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Nur330 Geiman Identify pertinent history questions to the eyes Obtain a history and perform a physical assessment on the eyes Differentiate between normal and abnormal system findings related to the eyes Identify actual/potential health problems related to the eyes External Structures Sclera: gives shape and structure to eye Iris: controls amount of light entering eye; provides eye color Extraocular muscles: control eye movement – Cranial nerves III, IV and VI External Structures Eyelids and lashes: protect the eyes from injury Lacrimal glands and ducts: produce tears Conjunctiva: provide lubrication External Structures Cornea: transparent, avascular outer layer of the eyeball Anterior chamber: filled with aqueous humor Pupil: the aperture of the iris, controls the amount of light allowed into the retina Lens: an elastic biconvex disc that bends the light wave entering the eye by either flattening or increasing the lens curvature. Internal Structures Optic disc and physiological cup: area where the optic nerve and the blood vessels enter the eye Retinal blood vessels: blood supply to eye Internal Structures Retina: inner layer; receives light waves that are sent to brain and converted into visible perceptions Macula: an indistinct, darker, avscular area on the retina responsible for night, color, and central vision and motion detection The optic fundus is the only area in the body where the blood vessels can be directly observed Can reveal systemic problems with circulation as in with chronic HTN and diabetes Extraocular muscles (CN: III, IV, and VI) Eyelids Constriction and relaxation of the muscular tissue of the iris and ciliary body allows for visual adaption CN control eye movements, muscles of the eye lids, opening and closing of eyes Vision from the time the image is transmitted on the retina What developmental variations of the eyes might be seen with: Children By the age of 5 to 6, children should have 20/20 vision Older adults Presbyopia – farsightedness begins to occur by the 4th or 5th decade Cataracts – the clouding of the lens Night vision impaired – degeneration of rods Age-related macular degeneration (AMD) – loss of central vision Diabetic retinopathy What cultural variations of the eyes might be seen with: Dark-skinned African Americans Asians What symptoms would signal a problem with the eyes? Vision loss/acuity Eye tearing Eye drainage Eye appearance changes Redness/swelling History of ocular problems? Pain Blurred vision Dry eyes Strasbismus/diplopia Patient-centered care Glasses/contact lenses Glaucoma Anatomical Landmarks: visual fields (superior, inferior, nasal, temporal) Approach: inspection, palpation, ophthalmoscopy Position: sitting Tools: visual acuity charts (Snellen), penlight, ophthalmoscope, cotton ball, cotton swab General survey and head-to-toe scan Far vision: Snellen eye chart Near vision: read newsprint 13 to 15” from eyes Color vision: identify color bars on Snellen or use color plates Peripheral vision: Confrontation test: come in from the periphery in all fields and note field cuts Test corneal light reflex Test six cardinal fields of gaze Testing Extra Occular Movements Cranial Nerves tested: •CN III •CNIV •CN VI Lids and lashes: color, lesions, edema, symmetry, position and distribution of lashes Lacrimal glands and ducts: color, edema, excessive tearing or drainage Conjunctiva: color, cyanosis, moisture, lesions, and foreign bodies Sclera: color, jaundice, moisture, lesions, or tears Cornea: clarity and abrasions, corneal reflex Anterior chamber: clarity, bulging iris, and blood Iris: color, size, shape, and symmetry Pupils: size, shape, reaction to light–direct and consensual, test accommodation Eye ball: consistency and tenderness Lacrimal glands and ducts: tenderness and excessive tearing Red reflex: presence, opacities Optic disc and physiologic cup: color, size, shape, borders, cup-disc ratio Retinal vessels: size ratio of arteries and veins, color, arteriole light reflex, crossings Retina: color, texture, exudates, lesions, hemorrhages, and aneurysms Macula and fovea: color, size, location, lesions Red reflex is the reflection of light off the retina Absence or red reflex could indicate cataracts or opacities in lens or vitreous humor Abnormally, progressive opacity of the lens Pupil may appear cloudy Red reflex may be absent or darkened Years of exposure to ultraviolet light are a risk factor for cataracts Separation of the retinal layer and choroid layer in the back of the eye Initial symptoms start with seeing floaters, flashing lights, and a slowing expanding shadow in the lateral fields of gaze Untreated retinal detachment results in irreversible blindness Characterized by increased pressure within the eyeball; can cause progressive damage to the optic nerve. Open-angle (chronic) glaucoma is by far the most common type of glaucoma. Regardless of race, adults starting at age 40 should be checked every 2 to 4 years and then every year starting at age 65 Person with diabetes should be checked annually What are the functions of auricle and external ear canal: collect and transmit sound waves Connects the auricle to the Tympanic Membrane (TM) Contains fine hairs and glands Protects the TM from external environmental factors What are the functions of the middle ear: Tympanic membrane (TM): divides external ear from middle ear; transmits sound waves Ossicles: three smallest bones in body, transmit sound waves Eustachian tube: equalizes pressure on both sides of TM What are the functions of the inner ear: Structures of inner ear: transmit sound waves to CN VIII and affect equilibrium Carrying sound waves through the external auditory canal to the TM. The sound vibrations cause the TM and the malleus, anvil and stapes bones to move, thus transmitting the vibrations to the inner ear structures An additional pathway whereby the sound waves vibrate the skull bones and transmit the vibrations to the inner ear structure. Hearing by both air conduction and bone conduction rely on intact skeletal structures What developmental variations of the ears might be seen with: Children – more prone to ear infections Older adults Presbycusis – usually high pitched sounds and consonants Excess accumulation of cerumen What symptoms would signal a problems with the ears? Earache Hearing loss (conductive vs. sensorineural loss) Vertigo Ringing in the ears (tinnitus) Ear drainage (otorrhea) Earache (otalgia) Infections Patient-centered nursing History of ear infections? Severe head injury or stroke? History of tinnitus? Vertigo? Medications? Exposure to loud noises? Smoker or exposure to second hand smoke History of hearing loss in the family? Anatomical landmarks: angle of attachment of the ears Approach: inspection and palpation Position: sitting Tools: tuning fork, otoscope, thermometer, watch General survey and head-to-toe scan Angle of attachment and position Size, shape, and symmetry Drainage: clear, blood, or purulent Consistency and tenderness Palpate tragus, mastoid, and helix for tenderness Preauricle tag Hold the otoscope upside down like a pencil. Pull the pinna of the ear up and back for adults, ear down and back for children Brace you insertion hand on the patient’s head for stabilization OR Hold the otoscope handle upright and slowly and gently insert the scope along the axis of the external auditory canal (1/2 inch in adult) Put your eye up to the viewing lens Do not insert further, gently apply more traction on the ear External ear canal: patency, color, drainage, lesions, and foreign objects Tympanic membrane: Color – normal TM should be shiny, pearl gray, intact and mobile Whispered voice test (for low pitch) Stand 1-2 feet behind client so they can not read your lips. Instruct client to place one finger on tragus of left ear to obscure sound. Whisper word with 2 distinct syllables towards client's right ear. Ask client to repeat word back. Repeat test for left ear. Client should correctly repeat 2 syllable word. Weber test – assess lateralization of sound through both BC and AC Hold tuning fork by stem and tap with palm of hand Place vibrating tuning fork in the middle of the patient’s forehead or top of the head NORMAL FINDING: The sound is heard in the center of the head or equally in both ears. Abnormal: If there is a conductive hearing loss present, the vibration will be louder on the side with the conductive hearing loss. If the patient doesn't hear the vibration at all, attempt again, but press the butt harder on the patient's head. Rinne test - Test compares air and bone conduction hearing. Strike the tuning fork softly. Place the vibrating tuning fork on the base of the mastoid bone. Ask client to tell you when the sound is no longer heard. Note the time interval and immediately move the tuning fork to in front of the ear Ask the client to tell you when the sound is no longer heard.. Note the time interval and findings Rinne Test Results Normal hearing clients will note air conduction twice as long as bone conduction (ie, bone conduction is less than air conduction) With conductive hearing loss, bone conduction sound is heard longer than or equally as long as air conduction With sensorineural hearing loss, air conduction is heard longer than bone conduction in affected ear, but less than 2:1 ratio The Vestibular apparatus – test the inner ear’s vestibular apparatus by performing the Romberg test. Meniere’s Disease Chronic, progressive disease of the inner ear that leads to permanent hearing loss Affects proprioception Sensation of fullness or pressure in the ears and recurrent episodes of vertigo, tinnitus, and hearing loss Disturbance of balance and gait Presbycusis Diminished hearing acuity in older adults specifically for high-pitched sounds Hearing acuity decreased