N190 Physical Assessment Week 2 Ears Eyes Nose

Snellen Chart

Testing Distant Vision

• Stands 20 ft away

• Checks Visual Acuity

• Normal 20/20

  • Ex: 20/30 the pt reads at 20 ft what a normal person reads at 30 ft

• Pt states having trouble seeing the whiteboard- do this test

• If they can read 7-8 letters on one row, have them go to the next row down

• if less than 7-8 letters then have them go back one row up

• legally blind is 20/200

Myopia

Inability to see objects at a distance (Near-Sighted)

Hyperopia

Inability to see objects at close range (Far-Sighted)

Rosenbaum Chart

Testing Near Vision

• Distance of 12 ft

• Normal= 14/14

Presbyopia

Inability to accommodate for near vision (age-related far sightedness)

• Common in 65+

• Normal Eye Condition for elderly aka Age Related

• Drooping appearance, loses elasticity, weakened muscles, decreased tears (dry eyes)

• “Age related farsightedness”

Direct Confrontation

Testing Peripheral Vision (Nurse and Pt cover one eye)

6 Fields of Cardinal Gaze

H Method or Wagon Wheel

• Looking for Nystagmus (fluttering of the eyeball) weakness in extraocular muscles or cranial nerve 3, 4, 6

• Penlight 12 inches away

Hirschberg Test Corneal Light Reflex

• Twinkle in both eyes

• If the light is not symmetric= weakness in extra ocular muscles

• Shine light between eyes

Cover/Uncover Test

Steps:

1. Cover one eye with card and observe uncovered eye (focused on a distant point)

2. Quickly remove card and observe the eye for movement

3. Normal: It should focus straight ahead

• Test determines balance mechanism (Fusion Reflex)- Keeps eyes Parallel

• Abnormal: Strabismus: Lazy Eye/Cross Eye. Needs eye glasses

Inspection of the Eye

One Eyelid Drooping= Ptosis, dysfunction of CN III

Accommodation

• Hold a Penlight 4-5 inches, then ask the pt to shift the gaze from distant point to the penlight

• Normal: Eyes converge (turn inward), pupils constrict as it focuses on penlight

• Lack of Convergence: Dysfunction in CN 3,4,6

Red Reflex

Using Ophthalmoscope

• Abnormal: Milky or Yellow

• Uses your right hand and right eye and stand on the right side of the patient and then switch

Miosis

Contraction of the pupil

Cataracts

Older adults are at risk, leading cause of blindness, cloudiness in the lens

• An opacity in the lens; usually occurs in aging

• Among African Americans, are the leading cause of blindness

Wharton’s Ducts

• Submandibular open close to the lingual frenulum

• Salivation

Tonsil Grades of Swelling

• Grade 0: Absent

• Grade 1 (Normal): Tonsils are hidden behind the tonsillar pillars

• Grade 2: Tonsils extend to the edges of the tonsillar pillars

• Grade 3: Tonsils extend beyond the edges of the tonsillar pillars but not to the midline

• Grade 4: Tonsils extend to the midline

Acute Glaucoma

Sudden increase in IOP

• Pupil is oval shaped and dilated

• Red Sclera, Yellow Patches

• Damage to the Optic Nerve

• Cornea= Cloudy

• Pain!

• Decrease in vision and halos around lights

• Risk Factors:

  • African American

  • Over 60

  • Prolonged Steroid Use or High Dose

  • Hereditary

  • Eye Injury: Blunt Force Trauma

  • Hypertension

Age Related Macular Dengeneration (AMD)

• Degenerative condition of the macula, the central retina, causing the gradual loss of central vision (not peripheral)

• Risk Factors:

  • Hypertension

  • Cigarette Smoking

Ears

• Adult: Pull Pinna up and Out

• Infant: Down and Back

• Irrigate with WARM water if there is an obstruction from an object like an insect

• if too much cerumen first choice is hydrogen peroxide and mineral oil drops

• No soap, no cold water, no QTIP

Tympanic Membrane

• Flat, Gray, Translucent and Shiny

• Cone Shape reflect at 5 o clock= right, 7 o clock in left ear

Whisper Test

• Evaluated acquit of high frequency sounds

• Ask client to occlude left ear

Tuning Fork

• Used to evaluate auditory

• Produce Sound Waves

• Evaluate Conductive vs Perceptive Hearling Loss

Types of Conduction

• Air Conduction: Transmission of sound through the tympanic membrane to the cochlea and auditory nerve

• Bone Conduction: Transmission of sound through the bones of the skill to the cochlea and auditory

• Bone

  • Strike the Fork

  • Place it on Mastoid Process

  • Have the Client tell you when the sound is no longer heard

  • Note number of Seconds

• Rinne Test: Air Conduction

  • Should be 1-2 cm front of external auditory meatus

  • Note when sound is no longer heard

  • AC twice as long as BC= Normal

Weber Test

• Bone Conduction to evaluate hearing in person who ears better in one ear than the other

• Place base of vibrating tuning fork against the skill- midline of the anterior portion of frontal bone

• Record which ear hears betters (laterallization in right ear means you have problems in right ear)

• (If its louder in one ear then that’s abnormal)

Romberg Test

• CN VIII

• Tests balance and equilibrium

• Stand with feet and arms together at side

• close eyes

• wait 20 seconds

• Should maintain position with mild swaying

• Normal: Minimal/No Swaying

Otitis Externa

• Infection of Outer Ear

• “Swimmer’s Ear”

• Redness & Swelling of Auricle and Ear Canal

• Drainage is usually scanty (Not a lot)

• Itching, Pain, fever, enlarged lymph Nodes

• Tympanic Membrane will be normal

Otitis Media

• Infection of inner/middle ear

• Producing a painful, red or yellow bulging eardrum, fever, and hearing loss

• Exam reveals absent light reflex

• More common in children who auditory tubes are wider, shorter & more horizontal- easier access for infection from pharynx

Tophi

• Small white Nodules on the helix or antihelix

• Nodules contain uric acid crystals= sign of gout

Epistaxis

• Nosebleed

• Because of trauma, rhinitis, hypertension

Sinusitis

• Inflammation of sinus usually following upper respiratory infection

• Causes facial pain, inflammation and discharge

• Fever, chills, frontal headache

• Dull, pulsating pain in cheeks or teeth

Ankyloglossia

• Fixation of the tip of the tongue to the floor of the mouth

• Shortened Frenulum

• Corrected Surgically

Ulcers- Canker Sores

• Small, Round, White lesions

• Associated with stress, exhaustion, allergies to certain food

• Pain when contact with tongue

Black Hairy Tongue

• Caused by inhibtion of normal bacteria & overgrowth of fungus on papillae of the tongue

• Extended use of antibiotics

Gingival Hyperplasia

• Enlargement of Gums

Gingivitis

• Inflammation of gums

• Poor dental hygiene, deficiency of Vitamin C

Tonsillitis

• Inflammation of tonsils

• Throat is red & tonsils are swollen- covered by white or yellow patches or exudate

• Lymph Nodes in Cervical Chain may be enlarged

Smooth Tongue

• Vit B & Fe deficiency

• Smooth & Red with shiny appearance