NURS 125 Eyes, ears, and mouth

CN I-olfactory

sensory nerve responsible for smell and plays a key role in the sense of taste

• assessment: through identification of odours presented to each nostril while the other nostril is occluded

CN II-Optic

sensory nerve that controls vision, visual acuity, field of vision

• involved in the pupillary light response

  → assessment:

• visual acuity tested using the Snellen chart for distance vision

• colour perception using pseudoisochromatic plates(colour blindness twst)

• fundoscopic exam(ophthalmoscope)

CN III-Oculomotor

motor nerve controls movements of the eyeball (up, down, medial) and upper eyelid

• Assessment:

  • Pupil response→ Shine a light into each eye (check for direct and consensual response).

  • Accommodation→ Ask the patient to focus on a near object (check for pupil constriction).

  • Eye movement→ Have the patient follow your finger in 6 cardinal directions( draw an H with your finger)

CN IV-trochlear

motor nerve that controls eye movement (downward and inward)

• Assessment: Ask the patient to follow your finger as you move it toward their nose (testing downward and inward eye movement).

CN V-trigeminal

sensory: general sensation in face, scalp, corneas, nasal and oral cavities

• assessment→ Lightly touch(cotton swap) the forehead, cheeks, and chin on both sides of the face and ask if the sensation is the same on both sides aka “dull/sharp test”

  • pain and temperature- use cool end of tuning fork

motor function: chewing

• assessment→ Ask the patient to clench their teeth while palpating the masseter and temporalis muscles to check for strength

  • move jaw side to side as examiner attempts to push midline in each direction

CN VI-abducens

motor nerve involves movement of the eye(lateral, outward)

• assessment→ Ask the patient to follow your finger as you move it laterally (test for the ability to move the eye outward).

CN VII-facial

motor: facial expressions

• raise eyebrows, show teeth

• puff cheeks/close lips tight

• close eyes tight→ 7 hook(closes the eye)

• secretion of saliva

parasympathetic:

• lacrimal glands→ ask about dry eyes

• salivary glands→ ask about dry mouth

sensory: taste anterior 2/3 of the tongue

• external ear sensation→ contracts the stapedius muscle

CN VIII-Vestibulocochlear(auditory)

sensory nerve controlling hearing and balance

• observe eyes for nystagmus(rapid, uncontrolled eye movements)

Assessment: Hearing: Perform Rinne and Weber tests with a tuning fork.

• perform Romberg test(measures a person’s sense of balance)→ needs proprioception, vision, and vestibular function

• whisper test

• Balance: Ask if the patient feels any dizziness or unsteadiness.

CN IX-glossopharyngeal

• sensory→ taste and sensation from back of tongue

• motor→ swallowing and speech

• parasympathetic→ saliva secretion

• assessment→ Taste on the back 1/3 of the tongue, swallowing, salivation, gag reflex

CN X-vagus

sensory: taste and sensation from epiglottis and pharynx

motor: swallowing and speech

• Ask the patient to say "ah" and observe the uvula. It should remain midline

  • assess palatal arches- damaged side cannot counteract(look for lowered and flattened palatal arch)

• parasympathetic→ muscle contraction of thoracic and abdominal organs and secretion of digestive fluids

CN XI-accessory

motor→ head shoulder movement(larger muscle control) e.g. sternocleidomastoid

• Shoulder shrug and head turn

• Ask the patient to shrug both shoulders against resistance. Also, ask them to turn their head against resistance on each side.

CN XII-hypoglossal

motor→ movements of the tongue, cheek, and jaw

• Ask the patient to stick out their tongue. Check for asymmetry, atrophy, or tremors. Ask the patient to move the tongue from side to side.

general survey of eyes and ears

look at the overall impression

• observe the skin→ colour, rashes/tags, other

• anatomy→ as expected, symmetry

• movement→ expected

• look at the presence of eyebrows, lashes

• look at the skin around the eyes and ears

• behaviour→

myopia

a common vision condition where close objects are seen clearly, but distant objects appear blurry, also known as nearsightedness

hyperopia

a vision condition where distant objects are seen clearly, but close objects appear blurry, also known as farsightedness

presbyopia

vision deteriorates with age, making it difficult to focus on close objects.

astigmatism

a common refractive error caused by an irregular shape of the cornea or lens, leading to blurred or distorted vision at all distances

photophobia

sensitivity to light, causing discomfort or pain in bright environments

strabismus

a condition in which the eyes do not properly align with each other, often resulting in double vision or the inability to focus on a single object

diplopia

the perception of two images of a single object, commonly known as double vision

Health History

PERMAFRost

Past medical history

Examination

Radiographs

Medications

Allergies

Family history

Review of systems

Oral conditions

Social history

Treatment history

physical assessment of the eyes

inspection and palpation(only)

inspection: looking into all part of the anatomy from the eyebrow to the pupil

• can be uncomfortable so wear a mask

• take note of differences in anatomy due to aging e.g. no eyebrows in elderly

conjunctiva and sclera assessment

conjunctiva→ thin, transparent membrane lining the inner eyelids and covering the sclera

expected: clear, some small blood vessels

Sclera→ white part of the eye

expected- white

Assessment: gently pull down underneath the eyelid with finger pads to inspect sclera and conjunctiva

anisocoria

unequal pupil sizes that can indicate neurological issues or trauma(can be harmless)

miosis

small constricted pupils, eyes are asymmetric, different looking eyelids that can indicate trauma

mydriasis

dilated pupils that can be normal if given eye drops but can also indicate brain injury

arcus senalis

• discolouration around the cornea that represents cholesterol deposits that have affected the eye

• common in older adults

• greater concern in young people

pupillary light response

pupils should respond symmetrically and expected when a light source is introduced

• look for direct and consensual response

• look at the pupil the light is shinning on as well as opposite eye pupillary response(to make sure pupils are responding as they should)

• this test is done with every eye related appointment and on all newborns

visual acuity

tests body and eye anatomy ability to accommodate to see far and near

• Snellen test→ measures distance visual acuity

• Jaegar test→ measures near vision

Snellen’s test

distance visual acuity that is considered the gold standard

• distance from the chart(always 20 feet)

• 20/20= normal vision

• legal blindness is best corrected vision 20/200

• The numerator (20) refers to the distance at which the test is conducted (usually 20 feet).

• The denominator (20) represents the distance at which a person with normal vision can read the same line of letters.

Jaegar test

measures near vision

• chart with letters are placed 14 inches from the eyes

• read to smallest letter(i.e. 14/14)

macula

small, central part of the retina in the eye

• responsible for sharp, detailed vision needed for activities like reading, driving, and recognizing faces

• contains a high concentration of photoreceptor cells (rods and cones), especially cones, which help with color vision and fine details.

• Damage to the macula can lead to macular degeneration, affecting central vision.

static and kinetic confrontation

Static confrontation:

• examiner holds up a static (non-moving) number of fingers in different areas of the patient’s visual field while one eye is covered

• The patient identifies the number to check for blind spots or peripheral vision loss.

Kinetic confrontation:

• examiner moves a small object or wiggling fingers from the periphery toward the center while the patient states when they first see movement

• This tests the patient’s ability to detect motion and peripheral vision range

red light reflex

the reddish-orange reflection seen in the pupil when light from an ophthalmoscope shines into the eye

• It helps check for eye health and detect conditions like cataracts, retinal detachment, or tumors.

• A normal red reflex means there are no major blockages in the ey

• important screening tool for children(retinoblastoma)

how to perform the red light reflex

• Darken the room to make the reflex more visible.

• Use an ophthalmoscope and set it to 0 diopters.

• Stand about 2 feet away and shine the light into the patient's eyes.

• Look for a red or orange glow in both pupils.

• If the reflex is white, dim, or absent, further evaluation is needed.

air conduction

how sound travels through the air, entering the ear canal, passing through the eardrum and middle ear, and reaching the inner ear (cochlea) to be processed by the brain

• It is the normal way we hear sounds, like voices or music.

• most efficient and usual pathway for sound to travel to the inner ear

• measured using Rhinne’s test→ place tunning fork on the mastoid process(bone conduction), when patient stops hearing it move the tunning fork towards the ear(air conduction)

Bone conduction(BC)

bypasses the external ear and delivers sound ways/vibrations directly to the inner ear via the skull

conductive hearing loss

caused by blockage in the ear canal or middle ear(wax or fluid)

• wax blockage can easily be removed

• fluid buildup needs further testing

• Conductive Hearing Loss: Bone conduction (BC) is greater than or equal to air conduction (BC ≥ AC).

sensorineural hearing loss

caused by damage to the inner ear, nerve, or brain

• common causes→ aging, loud, ototoxic drugs

• presbycusis= age related hearing loss

• hypertension linked to hearing loss

tinnitus

ringing or noises in the ears

vertigo

type of dizziness related to the inner ear or something else(more detailed assessment)

otalgia

earaches/ ear pain

infections/discharge

otorrhea

Inspection and palpation

inspection: know the anatomy of the ear

• notice if something looks different

Palpation:

• palpate the lobe for lesions, cysts, etc

• triangle fossa, helix→ assess how they bend to ensure cartilage is there(especially young kids)

how to use otoscope in the ear

• adult: pull the pinna up and back

• infant/child under 3: pull pinna straight down→ pull cartilaginous structure away

bracing technique

used to stabilize the otoscope and prevent injury while examining a patient’s ear.

• How to Perform It:

  1. Hold the otoscope like a pencil, using your dominant hand.

  2. Rest the side of your hand or fingers against the patient’s cheek or head to steady your hand.

  3. Gently pull the ear (up and back for adults, down and back for children) to straighten the ear canal.

  4. Insert the otoscope slowly while keeping your hand braced to prevent sudden movement if the patient shifts.

• left hand to left ear, opposite hand supporting

whisper test

evaluates for loss of high-frequency sounds and shows the highest specificity for identifying hearing loss

• 60 cm away from the person, one ear is closed(press gently on tragus), one is open

• whisper something(numbers and letters) person should be able to hear clearly in both ears

• it is the 1st assessment of hearing, if it fails move onto Weber and Rhine’s test

weber test

tunning fork either 512 or 1024hz vibrated on forehead

• normal findings: no lateralization

• Conduction hearing loss(CHL)= lateralization to diseased ear

• Sensorineural(SNHL)→ lateralization to healthy ear

rinne test

measures better bone conduction vs air conduction

• air conduction should be better than bone conduction

• tunning fork(512 or 1024 hz) vibrated first in front of ear on the mastoid process

• normal finding: better air conduction

• CHL→ better bone conduction

• SNHL→ cannot be teste

cataract

lens fills up with fluid and plaques

• becomes opaque making it difficult to see

• can cause blindness

gingivitis

inflammation and infection of the gums

cavities

very small hole that forms on the surface of a tooth

oral cancer

disease resulting from abnormal cell growth in the mouth, lips, tongue or throat

general survey of the mouth

• uniform colouring of lips, mouth, and area around the mouth

• are there rashes, tags, and tags?

• observe tongue movement and teeth

history of present illness

Location

Associated signs and symptoms

Timing

Exposure/environmental factors

Reliving factors

Severity

Nature/quality

Aggravating factors

Patient perspective

significance to the patient

Physical assessment

inspection of the lips, mouth, tongue, ulva, teeth

• use tongue depressor to move the cheeks away

• look at the inside of the cheeks for lesions, colourations, etc

  Expected findings:

• ulva should be present

• complete upper and lower palate

palpation of the lips(not a lot of palpation is done) with gloved hand

red flags

• trauma to the eyes or ears→ e.g. Battle’s sign or raccoon eyes

• sudden changes in vision of hearing

• fluid leaking from the ears flowing head trauma→ could potentially be Cerebrospinal fluid leaking out