Eyes

Nursing 330

Shirley Comer

External Eye structures

Inner Eye Anatomy

Visual Acuity

Snellen eye chart– Position pt 20 ft away– Leave glasses or contacts on– No squinting or leaning allowed– Have pt read smallest line they are able– Test each eye independently (os=left eye od=right eye)– Record as a fraction (20/20)

Numerator = # of feet from chart Denominator = distance at which normal eye can read a line Refer pt at 20/30

Snellen chart

Other charts

Can test with other charts for– Colorblindness

Green/red Black/brown

– Depth perception– Presbyopia

Decrease in power of accommodation r/t aging Holds objects father away to see upclose

Color Blindness pix

Visual Fields

Visual Fields are tested by confrontation– Position yourself in front of pt about 2 ft

away– Cove one eye and look straight at you – Hold object out of visual field and slowly

move it inward– Pt should see object at the same time you

do– Test in 6 fields ( up, down, sides, transverse)

Extra ocular Movements

Ask pt to look at you and follow object only /c eyes Hold object about 12 inches from pt Test Six cardinal positions of gaze Observe any extra eye movements- eyes should move

together Nystagmus- a fine oscillating movement around iris

– Normal only in extreme lateral gaze– Indicates a neurological problem

6 Cardinal Positions of Gaze Pix

Inspect external structures

General functional ability Eyebrows-symmetrical Eyelid and lashes- drooping, lid lag, periobital

edema, discharge, lesions, bulges Eyeballs- color, smoothness, exopthalmos Conjunctiva and sclera-inspect blood vessels,

clear, blacks may have macules,

Eye Structures cont

Cornea and lens- – shine a light from the side and look for smoothness

and clarity – cataract=opacity of lens – arcus senilis=white line on top of lens-normal in

elderly– Abrasion of cornea causes irregular ridges in

reflected light- must stain eye to see

Iris and Pupil

Iris is round colored portion of eye – shape should be symmetrical – maybe irregular with lens implants following cataract

removal Pupils

– should be equal in size and react together – if unequal may be neuro problem – pupils will not react if pt has using glaucoma

medications or has had lens implants

Pupillary light reflex

Darken room Ask pt to gaze into the distance to dilate pupils Shine light in from side of eye and note

response Record as PERRLA (pupils equal, round, react

to light and accommodation) Compare sizes to established charts

Fundus

Darken room Remove pt and your glasses Locate fundus using ophthalmoscope Observe optic disk (creamy yellow orange) Observe retinal vessels Observe general background-light red to brown Observe macula

Red Reflex

Retina

Age Specific Considerations

Infants – Absent pupillary light reflex esp after 3 weeks

indicates blindness– Strabismus ie crossed eyes can lead to permanent

vision damage if not treated– May have an epicanthal fold- excess skin fold

extending over the inner corner of eye. Disappears later.

– Mongolian slant- seen with down’s syndrome

Age Specific Cont

Elderly– Arcus Senilis normal – Sparse eyebrows– Lower lid droop r/t decreased skin elasticity– Decreased orbital fat r/t sunken eye appearance– Decreased tear production– Pinguiculae-yellow nodules on sclera normal– Xanthelasma- soft raised plaques at tear ducts– Drusen- yellow spots on retina

Practice Exam Question

You are conducting Joe’s pre employment eye exam. Joe can read line 20/40 while squinting and 20/50 w/o squinting. How should you record Joe’s visual Acuity?

A. 20/40 B. 20/90 C. 20/50 D. none of the above

Rationale

The correct answer is c. The Snellen chart score should be recorded at the level the pt can read it w/o cheating ie squinting or leaning in.

Ears

Nursing 330

Shirley Comer

Ear Anatomy

Inspect and Palpate External Ear

Size and shape Skin Condition

– Discharge or crusting indicate infection Tenderness External meatus

– Otitis externa (infection of ear canal) = sticky yellow discharge

– Otitis media (infection of middle ear)

Test hearing Acuity

Whisper test detects high tone loss Tuning forks

– Weber test- place fork on top of head Should be able to hear equally in both ears by bone

conduction

– Rinne test- place fork on mastoid and move to ear canal /p pt reports being unable to hear it

Tests bone v. air conduction Should hear 2x as long by air

Weber and Rinne Tuning fork placement

Otoscopic Examination

Use largest speculum that will fit Tilt head away from you toward opposite

shoulder Pull up on pinna (auricle) to straighten canal on

adult ( on child pull down) Hold scope up side down to steady and insert

into external canal Don’t force but advance as much as possible

Otoscopic Exam cont

External Ear Canal – Note redness– Swelling– Discharge– Tenderness– Blood– Ruptured ear drum– CSF

Tympanic Membrane

Should be pearly grey color Locate cone of light Observe attachment of malleus Note position ie bulging, or retracted Ear infection will cause scaring of membrane Note perforations Fluid behind membrane

Tympanic Membrane

Otitis Media

Otitis External and Otitis Media

Age specific considerations

Elderly– Often have hearing loss– High tone loss cases trouble hearing consonants– Caused by noise and aging– May have hair in ears– May have ears occluded with cerum

Practice exam question

Mr. Jones across the street knows you are a nursing student and want you to remove some ear wax which has been troubling him. He tells you his ear is sore and draining a yellow liquid and he tried to get the wax out with a q-tip but was unable. He feels sure that if the wax would come out he’d feel better. You should?

A. Refer him to a doctor, he probably has an ear infection B. Rinse his ear out with peroxide and water C. Tell him to get an ear syringe kit from Walgreens D. Tell him to try harder with a Q-tip.

Rationale

The correct answer is A. The pain and discharge indicate that an infection and not ear wax is causing his problem

The other options may result in injury and should not be attempted. Refer all such complaints to a doctor.