What are the age-related changes to the eyes?
most common causes of vision decrease are
1. cataract formation
2. glaucoma- increased intraocular pressure gradual loss of peripheral vision
3. macular degeneration- breakdown of cells in macula of retina, loss of central most accurate vision, most commo
Explain how to assess the pupillary light reflex and consensual light reflex?
The pupillary reflex occurs when in a darkened room the examiner shines a penlight from the client's side and shine directly into one eye while the client looks straight ahead. The pupil should constrict- note the size of the pupil before and after. The c
Explain how to test for accommodation?
To test for accomodation, the person focuses on a distant object and then shifts the gaze to a near object about 6 inches away. At near distance, you would expect the pupils to constrict, and the axes of the eyes to converge. (see Fig. 14-19, p. 296).
PERRLA
Pupils Equal Round React to Light and Accommodation
Explain how to use the Snellen test and what do the readings mean, for example, O.D. 20/40-2, with contacts?
Top number (numerator)- distance person is from chart
Bottom number (denominator) is normal distance a normal eye can see the chart line.
"You can read at 20 feet what a normal eye can see from 40 feet away." -2 means missed 2 letters
Larger denominator,
Explain how to use the handheld vision screener for near vision and what is a normal finding and what does it test for?
Vision screener for near vision
Jaeger card is held 14 inches away- the opposite eye being tested is covered and the client read the smallest line possible.
14/14 is normal.
Presbyopia is decrease in power of eye accomodation with aging- see person move c
Presbyopia
Presbyopia is decrease in power of eye accomodation with aging- see person move card further away and have problems reading smaller print.
Explain how to perform the confrontation test and what is the test used for?
Gross measure of peripheral vision
Eye level, 2 feet apart. Cover your opposite eye to client being tested and use flicking finger and advance periphery several directions and as you can see the finger- does the client? Client says, "now" when she/he sees
Explain the purpose of the corneal light test and how to perform it?
Also called Hirschberg test
Screen to test parallel alignment of eye axes.
12 inches away from client, shine light onto corneas and see if same level the light shines on both eyes.
Abnormal: asymmetry of light reflex will need to perform cover test.
Hirschberg test
corneal light test
Explain when the cover test is used and how to perform it?
When a client fails the screening corneal light reflex.
Have client stare away at your nose. Cover one eye and client continues to stare that direction. Note that the uncovered eye should have a steady fixed gaze. Uncover the covered eye and it should hav
Explain how to perform the 6 cardinal positions of gaze and what is it used for?
Test EOMs- extraoccular movements
See page 291
Hold finger or pencil 12 inches away so person can focus on the object and follow it through the 6 cardinal positions of gaze
Normal: parallel tracking of object with both eyes; charted as EOMS intact x 6
Abn
Explain the two types of hearing loss and the causes?
Conductive hearing loss- mechanical dysfunction of external or middle ear because of impacted cerumen, foreign body, perforated tympanic membrane, pus or serum in middle ear, or otosclerosis (decrease in movement of ossicles). If the amplitude is increase
Conductive hearing loss-
mechanical dysfunction of external or middle ear because of impacted cerumen, foreign body, perforated tympanic membrane, pus or serum in middle ear, or otosclerosis (decrease in movement of ossicles). If the amplitude is increased, the person can hear.
Sensorineural or perceptive loss is
Sensorineural or perceptive loss is pathology of inner ear, CN 8 or auditory area of cerebral cortex, or age-related gradual nerve degeneration and or use of ototoxic drugs called presbycusis.
pathways for hearing
Normal pathway for hearing is air conduction. Alternate route is bone conduction.
Explain the subjective and objective data for vertigo and why a person has it?
Vertigo- spinning, twirling sensation because of dysfunction of labyrinth
Objective vertigo: feel like room spins
Subjective vertigo: feels like individual is spinning
Make sure to distinguish from dizziness or light-headedness
What are age-related hearing changes?
Cilia lining ear become coarse and stiff leading to accumulation of cerumen reducing hearing. Impacted cerumen is common in aging adults. (Use ceruminolytics or wax-softening agents to help with removal of excess wax or manual irrigators).
Cerumen gets dr
What are the two types of cerumen and which group of people have which type?
1. Dry cerumen, gray, flaky, forms thin mass in ear canal (Asians and Native Americans)
2. Wet cerumen, honey brown to dark brown, moist (Caucasians and African Americans)
What is a reason for tinnitus and what is the definition?
Ringing, crackling, buzzing in ears.
Reasons: ototoxic meds- medications that can cause damage to the inner ear leading to tinnitus, balance problems and hearing problems: aspirin, aminoglycosides, ethacrynic acid, furosemide, indomethacin, naproxen, quin
What is the proper way to clean the ear canal before an exam, if needed?
If the eardrum is intact and no current infection is present, then use warmed mineral oil with hydrogen peroxide to soften ear wax. Then irrigate with warm water (body temp.) using a bulb syringe or low setting of a Water Pik. Direct the fluid to the post
When assessing the ear, what does it mean if the tragus or pinna is tender?
When moving the pinna and pushing on the tragus, it should feel firm and not produce pain.
Otalgia, or pain in the ear occurs with otitis externa, also called Swimmer's ear, see page 341 (inflammation of outer ear and ear canal) and furuncle (painful, red
Otalgia
, or pain in the ear occurs with otitis externa, also called Swimmer's ear, see page 341 (inflammation of outer ear and ear canal) and furuncle (painful, reddened, infected hair follicle on tragus on cartilage part of ear canal, see page 345).
When performing the otoscopic exam, what position of the ear is needed for the adult to see into the ear canal? What is the difference for a child?
To straighten the ear canal:
Adult: Pull pinna up and back
Child younger than 3 years: pull pinna straight down
Describe the normal findings of the tympanic membrane for the right and left ear?
Over-all TM is shiny, translucent, pearl gray color, may see landmarks as described in book, page 324, fig. 15-3.
Right ear: cone-shaped light reflex is in the 5'o clock position in right drum in the anteriorinferior quadrant.
Left ear: cone-shaped light
Explain how to perform the whispered voice test (Whisper test) and significant abnormal finding?
Have client place finger on tragus of opposite ear to keep from hearing with opposite ear. Stand slightly behind client and 1-2 feet from their ear and cover your mouth so they can't lip read. Whisper a set of 3 random numbers and letters and ask the clie
Weber Test-
used to evaluate hearing in a person who hears better in one ear than the other; tests bone conduction. The tuning fork is tuned to frequency of normal speech, 512 cycles/sec.
Vibrating fork on middle of skull and the nurse asks if she hears the sound in
Rinne test-
performed after Weber. Compares air conduction of sound with bone conduction.
Place vibrating fork over mastoid process after striking it and ask to tell when it stops vibrating; note length in seconds. Next, move the vibrating tuning fork next to ear ope
Explain how to perform the Romberg test and what it is used to test for and what is an abnormal finding and a normal finding?
Assess ability of vestibular apparatus in inner ear to maintain standing balance. Assesses CN VIII. Assesses intactness of cerebellum and proprioception.
Ask client to stand with feet together and arms at sides; first with eye open and then eyes closed. W
What are the age-related changes for the nose, mouth, and throat?
In aging adults, loss of subcutaneous fat may make the nose appear more prominent. Older adults also may experience a decreased sense of smell and taste from decrease in olfactory nerve fibers and atrophy of epithelium in tongue and cheek leading to decre
If tooth loss occurs
If tooth loss occurs, the remaining teeth drift, causing malocclusion. The stress of chewing with maloccluding teeth causes the following problems:
Excessive bone resorption with further tooth loss.
Muscle imbalance resulting from a mandible and maxilla n
If a client is a mouth breather and the nurse needs to assess for a deviated nasal septum, how is this done? Explain how to test the CN I?
CN I is not routinely assessed unless client complains of decreased or absent smell. Can have close eyes and smell open alcohol pad, or cotton dipped into coffee.
Deviated septum is common and not significant unless air flow is obstructed. Check patency o
Explain what findings a nurse would find if a client has a sinus infection when using transillumination? How is it performed?
The diagnosis requires distinct differences in the illumination of one of the sinus pair. It woulf help in chronic sinusitis that has diffuse swelling of all sinus mucosa. Note that it is not very accurate and not usually performed since it does not disti
Explain the grading system for tonsils?
1+ visible
2+ halfway between tonsillar pillars and uvula
3+ touching the uvula
4+ touching each other
Normal: 1+
Acute infection- tonsillitis, see enlargement above 1+
Explain the following cross-cultural care related items:
Cleft lip, see page 375 and palate, see page 381- most common in Asian-American newborns and American Indians. Less common in Caucasians and least common in African Americans
Torus palatinus- benign bony ridge runs in the middle of the hard palate; higher
What unique characteristics should you expect while assessing RJ since she is Native American?
What are some problems you have noted from the interview?
What additional assessments should you make in addition to the screening exam?
Native Americans have different cerumen- dry, gray and flaky.
May have bifud uvula- happens in 18% of some Native American groups.
Problems: frequent migraines; stress at work; does not use safety glasses- previous injury to cornea from metal; allergies-
temporal artery What is the difference between normal as with RJ and abnormal?
Normal- smooth, pulse present, normal +2
Abnormal- tortuous, hard and tender- see with temporal arteritis.
Temperol arteritis, the artery is tortuous and feels hard and it is tender. Client will have visual disturbances such as diplopia, loss of vision or
Nurse Assesses TMJ just below the temporal artery and anterior to tragus
Abnormal- see crepitation, limited ROM, and or tenderness
sinuses abnormals
The nurse inspects RJ's face She shows where the pain is, especially if she bends over, and she has dark circles
sinusitis
inflammad sinus lining, excess mucous, and infection
1cm are warm, tender, firm, but freely moveable. Deep cervical node
infection
if not moveable points to cancerous
Anterior Cervical (both superficial and deep location
Nodes that lie both on top of and beneath the sternocleidomastoid muscles (SCM) on either side of the neck, from the angle of the jaw to the top of the clavicle. This muscle allows the head to turn to the right and left. The right SCM turns the head to th
Anterior Cervical (both superficial and deep DRAINAGE
Drainage: The internal structures of the throat as well as part of the posterior pharynx, tonsils, and thyroid gland.
Posterior Cervical:
Extend in a line posterior to the SCMs but in front of the trapezius, from the level of the mastoid bone to the clavicle.
Posterior Cervical drainage
Drainage: The skin on the back of the head. Also frequently enlarged during upper respiratory infections (e.g. mononucleosis).
Tonsillar
Located just below the angle of the mandible.
Tonsillar drainage
The tonsilar and posterior pharyngeal regions.
Sub-Mandibular: & drainage
Along the underside of the jaw on either side.Drainage: The structures in the floor of the mouth.
Sub-Mental:
Sub-Mental: Just below the chin. Drainage: The teeth and intra-oral cavity.
Supra-clavicular
Supra-clavicular: In the hollow above the clavicle, just lateral to where it joins the sternum. Drainage: Part of the throacic cavity, abdomen.
Trachea asssessment
How did the nurse do this?
What is a normal finding?
What is an abnormal finding?
RJ trachea shifts to the left side- what could be going on?
The nurse places the index finger on the trachea in the sternal notch and slides it off to each side. The space between the trachea and sternomastoid muscle should be symmetrical on both sides- normal is midline trachea.
Abnormal- tracheal shift
Towards u
which way tachea will shift with different diseases
Towards unaffected, healthy side with aortic aneurysm, tumor or unilateral thyroid lobe enlargement or pneumothorax.
Trachea is pulled toward affected, diseased side of large atelectasis, fibrosis of lung.
Tracheal tug is a pull downward synchronous with
The nurse assesses the thyroid using the posterior approach
How did the nurse do the assessment?
What is a normal finding?
What finding would you expect RJ to have?
What additional assessment needs to be performed?
What lab test is needed to assess the th
RJ sits up straight with head bent slightly forward and to right. The nurse uses fingers of left hand to push the trachea slightly to the right and curves fingers between trachea and sternomastoid muscle, retracting it slightly. Nurse palpates as RJ takes
The nurse now examines RJ's eyes
Eyebrows are symmetrical
Eyelids meet when closed
Eyelashes evenly distributed
Conjunctiva are pale on lower lid; sclera clear and white
No redness or edema in lacrimal apparatus.
Snellen chart- 20/30 without lens; 20/20 w
Pallor in lower lid is an indication of anemia- needs hemoglobin/hematocrit
She can read at 20 feet what a normal eye can see at 30 feet; has myopia; floaters common with myopia (near sighted, hyperopia is farsighted)
A shade or cobwebs of the vision- mor
normal confrontation test findings
Confrontation test- gross measurement of peripheral vision. How should the nurse perform this?
Client has 50 degrees upward, 90 degrees temporally; 70 degrees down; 60 degrees nasally.
Hirschberg test (Corneal light reflex)
Nurse shines light about 12 inches away as RJ stares straight ahead.
Light seen at same spot in both eyes.
Is the client normal?
What is an abnormal finding, if not the one described above?
Abnormal is deviation of alignment from eye muscle weakness or paralysis. If abnormal, do the cover test. Eye uncovered is fixed on object. When the covered eye is uncovered it will drift.
Phoria is mild weakness and tropia is constant malalignment of eye
Testing EOMs how to do it and what an abnormal finding indicates
Six cardinal positions of gaze or diagnostic positions test- target 12 inches away from client; head held steady; eyes follows finger or object
Failure would be weakness in an extraocular muscle or dysfunction of CN innervating it.
Nystagmus, from disease
The nurse examines RJ's pupils
Pupils- size and are they equal and if round or irregular
No presence of aniscoria (may indicate neuro disease; only 5% normally have unequal pupils); pupils round
Pupillary light reflex- direct light reflex and consensual light reflex (size of pupils in
Next the nurse inspects the ocular fundus (internal surface of the retina)
Black numbers indicate postive diopter; focus on objects near
Red numbers negative diopter to focus on objects farther away
Contact lens may be left in; no physical obstruction of view like glasses
Inspects external ears-
Inspects external ears- equal size, shape and properly aligned on head; L ear external auditory meatus is swollen and red and has purulent discharge present
Tilts head of client slightly away from nurse and straightens ear canal- how
Adult ear canal is straightened by firmly pulling the pinna up and back.
difference between right and left ear, and what a normal and infected TM looks like
Pix on left is the right ear because the light reflex is at 5 O'Clock in the anteroinferior quadrant; normal tympanic membrane- shiny, translucent with pearly gray color.
Pix on right is left ear drum with light reflex at seven O'Clock and it is infected-
Whispered voice test-
can repeat 3 random numbers and letters correctly with right ear and unable to repeat words on left ear.
A whisper is high frequency and can be used to detect high tone loss.
A tuning fork test measures hearing by air conduction or bone conduction.
Test i
Info about AC and BC
The AC route is through the ear canal and middle ear; usually more sensitive route. Bone conduction is transmission of sound through bones of skull to cohlea and auditory canal.
"According to Jarvis (2011), the Weber and Rinne tests according to evidence
Rinne Test
Compares air and bone conduction
Strike tuning fork on hand; place base of fork on mastoid process to test bone conduction; ask RJ to tell you when she hears it no longer- time it in seconds.
Then immediately move the tines to 1-2 cm or � inch from the me
Results of Rinne Test
Normal- AC is twice as long as BC
Abnormal- BC longer or same as AC is conductive hearing loss; if loss on one side, probably external or middle ear disease; look at TM
Romberg Test
Assess RJ's equilibrium
Asks RJ to stand with feet together and arms at sides; first with eye open and then eyes closed.
Wait 20 seconds and assess.
Mild swaying is present, but able to keep balance.
Normal Romberg test- assesses CNVIII
If abnormal, would
Nostril patency-
Nostril patency- pushes each nostril shut and has RJ sniff in through opposite nostril
RJ has limited ability on her left side.
Lack of patency is sign of infection or obstruction.
Also if breathing was noisy or drainage present- same thing.
Cues support
Paranasal sinuses are palpated
frontal sinuses below eyebrows and maxillary sinuses below cheekbones.
RJ complains of tenderness in both areas.
Nasal cavity
Nasal cavity is inspected using a nasal speculum. Inserted horizontally with blades closed into nares. Avoids sensitive septum, and opens blades and visualizes inferior turbinates and with head tilted back looks at middle meatus, middle turbinates. Examin
Transilluminate the Sinuses what no transillumination would indicate and where you would shine the light
Because the sinuses are filled with fluid there is no transillumination. This supports the infection.The nurse shines a pen light onto RJ's frontal sinus over each eye and hold the hand over it.
No red glow is seen
The nurse then shines the light directly
The Nurse Assesses RJ's Mouth and Throat examples of what you would document/look for
RJ has her original teeth; no C/O dental related pain
Lips- pink, moist, symmetrical without craking or lesions.
Teeth- white, straight, evenly spaced, free of decay. RJ is asked to bite down and the teeth are aligned with front teeth of upper slightly ov
Comparing Headaches Migrains
migrain- PF- stresee, menses, chocolate, cheese, trigger foods. S/S- V/V, visual disturbances, photophobia, located around eye temples and forehead. Relief- rest, cool, dark room, and analgesics, such as NSAIDS or narcotics.
Comparing Headaches Cluster
PF- alcohol, ingestion, daytime napping. S/S- eye redness, tearing, nasal congestion. Relief- walking back and forth can relieve it
Comparing Headaches Tension
PF- anxiety, stress, S/S- tight, viselike pain in frontal, temporal or occipital region. Relief- local heat, massage, analgesics, muscle relaxants
Comparing Headaches Meningitis HA
PF- Infection in the meninges of the brain
S/S- Stiff neck, photophobia, and other neuro signs
Relief- Antibiotics if bacterial meningitis,
Cool, dark room, and analgesics/narcotics
Health Promotion Goals: Eyes
Decrease effects of eye disease associated with aging: presbyopia, diabetic retinopathy, glaucoma, cataracts, macular degeneration
Clients with DM- annual dilated eye exam to establish retina health
Prevent occupational or recreational risk for eye injury
Cranial Nerves: Eye Exam
CN II- optic nerve- visual acuity, visual fields, fundoscopic exam
CN III- occulomotor- cardinal fields of gaze, inspect eyelids, pupil reaction direct/consensual/accomodation
CN IV- trochlear- cardinal fields of gaze
CN V- abducens- cardinal fields of ga
Health Promotion: Hearing
Ear protective devices and measures to decrease industrial noise
Keep volume down on MP3 players, etc.
Access to assistive hearing devices
Screening of hearing
Sun protection- helix prone to cancer
Monitor ototoxic drugs- aminoglycosides, vancomycin, ibup
Non-verbal Cues of Hearing Problems
Leaning forward and positioning good ear to hear
Concentration on lip or face movement and not eye contact
Answering incorrectly
Asking to repeat questions
Levels of auditory system
1. Peripheral- ear transmits sound and converts vibrations into electrical impulses; sound waves produce vibrations on TM; travel to ossicles and to oval window to cochlea, basilar membrane, organ of corti to CN VIII to brainstem
2. Brainstem- can determi
tobacco
The health risks of smokeless tobacco (SLT) are discussed. The two types of SLT most commonly used in the United States are chewing tobacco and snuff. These products contain cancer-producing chemicals, such as nitrosamines, that cause an increased risk fo