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?