Eye - Amy Rangel PDF

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Amy Rangel...

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Eye, Ear, Mouth, Throat, & Nose Assessment 1. Identify external structures and landmarks for assessment.

2. Describe and document assessment finding of eye, ear, mouth, nose and throat. EYE  Visual acuity  Visual field  EOM Function o Corneal light reflex o Diagnostic position test  Inspect external eye structures o General o Eyebrows o Eyelids/Eyelashes o Eyeball Alignment o Conjunctivae and sclerae  Inspect Anterior Eyeball structures o Cornea/Lens o Iris/Pupil o PERRLA o Accomodation  Inspect Ocular Fundus o Optic disc o Retinal vessels o General background o Macula EAR  Inspect external ear o Size/shape of auricle o Position and alignment on head o Skin condition of ear  Otoscopic Exam o Extername canal  Cerumen, discharge, foreign body, lesion? o Tympanic Membrane  Color/characteristics  Position (bulging/flat)  Integrity of membrane o Test Hearing acuity NOSE  Inspect external nose o Symmetry, deformity, lesions Deviated septum?  Palpate for patency of nostril  Inspect cavity using nasal speculum  Palpate sinuses for tenderness MOUTH/THROAT  Inspect using penlight (Lips, teeth, gums, tongue, buccal mucosa, palate, uvula, tonsils)

3. State health history questions used to collect subjective data for the eyes, ears, mouth, throat, nose assessment. Eyes  Determine if a patient has history of eye disease (e.g., glaucoma, retinopathy, cataracts), eye trauma, diabetes, hypertension, or eye surgery.  Determine problems that prompted patients to seek health care. Ask patient about eye pain, photophobia (sensitivity to light), burning or itching, excess tearing or crusting, diplopia (double vision) or blurred vision, awareness of a “film” or “curtain” over field of vision, floaters (small, black spots that seem to float across field of vision), flashing lights, or halos around lights.  Determine whether there is family history of eye disorders or diseases.Ask patient if he or she wears glasses or contacts and, if so, how often.  Determine when the patient last visited ophthalmologist or optometrist.  Assess medications including eyedrops of ointment Ears  Ask if a patient has experienced ear pain, itching, discharge, vertigo, tinnitus (ringing in ears), or change in hearing.  Assess risks for hearing problems.  Assess if a patient takes large doses of aspirin or other ototoxic drugs (e.g., aminoglycosides, furosemide, streptomycin, cisplatin, ethacrynic acid).  Determine whether a patient uses hearing aid.  If a patient had recent hearing problems, note onset, contributing factors, affected ear, and effect on activities of daily living.  History of cerumen buildup Nose  Nasal discharge, symmetry  Frequent colds – infections  Change in sense of smell  Allergies  Epistaxis  Snoring at night can indicate septal deviation or obstruction Mouth  Presence of sores or other lesions  Pain  Bleeding gums  Hygiene and dental care  Difficulty swallowing  Changes in taste 4. Perform and document a visual acuity examination.  At the bedside- can be checked with Snellen Chart or Wall Clock  Also have patient read some small print  Check each eye separately  A value of 20/40 means that the patient, standing 20 feet away, can read a line that a person with normal vision can read from 40 feet away. 5. Perform a visual field test.  Visual Fields-the total area where objects can be seen in the peripheral vision while the eyes are focused on a central point.  This is important for stroke patients  May detect cerebral lesion  Visual field deficiency may help determine localization of lesion  Pt covers one eye, you close the opposite eye, move your finger outside the field of vision and then into vision, If you see a finger before pt, pt visual field is reduced. 6. Identify Assessment Alerts (abnormal findings) and necessity of communicating findings to health care providers in a timely manner.

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Deviated septum Palpable non tender lymph nodes No PERRL Exophthalmos- protruding eyes Enophthalmos- sunken eyes Jaundice of eyes Ectropion- Droop or eyelid Entropion- inward of eyes Foreign body

7. Demonstrate mouth assessment and identify possible problems with: Mucous membranes/Tonsils/Dental Hygiene/Teeth Mucous Membranes  Rhinitis- inflammation of mucous membranes  Deviated Septum- off center septum  Epistaxis- nosebleed Tonsils  Tonsillitis: In infection, they are enlarged Dental Hygiene  Halitosis o DKA has sweet fruity smelling  Dental Caries- tooth decay  Cheilitis- cracked lips 8. Demonstrate eye assessment and identify possible problems with: Visual acuity Visual Acuity Problems  Hesitant  Squinting  Leaning  Misreading  Presbyopia- decrease in power of accommodation with aging 9. Demonstrate assessment of the ear and identify possible problems with: Hearing Hearing Problems  Tympanic membrane abnormalities o Retracted eardrum o Excessive cerumen o Otitis media o Perforation...