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Eyes and Ears Skills Lab.

Eye Examination and Diagnostic Procedures Common Abbreviations (& Terms) OD Oculus Dexter (right eye) OS Oculus Sinister (left eye) OU Oculus Uterque (both eyes) V Vision VA Visual Acuity UCVA Uncorrected Visual Acuity HM Hand Motion LP Light Perception NLP No Light Perception Ophthalmologist Medical Doctor (M.D.) Optometrist Doctor of Optometry (O.D.) Ocularist technician who makes ophthalmic prosthesis Tonometer- an instrument for determining tension/pressure (IOP) Physical Assessment of the Eye 1. Globes inspect for protrusion 2. Palpebral Fissures (longitudinal openings between the eyelids inspect for width and symmetry Normal Findings: Appear equal in size when the eyes are open. Upper lid covers a small portion of the iris and cornea Lower lid margin is just below the junction of the cornea & sclera (limbus) Abnormal Findings Ptosis the drooping of eyelids LID MARGINS inspect for scaling, secretions, erythema, position of lashes Normal Findings: Clear, the lacrimal duct openings (puncta) are evident at the nasal ends of the upper & lower lids. Eye lashes normally are evenly distributed and turn outward. CONJUCTIVAE - inspect for congestion & color Bulbar Conjuctiva membranous covering of the sclera (contains blood vessels) *consist of transparent, red blood vessels which may become dilated and produce the characteristic blood shot eyes. Palpebral Conjunctiva membranous coverings of the inside of the upper & lower lid (contains blood vessels).

Normal Findings: white & clear Abnormal Findings: Conjuctivitis: inflammation of the conjuctival surfaces SCLERAE inspect for color Should be white & clear PUPILS inspect for size, shape, symmetry, reaction to light and accommodation (ability of the lens to adjust to objects at varying distances). Normally constrict with increasing light and accommodation. Normally round and can range in size from varying small (pinpoint) to large (occupying the entire space of the iris. How to check for Pupillary Reaction (Light) 1. Dim the room lights as necessary. 2. Ask the patient to look into the distance. 3. Shine a bright light obliquely into each pupil in turn. 4. Look for both the direct (same eye) and consensual (other eye) reactions. 5. Record pupil size in mm and any asymmetry or irregularity. (Accommodation) 1. Hold your finger about 10cm from the patient's nose. 2. Ask them to alternate looking into the distance and at your finger. 3. Observe the pupillary response in each eye. EYE MOVEMENT inspect for extraocular movements, nystagmus, convergence NYSTAGMUS rapid, lateral, horizontal or rotary movement of the eye *maybe seen normally as a result of eye fatigue. CONVERGENCE ability of the eye to turn in and focus on a very close object. *fails when double vision occurs usually 10-15 cm from nose. DIAGNOSTIC ASSESSMENT FOR EYE DISORDERS I. VISUAL ACUITY TEST - use Snellens Chart, Tumbling/E- Chart, Broken Wheel chart, Landolt Ring Symbol - determines the patients distance and near visual acuity. - also measures the ability to distinguish details and shapes - N = 20/20 1. Patient is placed at the prescribed distance from the chart & is asked to read the smallest line that he or she can see starting from the biggest letter. (E) 2. OD is commonly tested first & then OS 3. The patient is encouraged to read every letter possible.

4. Results are recorded as fraction. numerator: distance from the chart (20 feet) denominator: distance at which a person with normal vision can read the last line the client read. if the patient is unable to see the letter E at any distance, determine if the patient can count fingers (CF) if (-) CF, the examiner does hand motions (HM). a patient who can perceive only light is described as having LP. a patient who is unable to perceive light is described as NLP S t e p s: 1. Position the patient 20 feet from the Snellen chart. 2. Have the patient cover one eye at a time with a card. 3. Ask the patient to read progressively small letters until they can go no further. 4. Record the smallest line the patient read successfully. 5. Repeat with the other eye. 2. Confrontational Visual Field Examination - determines if the patient has a full field of vision VISUAL FIELD indicates the ability of each eye to perceive objects to the side of the center area of the vision. - Normal: 180 (half a circle) S t e p s: 1. Stand 2 feet in front of the patient & have them look into your eye. 2. Hold your hands to the side halfway between you and the patient. 3. Wiggle the fingers on one hand. 4. Ask the patient on which side they see your hands move Repeat 2 or 3 times to test both temporal fields. 3. Color Vision Tests These Tests are done to determine the persons ability to perceive primary colors and shades of colors. It is particularly significant for individuals whose occupation requires color perception: Transportation workers, surgeons, nurses, artists etc. Equipment: Polychromatic Plates Individual Colored Discs Procedure: 1. Various polychromatic plates are presented to the patient under a specified illumination. 2. The patterns maybe letters or numbers that the normal eye can perceive instantly, but that are confusing to the person with a perception defect. 3. Outcome: a. Color-blindness - person is unable to perceive the figures

b. Red-green blindness 8.0% of males, 0.4% of females c. Blue-yellow blindness extremely rare. d. II. OPHTHALMOSCOPY - provides a magnified view of the retina and optic nerve head. - a hand-held instrument called ophthalmoscope with various plus and minus lenses is used. NURSING RESPONSIBILITIES: 1. Room should be darkened. 2. Eye of the patient should be at the level of the examiner. 3. Instruct the patient to have a steady gaze. SLIT-LAMP MICROSCOPY - provides a magnified view of the anterior part of the eye - usually done after a trauma or injury - the instrument is a binocular microscope mounted on a table. This enables the user to examine the eye with a magnification of 10-40x the real image. OPHTHALMIC INSTILLATION Reference: pages 172-175 (Manual of Nursing Procedures) Ophthalmic Instillilation is the insertion of a medication in the form of liquids or ointments into the eyes. PROCEDURE: 1. Preparation: usual procedure in administration of medications 2. Position: either sitting or lying. Tilt the clients head toward the affected eye. 3. Place a drape or basin against the cheek below the eye on the affected side. 4. Assess for the following: redness, discharges, lacrimation, swelling. 5. Note for complains like itching, burning, pain, blurring 6. Observe the clients behaviour like squinting, blinking excessively, frowning, rubbing of the eyes. 7. Clean the eyelids & lashes using a sterile cotton balls moistened with sterile normal saline, and wiping from the inner canthus to the outer cantus. 8. Instill medication: - If an ointment is used, discard the first bead. - Instruct client to look up to the ceiling. - Expose the lower conjunctival sac by placing the thumb or fingers of your non dominant hand on the clients cheek bone just below the eye and gentl;y drawing down the skin on the cheek. - Using a side approach, instill onto the outer third of the lower conjuctival sac Eye drops Hold dropper 1 to 2 cm above the sac Eye Ointment - Hold the tube above the lower conjuctival sac, squeeze 3 cm of ointment from inner to outer canthus. 9. Instruct client close eyes slowly but not to squeeze them. 10. Wipe off excess solution with a gauze square. III.

OPHTHALMIC IRRIGATION OPHTHALMIC IRRIGATION is the washing out of the conjunctival sac PROCEDURE: 1. Preparation: same with ophthalmic instillation 2. Irrigation: I. Check the type, amt, temp and strength of the solution and frequency of the irrigation. II. Expose the lower conjunctival sac by separating the lids with the thumb and fore finger. III. Instruct patient to look up; avoid touching with dropper. IV. Hold the irrigator about 2.5 cm above the eye. V. Direct the solution onto the lower conjunctival sac and from the inner cantus to the outer cantus. VI. Irrigate until the eye is clear (no discharges) or until the solution has been used. APPLICATION OF AN EYE PATCH Purposes: 1. To keep an eye at rest, thereby promoting healing. 2. To prevent the patient from touching his eye. 3. To absorb secretions. 4. To protect the eye. Procedure: 1. Instruct the patient to close both eyes. 2. Place patch over the affected eyes. 3. Secure the patch with 3 or more strips of special transparent tape; tape from mid-forehead to below ear. 1. For the unconscious patient, moisten the eye patch. REMOVING A PARTICLE FROM THE EYE Equipment: local anesthesia, hand lens, cotton applicator sterile fluorescein strips , saline, antibiotic solution. Procedure: 1. As patient looks upward, evert lower lid to expose the conjunctival sac 2. With small cotton applicator dipped in saline, gently remove the particle, wipe gently across lid (inner to outer). Use magnifying lens if necessary. 3. If offending particle is not found, proceed to examine upper lid. 4. Have the patient look downward while you stand in front of him. 5. Place cotton applicator stick or tongue blade horizontally on outer surface of upper lid. Apple pressure about 1 cm above lid margin.

REMOVING A PARTICLE FROM THE EYE Procedure: 6. Grasp upper eyelashes with fingers of other hand and pull the upper lid outward and upward over cotton stick. 7. With cotton applicator moistened with saline, gently remove particle. 8. Use fluorescent strip to detect corneal abrasion. (Green stain will so indicate if abrasion is present). Nursing Alert: *Determine what the nature of particle is (wood, metal etc). *If particle cannot be removed by the method described, it may become embedded in lens or vitreous in which case an ophthalmologist is required.

The ear
is the organ of hearing. The parts of the ear include: external or outer ear, consisting of: - pinna or auricle - the outside part of the ear. - external auditory canal or tube - the tube that connects the outer ear to the inside or middle ear. tympanic membrane - also called the eardrum. The tympanic membrane divides the external ear from the middle ear.

middle ear (tympanic cavity), consisting of: - ossicles - three small bones that are connected and transmit the sound waves to the inner ear. The bones are called: - malleus - incus - stapes eustachian tube - a canal that links the middle ear with the throat area. The eustachian tube helps to equalize the pressure between the outer ear and the middle ear. Having the same pressure allows for the proper transfer of sound waves. The eustachian tube is lined with mucous, just like the inside of the nose and throat. inner ear, consisting of: - cochlea (contains the nerves for hearing) - vestibule (contains receptors for balance)

- semicircular canals (contain receptors for balance)

DEFINITION OF TERMS: OTOLOGIST a physician who specializes in the diagnosis and treatment of problems of the ear. OTOLARYNGOLOGIST a physician who specializes in problems related to the ear, nose and throat. AUDIOLOGIST an individual who specializes in non-medical evaluation and rehabilitation of hearing disorders usually not a physician. CLASSIFICATION OF HEARING LOSS : (1) Conductive loss a hearing loss due to an impairment of the outer or middle ear or both. If causative problem cannot be corrected, a hearing aid may help. (2) Sensorineural (perceptive) loss a hearing loss due to disease of the inner ear or nerve pathways; sensitivity to and discrimination of sounds are impaired. Hearing aids usually are helpful. ASSESSMENT & DIAGNOSTIC PROCEDURES NURSING HISTORY 1. Should include questions designed to reveal status of adult hearing. 2. Make use of an assessment tool. PHYSICAL EXAMINATION (Objective Assessment) Examination Techniques: Inspection Palpation Mechanical tests Otoscope examination Inspection 1. Pinna examine for size, shape, color, lesions, masses. 2. External Canal examine with the otoscope for discharge, impacted cerumen, inflammation, masses, or foreign bodies. It is normally clear with perhaps minimal cerumen. 3. Tympanic Membrane examine for color, luster, shape, position, transparency, integrity and scarring. Palpation 1. Pinna: examine for tenderness, consistency of cartilage, swelling. MECHANICAL TESTS WATCH TICK TEST Test each ear for gross hearing acuity using a whispered word or watch. Cover the ear not being tested.

A person with normal hearing can hear a whispered word approximately 4.5 meters (15 feet). A person with normal hearing can hear a tick of a watch from 30 cm (12 inches). The patient should hear the sound equally well in both ears, that is, there should be no lateralization. Weber Test test for lateralization of vibration. Place the tuning fork in the center of the scalp near the forehead Normal: (-) for lateralization Deviations from normal 1. In unilateral conduction deafness, the sound is heard best in the affected ear. 2. In sensorineural loss, the sound lateralizes to the unaffected ear. Nursing Alert: In patients with ear pain, suggest examining the good ear first. 1. Otherwise, if sensitive ear is hurt during examination, the examiner risks not getting a good look at it or the good ear. 2. If gentleness is demonstrated during examination of the good ear, patients is more likely to submit examination of the painful ear. 3. Infection could be transmitted from painful ear to good ear. Note: Tuning fork tests (Weber & Rinnes tests) are used only for screening & confirmatory purposes. Mechanical tests includes Weber & Rinnes Test. MECHANICAL TESTS 1. Test each ear for gross hearing acuity using a whispered word or watch. Cover the ear not being tested. A person with normal hearing can hear a whispered word approximately 4.5 meters (15 feet). A person with normal hearing can hear a tick of a watch from 30 cm (12 inches). The patient should hear the sound equally well in both ears, that is, there should be no lateralization. 2. Weber Test test for lateralization of vibration. Place the tuning fork in the center of the scalp near the forehead Normal: (-) for lateralization Deviations from normal 1. In unilateral conduction deafness, the sound is heard best in the affected ear. 2. In sensorineural loss, the sound lateralizes to the unaffected ear. 3. Rinnes Test compares air & bone conduction 1. Place vibrating tuning forks in the mastoid process behind the ear and have the patient tell you when the vibrating stops. 2. Then, quickly hold the buzzing end of the tuning fork near the ear canal and ask if the patient can hear it.

3. Normal: The person should hear the sound of the tuning fork when it is placed in front of the ear. 4. Normal: Sound should be heard after vibration and can no longer be felt, that is, air conduction is greater than bone conduction. This indicates that AC > BC ; a normal result called Rinne positive Deviation from normal: 1. BC > AC (Rinne negative) CONDUCTIVE HEARING LOSS 2. AC is audible longer than BC in the affected ear SENSORINEUARAL HEARING LOSS 4. SCHWABACHS TEST A tuning fork test done by masking one of the patient's ears and placing the stems of vibrating forks on the mastoid process of the opposite ear, followed by placing the forks on the examiner's mastoid process. Schwabach diminished : if heard for less time by the patient than by an examiner with normal hearing, it indicates (sensorineural hearing loss). Schwabach prolonged : If heard longer by the patient than by an examiner with normal hearing, it indicates (conductive hearing loss).

AUDIOMETRY Determines hearing range of patient in terms of dB and Hz for diagnosing conductive and sensorineural hearing loss; tinnitus can cause inconsistent results. 1. PURE TONE AUDIOMETRY Sound stimulus consist of a pure (musical tone). The patient is instructed to put on earphones and to signal (1) when he hears the tone (2) when the tone disappears. The louder the tone required before the patient hears it, the greater the hearing loss. 2. SPEECH AUDIOMETRY Spoken word/words are used to determine the ability to hear and discriminate sounds or words. ADMINISTERING OTIC IRRIGATION & INSTILLATION (Pages 180-183 of the Manual of Nursing Procedures) Definition: Administering a prescribed medication to the clients ears applied either as an instillation. Solutions ordered to treat the ear are often referred to as otic (ear) drops or irrigation. Rationale: To soften earwax To relieve pain To produce anesthesia

To treat infection or inflammation To facilitate removal of a foreign body To apply heat Equipment for irrigation: 1. Container for the irrigating solution 2. Irrigating solution as ordered 3. Rubber bulb or asepto syringe 4. Kidney basin 5. Moisture resistant towel 6. Applicator swabs 7. Absorbent cotton balls 8. Gloves (optional) Equipment for instillation 1. Correct medication bottle with a dropper 2. Cotton-tipped applicator 3. Flexible rubber tip for the end of the dropper 4. Cotton fluff PLANNING & IMPLEMENTATION 1. Verify the medication or irrigation order. 2. Prepare the client For Irrigation: (1) Explain that client may experience a feeling of fullness, warmth, and, occasionally, discomfort when the fluid comes in contact with the tympanic membrane. (2) Position: sitting or lying with head turned toward the affected ear. (3) Place a moisture-resistant towel / basin under the ear to be irrigated. For Instillation: (1) Position: side lying position with the ear being treated at the uppermost. 1. Assess the pinna for: Signs of redness, abrasion or any discharge 1. Don gloves if necessary 2. Clean the pinna of the ear and the meatus of the ear canal using a cotton tipped applicators. 6. For irrigation only. (Omit this step for Instillation) Fill the syringe with solution or hang up the irrigating container, and run the solution through the tubing and the nozzle. 7. Administer the irrigation or ear medication For Irrigation: (1) Straighten the auditory canal. INFANT gently pull the pinna downward, ADULT pull the pinna upward and back. (2) Insert tip of the syringe in the auditory meatus, and direct the solution gently upward against the top of the canal. (3) continue until all the solution is used or the canal is cleaned. (4) Dry outside the ear with absorbent cotton balls, place cotton fluff in the auditory meatus. (5) Assist the client to a side lying position on the affected side


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For Instillation: (1) Warm the medication container. (2) Partially fill the ear dropper with medication. (3) straighten the ear canal.-Instill the correct number of drops along the side of

ear canal. (4) Press gently but firmly a few times on the tragus of the ear. (5) Ask client to remain in the side lying position for about 5 mins. (6) Insert a cotton fluff loosely at the meatus of the auditory canal for 15-20 mins.