EYE ASSESSMENT

• Visual acuity
o Snellen Chart (a chart that contains various-sized letters with standardized numbers
at the end of each line of letters)
o standardized numbers or denominators indicates the degree of visual acuity from a
distance of 20 feet
• Note for external lesions.
• Equality of eyelid movement
o Test extraocular muscle function:
 Record results. Eye movements should be symmetrical as both eyes follow the direction of the
gaze. The
upper eyelids cover only the uppermost part of the iris and are free from nystagmus
(involuntary, rhythmical oscillation of the eyes).
o Presence of discharge.
o Internal lesions.
o Differences between pupil size and reaction.

• Record results PERRLA (pupils equal, round, reactive to light and accommodation). Pupil
should constrict
quickly in direct response to light and the opposite pupil should also constrict. Pupils
should be equal in size.
• Pupillary accommodation causes constriction in response to objects that are near, and dilation
occurs to
accommodate distant vision, with symmetrical convergence of eyes.
Common Refractory Error:
• Myopia (nearsightedness) elongation of the eyeball or an error of refraction that causes the
parallel rays to
focus in front of the retina
• Hyperopia ( farsightedness) rays of light entering the eye are brought into focus behind the
retina
• Presbyopia ( far sightedness) results from loss of elasticity of the lens of the eye
• Astigmatism – unequal spherical curve of the cornea that prevents the light from being
focused directly in a
point on the retina

EAR ASSESSMENT
• The nurse should observe the client for signs of hearing difficulty during the physical
examination, such as turning the head, lip-reading, and speaking in a loud voice.
• Auditory acuity
• Whispered voice test:
• Weber test:
• Rinne test:
 • Note Presence of external lesions.
• Note Presence of discharge.

NOSE ASSESSMENT
 Inspect the nose for symmetry, deformity, flaring, or inflammation
 and discharge from the nares. Located symmetrically, midline of the face
 and is without swelling, bleeding, lesions, or masses.
 Test patency of each nostril by instructing the client to close the mouth
 and apply pressure on one naris and breathe.
 Assess nasal cavity with penlight:
 Assess each nostril.
 Palpate the nasal sinuses by applying gentle, upward pressure on frontal and maxillary
areas, avoiding pressure on the eyes, percuss with middle or index finger and note the
sound. Nontender, airfilled cavities, resonant to percussion.
*Pain or tenderness may be caused by viral, bacterial, or allergic processes - inflammation and
obstruction, eliciting a dull sound.

MOUTH AND LIP ASSESSMENT

MOUTH
• Stand 12–18 inches in front of client and smell the breath. Breath should smell fresh.
• Halitosis (foul-smelling breath) occurs with tooth decay or disease of gums, tonsils, or sinuses
or with poor
oral hygiene
• Acetone breath (“fruity” smell) is common in malnourished or diabetic clients with
ketoacidosis.
• Musty smell is caused by the breakdown of nitrogen and presence of liver disease.
• Ammonia smell occurs during the end stage of renal failure from a buildup of urea.

LIPS
• Lip lesion:
o Herpes simplex (cold sores or fever blisters) are painful vesicular lesions that
rupture and crust over.
o Chancre (primary lesion of syphilis) is a reddish round, painless lesion with a
depressed center and
raised edges that appears on the lower lip.
o Squamous cell carcinoma (most common form of oral cancer) usually involves the
lower lip and may
appear as a thickened plaque, ulcer, or warty growth.

• Lips and mucosa should be pink, firm, and moist without inflammation or lesions
o Pale or cyanotic lips may indicate systemic hypoxemia. Dry, cracked lips occur with
dehydration or exposure to weather.
o Swollen lips (angioneurotic edema) result from allergic reactions

GUMS
 are pink, smooth, moist and firm
  Pale gums that bleed easily may indicate periodontal disease or vitamin C deficiency.
 Inspect teeth: note tartar, cavities, extraction and color.
 Note position and alignment

TONGUE
 tongue lies midline, medium red or pink in color, moist and smooth along lateral margins,
with free mobility. Ventral surface is slightly rough (taste buds), and dorsum is highly
vascular.

*NOTE: Enlarged tongue may indicate glossitis or stomatitis or may occur with myxedema, acromegaly,
or amyloidosis.

• Inspect the hard and soft palate with penlight.

o Palates are concave and pink. Hard palate has ridges; soft palate is smooth
• Inspect pharynx using a tongue depressor and penlight
o Instruct client to say “ah.” Note the position, size, and appearance of tonsils and uvula
o With phonation, the soft palate and uvula rise symmetrically. The pharynx is pink,
vascular, lesion-free.

*NOTE: Reddened, edematous uvula and tonsillar pillars with yellow exudate indicate pharyngitis.