deviation from normal

Normal near visual acuity is 14/14

Presbyopia (impaired near vision)

Evaluating vision
Test visual fields for gross peripheral vision Deviation from normal

The client should see the examiners finger at the same time the examiner sees it

A delayed or absent perception of the examiners finger indicates reduced peripheral vision

Testing extraocular muscle function

Perform corneal light reflex Hold the penlight approximately 12 inches from the clients face Shine the light toward the bridge of the nose while the client stares ahead.

Testing extraocular muscle function

Perform corneal light reflex

Deviation from normal

The reflection of light on the corneas should be in the exact same spot on each eye, which indicate parallel alignment

Asymmetric position of the light reflex indicates deviated alignment of the eyes due to muscle weakness or paralysis

Testing extraocular muscle function

Perform cover test Ask the client to stare straight ahead and focus on a distant object. Cover one eye with an opaque card. As you cover the eye, observe the uncovered eye for movement. Now remove the card and observe the previously covered eye for any movement

Testing extraocular muscle function

Perform cover test Deviation from normal

The uncovered eye should remain fixed straight ahead. The uncovered eye should remain fixed straight ahead after being uncovered

The uncovered eye will move to establish focus when the opposite eye is covered. When covered eye is uncovered, movement to reestablish focus occurs Phoria, strabismus, tropia

Testing extraocular muscle function

Perform the positions test o Instruct the client to focus on an object you are holding (approximately 12 inches from the clients face) o Move the object through the six cardinal positions of gaze in clockwise direction, and observe the clients eye movement

Cardinal Positions of Gaze The six positions in which the eyes can be turned where each eye is controlled primarily by one muscle: up/right, right, down/right, down/left, left, and up/left.

Testing extraocular muscle function

Perform the positions test assesses eye muscle strength and cranial nerve function o Eye movement should be smooth and symmetric throughout all six direction Deviation from normal Failure of eyes to follow movement symmetrically indicates weakness Nystagmus, an oscillating (shaking movement)

External eye structure inspect the eyelids and eyelashes Note width and position Deviation from normal
of palpebral fissures

Upper lid margin should be between the upper margin of the pupil The lower lid rest on the lower border of the iris. No white sclera is seen above or below the iris Palpebral fissures may be horizontal

Drooping of the eyelid(ptosis) oculomotor damage Retracted lid margins

External eye structure inspect the eyelids and eyelashes

Assess the ability of eyelids to close
o

Deviation from normal

The upper and lower lids close easily and meet completely when closed

Failure of lids to close completely puts client at risk for corneal damage

Note the position of eyelids in comparison with the eyeballs. Note any unusual turnings, color, swelling, lesion, discharge

External eye structure inspect the eyelids and eyelashes

Deviation from normal

Lower eyelid is upright with no inward or outward turning Eyelashes are evenly distributed and curve along the lid margins Xanthelasma, raised yellow plaques located most often near the inner canthus, are normal with increasing age

External eye structure inspect the eyelids and eyelashes

Inverted lower lid(entropion) may cause pain and injure the cornea Ectropion an evertted lower eyelid, results in exposure and drying of the conjunctiva

External eye structure inspect the eyelids and eyelashes

Observe for redness, swelling, discharge, or lesion
o

Deviation from normal

Skin on both eyelids is without redness, swelling, or lesion

Redness and crusting along the lid margins suggest seborrhea or blepharitis

External eye structure

Observe the position and alignment of the eyeball in the eye socket
o

Deviation from normal

Eyeballs are symmetrically aligned in sockets without protruding or sinking

Protrusion of the eyeballs accompanied by retracted eyelid margins is termed exophthalmus Sunken eyes may

External eye structure

Inspect the bulbar conjunctiva o Have the client keep her head straight while looking from side to side then up toward the ceiling o Observe clarity, color, and texture o This procedure is stressful and uncomfortable for the client. It is usually only done if the client complain of pain something in the eye

External eye structure

Inspect the bulbar conjunctiva Assess the areas over the lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid)

External eye structure

Inspect the bulbar conjunctiva Deviation from normal
o

Generalized redness of conjunctiva (conjuctivitis) o Bulbar conjunctiva is clear, moist, and o Areas of dryness are smooth. associated with allergies/ trauma o Sclera is white o Episcleritis is a local, noninfectious inflammation of sclera

External eye structure

inspect the palpebral conjunctiva o Put on gloves, first inspect the palpebral conjunctiva of the lower eyelid by placing your thumbs bilaterally at the level of the lower bony orbital rim and gently pulling down to expose palpebral conjunctiva o Ask the client to look up as you observe the exposed area

Inspect the palpebral conjunctiva Evert the upper eyelid Ask the client to look down with his eyes slightly open Place a cotton applicator approximately 1 cm above the eyelid margin and push down while still holding the eyelashes

External eye structure

Inspect the palpebral conjunctiva Deviation from normal

Clear and free of swelling or lesion Free of foreign bodies, or trauma

Cyanosis of the lower lid (lung heart disorder) Foreign body or lesion may cause irritation, burning, pain

External eye structure

Inspect the lacrimal apparatus Deviation from normal

No swelling/redness

Swelling of the lacrimal gland may be visible in the lateral aspect of the upper eyelid. May be cause by blockage, infection, or an inflammation

External eye structure

palpate the lacrimal apparatus o Put on disposable gloves to palpate the nasolacrimal duct to assess for blockage o Use one finger and palpate just inside the orbital rim

External eye structure

Palpate the lacrimal apparatus Deviation from normal

No drainage should be noted from the puncta when palpating the nasolacrimal gland

Expressed drainage from the puncta on palpation occurs with duct blockage

External eye structure

Inspect the cornea and lens o Shine a light from the side of the eye for n oblique view o Look through the pupil to inspect the lens

External eye structure

Inspect the cornea and lens

Deviation from normal Areas of roughness, dryness on the cornea are often associated with injury or allergic responses. Opacities of the lens are seen with

The cornea is transparent with no opacities. The oblique view shows a smooth and overall moist surface; the lens is free of opacities

External eye structure

Inspect the iris and pupil o Iris is typically round, flat, and evenly colored. The pupil, round with a regular border, is centered in the iris. Pupils are normally equal in size (3-5mm) o anisocoria Deviation from normal
o

Irregularly shape irises, miosis, mydriasis, and anisocoria

External eye structure

Test pupillary reaction to light
o

Deviation from normal Monocular blindness can be detected when light directed results no response o When light is directed into the unaffected eye, both pupils
o

Normal reaction is constriction

External eye structure

Test accommodation of pupils Deviation from normal

The normal pupillary response is constriction and convergence of the eyes when focusing on a near object

Pupils do not constrict; eyes do not converge

Abnormal findings
Pseudostrabismus Ptosis

Abnormal findings

entropion

ectropion

Abnormal findings

Conjunctivitis

Ear Assessment

Structure and function

External ear Middle ear Inner ear

HEARING

Collecting subjective data

History

of present health concern

o Changes

in hearing - describe any recent changes in your hearing - Are all sounds affected with this change or just some sounds

Collecting subjective data

History o Other -

of present health concern

symptoms Do you have any ear drainage? Describe the amount and any odor

do you have any ear pain? If so, do you have an accompanying sore throat. Sinus infection, or problem with your teeth or gums?

Do you experience any ringing or crackling in your ears? Do you ever feel like you are spinning or that the room is spinning? Do you ever feel dizzy or unbalanced?

Past health history

Have you ever had any problems with your ears such as infection, trauma or earaches? Describe any past treatments you have received for ear problems (medication, surgery, hearing aids). Were these successful? Were you satisfied?

Family History

Is there a history of hearing loss in your family?

Lifestyle and health practices

Do you work or live in an area with frequent or continuous loud noise? How do you protect your ears from the noise? Do you spend a lot of time swimming or in water? How do you protect your ears? Has your hearing loss affect your ability to care for yourself? To work? Has your hearing loss affect

Lifestyle and Health Practices

When was your last hearing examination? How do you care for your ears?

Collecting objective data

Preparing the client o Make sure client is seated comfortably o Test should explained thoroughly to guarantee accurate results.

Collecting objective data

Equipment Watch with a second-hand for romberg test Tuning fork Otoscope

Collecting objective data

Physical assessment Recognize the role of hearing in communication and adaptation Know how to use the otoscope effectively Understand the usefulness and significance of basic hearing tests

External ear structures

Inspect the auricle, tragus, and lobule Ears are equal in size bilaterally (410cm) Skin is smooth with no lesion, lumps, or nodules No discharge should be present Darwins tubercle Deviation from normal Ears are smaller than 4cm Malaligned or low set ears may be seen with genitourinary disorder Enlarged preauricular and posturicular lymph nodes-infection

External ear structures

Palpate the auricle and mastoid process
o

Deviation from normal

Auricle, tragus, and mastoid process are not tender.

Painful auricle/tragus associated with postauricular cyst Tenderness over the mastoid process (mastoiditis) Tenderness behind the ear may occur with otitis

Internal ear: otoscopic examination

Inspect the external auditory

Deviation from normal Foul smelling, sticky, yellow discharge o Bloody purulent discharge o Blood or watery drainage o Impacted cerumen bloking the view of ear canal
o

Small amount of odorless cerumen (earwax) is the only discharge normally present

Internal ear: otoscopic examination

Observe the color and consistency of the ear canal walls
o

Deviation from normal

The canal walls should be pink and smooth without nodules

Reddened, swollen canals o Exostoses (nonmalignat nodular swellings) o Polyps

o

Inspect the tympanic Deviation from normal membrane Should be pearly, o Red, bulging eardrum gray, shiny, and and distorted, translucent with no diminished or absent bulging or retraction light reflex o slightly concave, o Yellowish, bulging smooth and membrane with bubbles behind o Bluish or dark red color o White spots o perforations
o

Perform the webers test o Helps to evaluate the conduction of sound waves o Strike a tuning fork softly with the back of your hand and place it in the center of the clients head or forehead. o Ask whether the client hears the sound better in one ear or the same in both ears

A tuning fork is an acoustic resonator in the form of a twopronged fork with the prongs (tines) formed from a Ushaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when set vibrating by striking it against a surface or with an object, and emits a pure musical tone after waiting a moment to allow some high

Perform the webers test if the client reports diminished or lost hearing in one ear

Deviation from normal

With conductive hearing loss, client reports lateralization of sound to the poor ear o With sensorineural hearing loss, client reports lateralization in good ear
o

Vibrations are heard equally well in both ears o No lateralization of sound to either ear
o

Perform the rinne test

Strike a tuning fork and place the base of the fork on clients mastoid process Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal Ask the client to tell you if the sound is audible after the fork is moved

Perform the rinne test

Deviation from normal

With conductive hearing loss, bone conduction sound is heard longer than or equally s long as air conduction side. o With sensorineural hearing loss, air conduction sound is heard longer than bone conduction sound
o

Air conduction sound is normally heard longer than bone conduction sound

Perform romberg test

Deviation from normal

Client maintains position for 20 sec without swaying or with minimal swaying

Clients moves feet apart to prevent falls or starts to fall from loss of balance. This may indicate vestibular disorder

Mouth, throat, nose, and sinus

Structure and function

Mouth Throat Nose Sinuses

Collecting subjective data

Tongue

and mouth do you experience tongue or mouth sores or lesions? Are they painful? How long have you had them? Do they recur? Is it single or do you have many? do you experience redness, swelling, bleeding, or pain of the gums or mouth? How long has this been happening? Have you lost any

Collecting subjective data

nose and sinuses Do you have pain over your sinuses? do you experience nosebleeds? How much bleeding? What color? Do you experience frequent clear or mucous drainage from your nose? Can you breath through both of your nostrils? Do you have a stuffy nose at times during the day or night?

Collecting subjective data

nose and sinuses Do you have seasonal allergies, had fever? Describe the timing of the allergies and symptoms have you experienced a change in your ability to smell or taste?

Collecting subjective data

throat Do you have difficulty chewing or swallowing food? How long have you had this? Do you have any pain? Do you have a sore throat? How long have you had it? Describe. How often do you get sore throats? Do you experience hoarseness? How long?

Past health history

Have you ever had any oral, nasal, or sinus surgery? Do you have a history of sinus infections? Describe your symptoms. Do you use nasal sprays?

Family history

Is there a history of mouth, throat, nose, or sinus cancer in your family

Lifestyle and health practices

Do you smoke or use smokeless tobacco? If so, how much? Are you interested in quitting this habit? Do you drink alcohol? How much and how often? Do you grind your teeth?

Lifestyle and health practices

Describe how you care for your teeth or dentures., how often do you brush and use dental floss? When was your last dental examination? o If the client wear braces: how do you care for your braces? Do you avoid any specific types of foods? Describe your usual dietary intake for a day o Do you brush your tongue? o How often are you in the sun? do you use lip sunscreen products?
o

Preparing the client

Place on sitting position Explain the procedure A gentle, yet confident and matter of fact approach may help the client to feel more at ease

Equipment
Gloves 4x4 gauze pad Penlight Short, wide- tipped speculum attached to the head of an otoscope Tongue depressor Nasal speculum

Physical assessment
When preparing to examine the nose and mouth o Be able to identify and understand the relationship among the structures of the mouth and throat, nose, and sinuses o Know age related changes of the oral cavity and nasal and sinus o Refine examination techniques

mouth
Inspect the lips (observe for lip consistency and color) Deviation from normal

Lips are smooth and smooth without lesions or swelling

Pallor around the lips o Reddish lips o swelling

o

mouth
Inspect the teeth and gums o Ask the client to open the mouth o Note the number, color, condition, and alignment of the teeth o Put on gloves and retract the clients lips and cheeks to check gums for color and consistency

Inspect the teeth and Deviation from normal gums Yellow or brownish teeth o Missing teeth can affect chewing as well as self image o White spot on teeth may result from antibiotic therapy
o

Thirty two pearly whitish teeth with smooth surface and edges o Some clients normally have only 28 teeth if the four wisdom teeth do not erupt
o

Deviation from normal

Gums are pink, moist, and firm with tight margins to the tooth. No lesion or masses

Red, swollen gums that bleed easily, scurvy (vitamin c deficiency), and leukemia. Enlarged reddened gums (hyperplasia)

Inspect the buccal mucosa o Use a penlight and tongue depressor to retract the lips and cheeks to check the color and consistency o Also note the stensons ducts (parotid ducts) located on the buccal mucosa across from the second upper molars

Inspect the buccal mucosa It should be appear pink, tissue is smooth and moist without lesions o Stensons duct are visible with flow of saliva and with no redness, swelling, pain, or moistness
o

Deviation from normal

Leukoplakia may be seen in chronic irritation and smoking o Leukoplakia is a percancerous lesion and client should be referred for evaluation
o

Inspect and palpate the tongue o Ask the client to stick out the tongue o Inspect the color, moisture, size, and texture o Observe for fasciculation's (fine tremors), and check for midline protrusion o Palpate any lesions present for induration (hardness)

Inspect and palpate the tongue

Deviation from normal

Deep longitudinal fissures seen in dehydration o Black tongue (bismuth toxicity) o Black, hairy tongue; smooth reddish, shiny tongue w/o papillae indicative of niacin or vit. B12
o

Tongue should be pink, moist a moderate size with papillae (little protuberances) present o No lesion are present
o

Assess the ventral surface of the tongue o Ask the client to touch the tongue to the roof of the mouth, and use a penlight to inspect ventral surface of tongue, frenulum o Palpate the area if you see lesion

Deviation from normal

o

It should be smooth, shiny, pink or slightly pale with no lesion

Leokoplakia, persistent lesions, ulcers or nodules may indicate cancer

Older client may have varicose veins on the ventral surface

Inspect for the whartons duct

Dviation from normal

The frenulum is mdline; whartons ducts are visible with salivary glands

Lesions, ulcers, nodules, or hypertrophied duct

Observe the sides of the tongue o use a square gauze pad to hold the clients tongue to each side o Palpate any lesion, ulcers, or nodules

No lesion, ulcers or nodules are apparent

Deviation from normal Canker sore may be seen on the sides of the tongue in clients receiving certain kinds of chemotherapy Leukoplakia, persistent lesion nodules may indicate cancer

Check the strength of the tongue Place your fingers on the external surface of the cheek Ask the client to press the tongues tip against the inside of the cheek to resist pressure Repeat from other side

Deviation from normal The tongue offers strong resistance

Decreased tongue strength may occur with 12 cranial nerve defect

Check the anterior tongues ability to taste o By placing the drops of sugar and salty water on the tip and sides of tongue depressor

Deviation from normal

The client can distinguish between sweet and salty

Loss of taste discrimination occurs with zinc deficiency, seven cranial nerve defect and certain medication use

Inspect the hard (anterior) and soft palate (posterior) and uvula

Ask the client to open the mouth wide while you use penlight to look at roof. Observe color and integrity

Deviation from normal

The hard palate is pale or whitish with firm, transverse rugae (wrinkle like folds)

Yellow tint to the hard palate may indicate jaundice An opening in the hard palate are called cleft palate

Note the odor

Deviation from normal

No unusual or foul odor is noted

Fruity or acetone breath is associated with diabetic ketoacidosis o Foul odors may indicate oral or
o

Assess the uvula

o Apply

tongue depressor to the tongue and shine a penlight into clients wideopen mouth o Ask the client to say ahhhhhhh

Deviation from normal No redness of or exudate from uvula or soft palate Midline elevation of the uvula and symmetric elevation of the soft palate

Bifid uvula looks like a split in two/ (submucous cleft palate) o Asymmetric movement or loss of movement (CVA)
o

Inspect the tonsils o Using the tongue depressor to keep the mouth open wide, inspect the tonsils for color, size, and presence of exudate or lesions

Deviation from normal They are normally pink and symmetric and may be enlarged to 1+ in healthy clients No exudate, swelling or lesions should be present

Tonsil are red, enlarge and covered with exudate Maybe indurated with pathches of white or yellow exudates

Inspect the posterior pharyngeal wall o Keeping the tongue depressor in place, shine the penlight on the back of the throat o Observe the color of the throat, and note any exudate or lesions

Deviation from normal

Throat is normally pink without exudate or lesion

A bright red throat with white or yellow exudate indicates pharyngitis o Yellowish mucus on throat may be seen with
o

nose
inspect and palpate the external nose Deviation from normal

Color is the same as the rest of the face; nasal structure is smooth and symmetric; clients report no tenderness

Nasal tenderness on palpation may accompanies a local infection

Check the patency of air flow through the nostril

By occluding one nostril at a time and asking the client to sniff

Deviation from normal

Client is able to sniff through each nostril while other is occluded

Client cannot sniff through a nostril o This maybe a sign of swelling, rhinitis, or a foreign object obstruction
o

Inspect the internal nose Dark pink, moist and free of exudate Nasal septum is intact and free of ulcers and perforation

Deviation from normal

Nasal mucosa is swollen and pale or bluish gray in clients with allergies

sinuses
Palpate the sinus Palpate the frontal sinuses using thumb to press up on the brow on each side of the nose Palpate the maxillary sinuses by pressing with thumbs up

Deviation from normal

Sinuses are not tender

The frontal and maxillary sinuses are tender in clients with allergies or sinus infection

Transilluminate the sinus (frontal and maxillary)

Deviation from normal

a red glow

Absence of red glow usually indicates a sinus filled with fluid, pus thick mucus