HEALTH ASSESSMENT (RLE) - Midterms

BS NURSING - 1B 2nd Sem - 2023

ASSESSMENT OF THE EYE STRUCTURE
Eye Assessment
The eye assessment includes:
• Inspection of the eye for abnormalities
• Testing the cranial nerves responsible for eye
function: III, IV, VI
• Assessing for nystagmus, accommodation,
pupil size, and reactivity to light
PARTS
❖ Eyelids are like two rapid window shades that
further protect the eye from injury, strong light,
and dust.
❖ Upper Eyelid is the larger and more mobile
one.
❖ Eyelashes are short hairs in double or triple
rows that curve outward from the lid margins,
filtering out dust and dirt.
❖ Palpebral Fissure is the elliptical open space
between the eyelids. When closed, the lid
margins approximate completely. When
open, the upper lid covers part of the iris.
❖ Lower Lid Margin is just at the limbus, the
border between the cornea and sclera.
❖ Canthus is the corner of the eye, the angle at
which the lids meet.
❖ At the Inner Canthus, the caruncle is a small,
fleshy mass containing sebaceous glands
❖ Within the upper lid, tarsal plates are strips of
connective tissue that give it shape.
❖ Tarsal Plates contain the meibomian glands,
modified sebaceous glands that secrete an
oily lubricating material onto the lids. This stops
the tears from overflowing and helps form an
airtight seal when the lids are closed
a deep recess and then folds back over the
eye.
❖ Bulbar Conjunctiva overlays the eyeball, with
the white sclera showing through. At the
limbus, the conjunctiva merges with the
cornea.
❖ Cornea covers and protects the iris and pupil.
❖ Lacrimal Apparatus provides constant
irrigation to keep the conjunctiva and cornea
moist and lubricated. The lacrimal gland, in
the upper outer corner over the eye, secretes
tears. The tears wash across the eye and are
drawn up evenly as the lid blinks. They drain
into the puncta, visible on the upper and
lower lids at the inner canthus. They then drain
into the nasolacrimal sac, through the -inch–
long nasolacrimal duct, and empty into the
inferior meatus inside the nose.
❖ A tiny fold of mucous membrane prevents air
from being forced up the nasolacrimal duct
when the nose is blown.
EYES
• Inspect the eyes, eye lids, pupils, sclera, and
conjunctiva.
• Is there swelling if the eyelids?
• Is the sclera white and shiny? not yellow as in
jaundice
• Is the conjunctiva pink, not red and swollen?
• Look for strabismus and anisocoria?
• Are the pupils clear…not cloudy

❖ The exposed part of the eye has a transparent

protective covering, the conjunctiva. The
conjunctiva is a thin mucous membrane
folded like an envelope between the eyelids
and the eyeball.
❖ Palpebral Conjunctiva lines the lids and is
clear, with many small blood vessels. It forms

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HEALTH ASSESSMENT (RLE) - Midterms
BS NURSING - 1B 2nd Sem - 2023

Test cranial nerves III (oculomotor), IV

(trochlear), VI (abducens)
Have the patient follow
your pen light by moving
it 12-14 inches from the
patient’s face in the six
cardinal fields of gaze
(start in the midline)
Watch for any nystagmus
(involuntary movements
of the eye)

Innervation of the Extrinsic Muscles of the Eye

MUSCLE ACTION INNERVATION
Superior rectus Eye looks up Oculomotor (III)
Inferior rectus Eye looks down Oculomotor (III)
Medial rectus Eye rotates Oculomotor (III)
medially
Lateral rectus Eye rotates Abducens (VI)
laterally
Superior oblique Eye rolls, looks Trochlear (IV)
down and to the
side
Inferior oblique Eye rolls, looks up Oculomotor (III)
and to the side

Reactive to light?
• Dim the lights and have the patient look at a
distant object (this dilates the pupils)
• Shine the light in from the side in each eye.
Note the pupil response: The eye with the light
shining in it should constrict (note the dilatation
size and response size (ex: pupil size goes from
3 to 1 mm) and the other side should constrict
as well.

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HEALTH ASSESSMENT (RLE) - Midterms
BS NURSING - 1B 2nd Sem - 2023
Equipment for Measurement:
• Snellen’s chart
• Pointer
• Occluder
• Pinhole
• Near vision chart
Accommodation
• Make the lights normal and have patient look
at a distant object to dilate pupils, and then
have patient stare at pen light and slowly
move it closer to the patient’s nose.
• Watch the pupil response: The pupils should
constrict and equally move to cross.
VISUAL ACUITY
• The visual acuity test is used
to determine the smallest
letters you can read on a
standardized chart (Snellen
chart) or a card held 20 feet
(6 meters) away.
• Special charts are used
when testing at distances
shorter than 20 feet (6 meters).
• Some Snellen charts are actually video
monitors showing letters or images.
Purposes
• For refraction
• For monitoring ocular health
Measurement
• The measurement of visual acuity is done to
monitor change in vision with disease
progression of disease or treatment plan.
• It is a way to measure ‘blur’ vision
Standard Test Distances
• Distance visual acuity – 20 feet or 6 meters is
equivalent to optical infinity
• Near visual acuity- 40 cm
How to perform?
2 commonly used tests are Snellen and Random E
Snellen Chart
- test uses a chart of letters or symbols. The letters
are different sizes and arranged in rows and
columns. Viewed from 14 to 20 feet away, this
chart helps determine how well one can see
letters and shapes.
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Random E
In the random E test, you’ll identify the direction
the letter “E” is facing. Looking at the letter on a
chart or projection, you’ll point in the direction the
letter is facing: up, down, left, or right.
Points to Remember
- Carefully observe whether the patient is
completely covering the eye with cup of
hand or not
- Observe the position of head whether he is
trying to see from side
- Tell the patient to sit straight
- As visual acuity plays a vital role in eye
examination it should be recorded accurately
ASSESSMENT OF THE EAR AND HEARING
ANATOMY AND PHYSIOLOGY OF THE EAR
The Ear
• Ears are sensory organs located on either side
of the head.
• They are involved in both hearing and position
sense.
• Hearing is the sense by which sound is
appreciated.
• Position sense (kinesthetic) includes orientation
and movement of the body in space
(balance and equilibrium)
Each ear composed of:
1. External Ear
2. Middle Ear
3. Internal Ear
EXTERNAL EAR
- Includes outer ear
projection, auditory canal,
ending at the eardrum
(tympanic membrane.)
- Its function is to receive
sound waves and direct
them to the eardrum.
❖ PINNA OR AURICLE –
projecting, visible part of ear
composed of cartilage covered by skin.
AURICLE (PINNA)
• Helix – outer rim of the pinna
• Concha – deepest part of the pinna which
leads to the ear canal
• Tragus and antitragus – triangular folds of
cartilage that project over the ear canal
entrance
• Temporomandibular joint (TMJ) – located in
front of the external opening to the ear
❖ EXTERNAL AUDITORY CANAL – passage from
the pinna extending inward, forward and
downward approximately 1 to 1 ½ inches in
adult.
HEALTH ASSESSMENT (RLE) - Midterms
BS NURSING - 1B 2nd Sem - 2023
EXTERNAL AUDITORY CANAL – first part of canal
contains ceruminous glands that form cerumen
(wax.)
MIDDLE EAR
Ear Drum or Tympanic Membrane
- Located at the end of auditory canal.
- Divides external auditory canal and middle ear
cavity.
- Normally, the eardrum vibrates with incoming
sound waves.
- The tympanic membrane protects the middle
ear and conducts sound vibrations from the
external canal to the ossicles.
- Has 3 layers
• an outer layer, continuous with the skin
of the ear canal
• a fibrous middle layer
• an inner mucosal layer, continuous with
the lining of the middle ear cavity.
- Approximately 80% of the tympanic
membrane is composed of all three layers
and is called the pars tensa.
- The other 20% of the tympanic membrane
lacks the middle layer and is called the pars
flaccida.
- The absence of this fibrous middle layer makes
the pars flaccida more vulnerable to
pathologic disorders than the pars tensa.
- Small, flattened space containing air and
three small bones (ossicles.)
OSSICLES
- Three bones joined together by synovial
(freely movable) joints.
- The ossicles, which are held in place by joints,
muscles, and ligaments, assist in the
transmission of sound.
- The bones and joints form a bony lever system
that amplifies sound waves received by the
eardrum, and transmits them to fluid in the
inner ear.
- THREE SMALL BONES:
A. MALLEUS (hammer) – first bone, has a
handlike portion attached to the
second bone
B. INCUS (anvil) – second bone
C. STAPES (stirrup) – third bone
- Two small fenestrae (i.e., oval and round
windows), located in the medial wall of the
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middle ear, separate the middle ear from the
inner ear.
- The footplate of the stapes fits into the oval
window.
- OVAL WINDOW (vestibular window) – is a small
opening in the wall between the middle ear
and the inner ear.
- WINDOWS:
• Oval Window - Transmits vibrations from
the stapes to the fluids in the inner ear.
• Round Window - Relieves pressure as
vibration exits the inner ear.
EUSTACHIAN TUBE OR AUDITORY TUBE
- allows air into the middle ear, thus equalizing
pressure on both sides of the ear.
- The mucosal lining of the middle ear is continuous
with that nasopharynx via the eustachian tube.
MASTOID AIR CELLS
- Air-filled spaces in a portion of the skull’s temporal
bone.
- The middle ear communicates posteriorly with the
mastoid air cells.
- These are air filled spaces that aid the middles ear
in adjusting to change pressure.
INNER EAR OR LABYRINTH
- Also called as the labyrinth because of its
complicated series of canal.
- A system of tubes and spaces within the
hollowed-out temporal bone (bony labyrinth).
- The inner ear is housed deep within the
temporal bone.
Consist of two main divisions:
1. Bony labyrinth: contains the semicircular
canal, the vestibule and cochlea.
- The cochlea vestibule and semicircular canals
are housed in the bony labyrinth.
- The bony labyrinth surrounds and protects
membranous labyrinth which is bathed in a
fluid called perilymph.
2. Membranous labyrinth
- The membranous labyrinth is composed of the
utricle, the saccule, the cochlear duct, the
semicircular canals, and the organ of Corti.
- The membranous labyrinth contains a fluid
called endolymph.
HEALTH ASSESSMENT (RLE) - Midterms
BS NURSING - 1B 2nd Sem - 2023
VESTIBULE ASSESSMENT OF THE EAR
- it communicates with the cochlea (toward
front) and semicircular canals (toward back). Symptoms
- In vestibule are vestibular receptors (utricle and • Hearing loss
saccule), which responds to the position of the • Pain or fullness in the ears
head as it relates to the pull of gravity. • Ear drainage
• Tinnitus (ringing in the ears)
SEMICICULAR CANALS • Loss of balance
- contains sensory organ of equilibrium. • Vertigo – sensation of motion while the
- The three semicircular canals—posterior, person is not moving
superior, and lateral, • Dizziness – sensation of unsteadiness and a
- Lie at 90-degree angles to one another feeling of movement within the head;
- Contain sensory receptor organs, arranged to lightheadedness
detect rotational movement.
USE OF OTOTOXIC MEDICATIONS
COCHLEA (SELECTED OTOTOXIC MEDICATIONS)
- Bony tube shaped like a • AMINOGLYCOSIDE ANTIBIOTICS
snail shell. - Streptomycin
- Contains organ of Corti - Neomycin
(the receptor end organ of - Gentamicin
hearing.) - Tobramycin
- Amikacin
Organ of Corti - Kanamycin
Coiled with epithelial cells and - Netilmicin
hair cells that are receptors for hearing. • OTHER ANTIBIOTICS
- Vancomycin
COCHLEA Is divided into three - Viomycin
channels - Polymyxin B
1. Cochlear duct - Polymyxin E
2. Scala vestibuli: ends in the - Erythromycin
oval window - Capreomycin
3. Scala tympani: ends on the - Chloramphenicol
round window - Minocycline
• OTHER DRUGS
Helicotrema - Chemotherapeutic drugs (bleomycin,
Separates the Scala tympani and vestibuli. cisplatin, nitrogen mustard)
- Salicylates
VESTIBULAR MEMBRANE - Quinine drugs
- Separates the cochlear ducts from the Scala - Quinidine
vestibuli. - Chloroquine
• DIURETICS
BASILAR MEMBRANE - Furosemide
- Separates the cochlear duct from the Scala - Ethacrynic acid
tympani. - Acetazolamide
- Resting on the basilar membrane is the Organ - Bumetanide
of Corti that contain hair cells. - Mannitol
- Inner hair cells and outer hair cells. • CHEMICALS
- These receptor end organs are stimulated by - Metals (lead, mercury, gold, arsenic)
changes in the person’s rate or direction of - Alcohol
movement. - Aniline dyes
- Caffeine
VESTIBULOCOCHLEAR (eight cranial nerve) - Carbon monoxide
Two parts: - Nicotine
• Cochlear nerve, connecting cochlea with the - Potassium bromates
brain - Povidone-iodine
• Vestibular nerve, connecting semicircular When a medication is ototoxic, it has a toxic
canals, saccule and utricle with the brain. effect on the ear or its nerve supply.
Furosemide can cause ringing in the ears or
hearing loss that usually goes away when the
medication is discontinued.

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HEALTH ASSESSMENT (RLE) - Midterms
BS NURSING - 1B 2nd Sem - 2023
OTOSCOPIC EXAMINATION • The examiner quickly brings the tuning fork in
• Assess the tympanic membrane for intactness; front of the pinna without touching the client
the normal tympanic membrane is and asks the client to indicate if he or she still
transparent, opaque, pearly gray and slightly hears the sound.
concave. • The client normally continues to hear the
• A slow, circular movement of the speculum sound 2 times longer in front of the pinna; such
allows further visualization of the malleolar folds results are a positive Rinne test.
and periphery. • If the client is unable to hear the sound
• The speculum is never introduced blindly into through the ear in front of the pinna, the client
the external canal because of the risk of may have a conductive hearing loss on the
perforating the tympanic membrane. side tested, in this situation, the bone
• The client’s head is tilted slightly away and the conduction is greater than the air conduction
otoscope is held upside down as if were a large (negative Rinne test.)
pen, for this permits the examiner’s hand to lay • The Rinne test is of no value in determining
against the client’s head for support. sensorineural hearing loss.
• Pull the pinna up and back to straighten the
external canal in an adult. WEBER’S TEST (512 Hz)
• Visualize the external canal while slowly Normal
inserting the speculum. - lateralization must be equal
• The normal external canal is pink and intact to both ears
without lesion and with various amounts of Conductive Deafness
cerumen and fine little hairs - Sound is louder on the
affected ear
AUDITORY ASSESSMENT - Sound is weaker on the
• An audiology exam normal ear
tests your ability to Nerve Deafness
hear sounds - Sound is weaker on the affected ear
• Sounds vary - Sound is louder on the normal ear
according to the
intensity (volume or • Place the vibrating tuning fork stem in the
loudness) and the tone (the speed of sound middle ear of the client’s head at the midline
wave vibrations) of the forehead, or above the upper lip over
the teeth.
Inner Ear • Hold the fork by the stem only.
• Fxn: Hearing and equilibrium • The client is asked whether the sound is heard
• CN 8 equally in both ears or whether the sound is
• Vestibulocochlear louder in one ear.
Vestibule = balance • Normal test result is hearing the sound equally
- (Romberg’s Test) in both ears.
Cochlear = sense of hearing • If the client hears the sound louder in one ear,
- (Weber’s and Rinne’s test) the term LATERALIZATION is applied to the side
o Air conduction hearing the loudest.
o Bone conduction • Such a finding may indicate that the client
has a conductive hearing loss in the ear to
RINNE TEST which the sound is lateralized or that
sensorineural hearing loss has occurred in the
Normal
opposite ear.
- patient should be able to hear
- AC > BC
Schwabach
Conductive Deafness
- BC > AC - The Schwabach test makes a comparison
Nerve Deafness between bone conduction of the patient
- AC and BC are both and the examiner.
impaired - The tuning fork is placed between the patient
Mask the non-test ear (massage tragus or use and examiner and a sound is created.
barany noise box) - If the patient can no longer hear the sound
• The test compares the client’s hearing by air even though the examiner can hear it, it is
conduction and bone conduction. indicative of a sensory neural loss
• The vibrating tuning fork stem is placed on the - If the examiner stops hearing it and the
client’s mastoid process and the clients is patient can still hear it, it suggests a
asked to indicate when he or she no longer conductive loss.
hears the sounds.

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HEALTH ASSESSMENT (RLE) - Midterms
BS NURSING - 1B 2nd Sem - 2023
Ears
Deaf Communication
• Lip reading, writing or signing
• Face to face
• Never shout
Audiometry • Allow time to respond
• Test of hearing
• Measured in decibels Caloric Test
- 20-40 mild deafness - Ear canal is irrigated with warm and cold water
- 40-70 moderate - Cold irrigation produces a rotary nystagmus
deafness away from the irrigated side COLD OPPOSITE
- 70-90 severe deafness - Warm irrigation produces a rotary nystagmus
- Above 90 profounds toward the irrigated side WARM SAME
- COWS - mnemonic
Hearing Loss - NOTE: check tympanic
• Conductive – impairment of the external and membrane
middle ear or both, hearing aid works best • Purpose:
• Sensorineural (Perceptive) – impairment of the - Vestibular check
inner ear or nerve pathways, hearing aid may - Rule out the source of vertigo
or may not help. • Rest for 5 minutes on each test
• Psychogenic – emotional disturbance, no
evident structural damage, may recover Caloric stimulation is a test that uses differences in
anytime temperature to diagnose damage to the
acoustic nerve. This is the nerve that is involved in
NORMAL HEARING? hearing and balance. The test also checks for
BONE CONDUCTION damage to the brain stem.
OR AIR CONDUCTION
Electronystagmography (ENG) -
a test that shows the movement of your eyes in
Today's Hearing Classification order to determine how well two cranial nerves
Hearing Threshhold within your brain are functioning. ... The acoustic
➢ Normal hearing- 10 to 15 dB nerve connects the brain and the inner ear and
➢ Slight hearing loss- 16 to 25 dB controls hearing and balance. The oculomotor
➢ Mild hearing loss- 26 to 40 dB nerve connects the brain to the muscles of your
➢ Moderate hearing loss- 41 to 55 dB eyes.
➢ Moderately severe loss- 56 to 70 dB
➢ Severe hearing loss- 71 to 90 dB Procedures and Dx Exams
➢ Profound hearing loss- 91 to 120 dB 1. Whisper Test
➢ Deaf- below 120 dB 2. Weber’s Test
3. Rinne Test
An audiology exam tests your ability to hear 4. Schwabach's Test
sounds 5. Caloric Test
Sounds vary according to the intensity (volume or 6. Audiometry DEAFNESS
loudness) and the tone (the speed of sound wave 7. Ear Irrigation
vibrations) 8. Ear Instillation

INTENSITY of sound is measured in decibels (dB):

A whisper is about 20 dB
Loud music (some concerts) is around 80 to 120
dB
A jet engine is about 140 to 180 dB sounds greater
than 85 dB can cause hearing loss in a few hours
TONE of sound is measured in cycles per second
(cps) or Hertz:
Low bass tones range around 50 to 60 Hz
Shrill, high-pitched tones range around 10,000 Hz
or higher
The normal range of human hearing is about 20
Hz to 20,000 Hz, and some animals can hear up to
about 50,000 Hz

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