Chapter 15: Eyes and Vision Assessment

Ch. 15, 16 & 24 HNEENT 2: Eyes, Ears, and Cranial Nerve Assessment Chapter 15: Eyes and Vision Assessment Focused Health History · Visual difficulties (acuity, blurring, blind spots) ↳ myopia: near sightedness → light focuses in front of retina ↳ hyperopia: far-sightedness → light focuses behind retina ↳ presbyopia: gradual loss of eyes'ability to focus (40-60 yrs) ↳ astigmatism: curvature of lens causing blurred distance and near vision · pain · photophobia · strabismus (eyes do not line up) · diplopia (double vision) · redness, swelling, discharge · medications · chronic illness · surgical history · allergies · use of glasses or contacts Physical Assessment ① inspection: eyebrows, eyelids, eyelashes, symmetry, conjunctiva etc. ② palpation: feel around eye, note tenderness or swelling of the eyebrows or eyelids NOTE: triage guide* ·>> Urgent Assessment · sudden vision loss/change · large foreign body in eye · lacerations (retinal tearing! ) · hyphema (blood in eye) · nausea, vomiting, sudden headaches Conjunctiva, Sclera, Iris, Pupil, Lens · conjunctiva: clear, some blood vessels · sclera: white · iris: colour, symmetrical, circular · pupil: round and equal at 2mm · lens: lens clear, red reflex Irregular Findings · anisocoria: different size pupils · miosis: excessive constriction of pupils · mydriasis: excessive dilation of the pupils · arcus senilis: fatty deposits around outer region of cornea · cataract: clouding of the lens Anisocoria Miosis Mydriasis Visual Acuity · visual acuity tests for macular function, because the macula gives rise to the majority of optic nerve fibers · Snellen Eye Chart - Distance Vision ↳ stand 20 ft away and read down the chart ↳ 20/20 is "normal vision" ↳ legal blindness is best corrected vision 20/200 · Jaegar Test - Near Vision ↳ 14 inches from eye ↳ read to the smallest letter · Ishihara Cards - Colour Vision ↳ being able to identify the hidden image - Extraocular Muscles and Movements ① Cardinal Directions ↳ move the patient through the 11 motions (H-shape), the patient's eyes should more smoothly and symmetrically ② Cover Test ↳ assesses ocular alignment/ocular deviation ↳ ask patient to focus on a near object. Cover patients eye and note any movement in uncovered eye, then remove cover and observe for refixation ↳ gaze should be steady and fixed ③ Corneal Light Reflex ↳ patient stares at your nose while you shine a light on their nose. Light reflection should be in the same spot on both eyes ↳ tests for strabismus (misalignment of the eyes) Cardinal Directions Visual Field Testing · perimetry: precise and systematic measurement of visual field function by eye care professionals ② Kinetic Confrontation ① Static Confrontation ↳ patient nurse cover same side eye, and have the ↳ patient + nurse cover same side eye, and have patient patient stare at the uncovered eye and tell you stare at uncovered eye and tell you the number of fingers when they see your fingers wiggle into view you have up when they move into vision Internal Ocular Structures · You use an opthalmascope to inspect the interior ocular structures (pupils slightly dilated) · Start by standing arms width away from the patient with your hand on their head to keep steady. Use your right eye to look into their right eye and left to left to avoid bumping noses → note the red reflex · Review the following structures: Optic disc ↳ optic disc ↳ optic nerve Optic cup ↳ vessels (veins > artery width) ↳ macula Artery ↳ periphery Vein Expected Findings: Note: Red Reflex is an important screening tool for retinoblasma in children · visual acuity: 20/20 bilaterally · lacrima: no redness or inflammation · conjunctiva: clear + transparent · sclera: White · cornea/lens: shiny + clear · eyes: symmetrical, equally spaced from nose · pupils: equal, round, reactive to light and accommodation · opthalmoscopic lens, retina, etc.: lens clear, bilateral red reflex, arterioles 2: 3 veins, optic disc round, yellowish pink - Chapter 16: Ears and Hearing Assessment Focused Health History · earaches (otalgia) · infections/discharge (otorrhea) · hearing loss · environmental noise · tinnitus · medications · vertigo Techniques of Assessment ① Inspection ② Palpation Urgent Assessment · foreign object in ear · foul smelling drainage · head/ear trauma · fluid leaking out of ears after head trauma (CSF) Know anatomy Inspection · inspect the ears. They should be symmetrical, equal size, and fully formed · colour of the skin should be even · inspect the helix for darwinian tubercle (painless nodule) Palpation · Palpate the auricle, tragus and mastoid process · ears should be non-tender, without lumps, and lymph tissue non-palpable Otoscopic Examination · Bracing Technique: brace the hand holding the otoscope on the patient's cheek to stabilize the otoscope and prevent harm to the auditory canal · Proper ear placement: in adults you take the helix and gently lift it up and back to straighten the ear canal for viewing of the tympanic membrane (TM) ↳ in children pull the pinna straight down · Tympanic membrane: ↳ colour ↳ position ↳ integrity ↳ structures ↳ light reflex (left vs. right) Genetic Considerations: · two types of cerumen 1. dry, light, flaky 2. wet, brownish-yellow, and smellier Hearing Assessment ① Whisper Test · identifies hearing loss often from high-frequency sounds · stand behind the patient and occlude the ear canal by pushing on the tragus and whisper a combination of numbers and letters or a 2-syllable word and have them repeat it back to you ② Rinne Test · strike the tuning fork and place it on the patient's mastoid process behind the ear. Note the amount of time until the patient can no longer hear the ringing, then place the tuning fork beside the patient's ear and note when the patient can no longer hear it · Air conduction should be twice as long as bone conduction (AC is twice BC) · rinne test determines if hearing is equal in both ears and if there is a conductive or sensorineural hearing loss ③ Weber Test · helps to differentiate the cause of unilateral hearing loss · place the activated tuning fork and place on the front of the parietal bone (top of head) · patient should hear equally in both ears Expected Findings · external ear: aligned, symmetrical, no pain upon palpation · ear canal: pink, minimal cerumen · eardrum (TM): pearly grey, intact, cone of light visible · hearing acuity: accurately describes low-whispered 2-syllable words · conduction: AC > BC bilaterally Chapter 24: ONLY Cranial Nerve Assessment - - · mneumonic: only one of the two athletes felt very good, victorious and healthy · supratentorial nerves: olfactory (I) and optic (II) ↳ originate from cerebellum not the brainstem so they are above the tentorium - - - - - - - - - - - - CN III: Testing Pupils in Patients with Brain Injuries · CN II & III for pupillary light reflex ↳ pupil should be able to constrict and dilate → if it cannot do this it is damaged and not sending info to the brain · Consider the tentorium, if any intercranial pressure pushes on CN III there will be no pupillary response ↳ the blood supply is also very close to CN III and can affect blood flow to the brain - - Blood supply A · Sensory Mixed (Both) Motor Mneumonic #2 : Some say marry money but my brother says , big brains matter most CN I: Olfactory · smell · tested by having someone distinguish between scents CN II: Optic · visual acuity · field of vision · visualization of the fundus · pupillary light response CN II and III: Optic and Oculomotor · PERRLA: pupils equal, round, reactive to light and accommodation CN III, IV, VI: Oculomotor, Trochlear, and Abducens LR6 · Cardinal Movements (H-shape) SO4 ↳ check convergence and nystagmus A03 CN V: Trigeminal ① Motor · open mouth and observe for jaw deviation · palpate masseter & temporalis and ask patient to clench jaw · patient moves jaw to each side as examiner pushes to midline > UMN Lesion · jaw jerk reflex ② Sensory · pain and temperature (cool end of tuning fork) · light touch (cotton wisp) CN VII: Facial · sensation taste (anterior 2/3 of tongue) · external ear sensation · function of stapedius muscle (muscle that dampens loud sounds in middle ear) ↳ hyperacusis · lacrimal glands - ask about dry eyes · salivary glands - ask about dry mouth CN V & VII: Trigeminal and Facial · corneal reflex · conjunctival reflex (both are blinking reflexes) CN VIII: Vestibulotrochlear · observe eyes for nystagmus · romberg test (standing w/eyes closed for over a minute) ↳ requires proprioception, vision and vestibular function · hearing tests (whisper test etc.) CN VII & VIII: Acoustic Reflex · contraction of the stapedius muscle with loud sound or own vocalizations ↳ hyperacusis: CN VII damage proximal to the stapedius muscle ↳ diminished reflex: sensorineural hearing loss CN IX & X: Glossopharyngeal and Vagus · say "ah" or "KKKK" to test pharyngeal muscles · swallowing · gag reflex · X alone - palatal arches ↳ damaged side can't counteract, look for lowered and flattened palatal arch CN XI: Accessory · test the strength of the trapezius and sternomastoid muscles CN XII: Hypoglossal · inspect movement and strength of tongue