Eye And Ear Assessment Nur 117 Ch 33

Front 1

Examination of the eyes include:

Back 1

*assessment of visual acuity
*extraocular mvmt
*internal & external eye structures
*visual pathways, fields & reflexs

Front 2

Technique for examination of the eyes

Back 2

inspection
palpation

Front 3

Eye History Questions to ask your client during Head assessment?

Back 3

-changes in vision?
-wear glasses or contact lenses?
-Have you ever had eye injury, eye surgery, blurred vision
-Have you ever seen spots or floater, flashes or light of halos around lights?
-last eye exam?
-hx of frequent or recurring eye infections, styes, tearing or dryness?

Front 5

Hyperopia

Back 5

farsightedness, a refractive error in which rays of light enter the eye and focus BEHIND the retina. Persons are able to clearly see distant objects but not close objects.

Front 6

Myopia

Back 6

snearsightedness, a refractive error in which rays of light enter the eye and focus in FRONT the retina. Persons are able to clearly see close objects but not distant objects.
*Assess using SNELLEN CHART

Front 7

Presbyopia

Back 7

impaired near vision or farsightedness in midle-age & older adults caused by loss of elasticity of the lens & assoc. w/ the aging process

Front 8

Screen for Presbyopia by using?

Back 8

Rosenbaum eye chart held 14 inches form clients face. Readings corrletate w/ the Snellen chart/

Front 9

Retinopathy

Back 9

noninflammatory eye d/o resulting from changes in retinal blood vessels.

*Leading cause of Blindness*

Front 10

Strabismus

Back 10

Congenital condition in which BOTH eyes do not focus on an object simultaneously:

*eyes appear crossed
*cover/uncover test

Front 11

What is the cause of Strabismus?

Back 11

impairment of the extraocular muscles or their nerve supply

Front 12

Cataracts

Back 12

-cloudiness over lens
-develop slowly & progressively after age 35 or suddenly after tramua

*Most common eye disorder*

Front 13

Glaucoma

Back 13

-intraocular structural damage resulting from ELEVATED Intraocular Pressure
-loss of visual field


-

Front 14

What is the cause of Glaucoma?

Back 14

-obstruction of the outflow of aqueous humor

-without tx leads to Blindness

Front 15

Glaucoma

Back 15

Front 16

Macular Degeneration

Back 16

blurred central vision often occuring suddenly
-Caused by progressive degeneration of the center of the retina
-Most common Visual Impairment

Hint 16

of individuals >50
-Most common cause of Blindness in older adults
*There is NO cue*

Front 17

Astigmatism

Back 17

-oblonged of "football" shaped cornea
-generally causes eye-strains, headaches & blurry vision
-associated w/ hyperopia(farsightedness) and Myopia (nearsightedness)
-

Front 18

1.VISUAL ACUITY

Back 18

-ability to see small things
-test central vision

Front 19

How do you assess near vision?

Back 19

ask client to read newpaper

Front 20

How do you assess distant vision?

Back 20

Snellen Chart
(test w/o contact 1st & then w/ contacts)

Front 21

What does the Standardized #'s at the end of each lines of the Snellen chart? (20/40)

Back 21

-20/ is the distance client stands from the chart
-40 the larger the denominator, the poorer the visual acuity (can read a line that a person w/ normal vision can read 40 ft away)

Front 22

Assessment for LIGHT PERCEPTION?

Back 22

-shine a penlight into the eye an then turn off
-If client notes when the light is turned on or off, Light Perception is intact.

Front 23

CN controlling Visual Acuity

Back 23

CN-II (Optic)

Front 24

2. Why do you assess EXTRAOCULAR MOVEMENTS?

Back 24

to determine the coordination of the eye muscles (6 small muscles control eye mvmt of each eye)

Front 25

Test used to assess EOM?

Back 25

-6 Cardinal Fields of Gaze

Front 26

Explain the 6 Cardinal Fields of Gaze test?

Back 26

-clients follows finger w/ eyes w/o moving head
-examiner moves finger in a wilde "H" pattern about 20 to 25 cm from clients eye

Front 27

As you r performing the 6 Cardinal Fields of Gaze test, what are you looking for ?

Back 27

-smooth and symmetrical eye mvmt w/ no jerky of tremor-like mvmts (nystagmus)

Front 28

CN controlling EOM?

Back 28

-CN III (Oculomotor)
-CN IV (trochelear)
-CN VI (Abducens)

Front 29

Nystagmus

Back 29

tremor-like mvmts (check for extraocular pressure)

Front 30

3. How do you elevate VISUAL FIELDS

Back 30

-check by your wiggling fingers on each side of the clients face
-Testing to see if client can see objects in the Periphery

Front 31

Visual field test is testing for?

Back 31

-Macular degeneration
-glaucoma

Front 32

CN controlling Visual Fields?

Back 32

CN II (Optic0

Front 33

Clients with visual field problems are at risk for ?

Back 33

-injury

Front 34

4, EXTERNAL STRUCTURES include assessing?

Back 34

-Position and Alignment- of the eyes in realation to 1 another
-Eyelids- close completely & open
-Eyelashs-curve outward/evenly
-Conjunctiva (pink/transparent) & Sclera (white)
-Corneas (clear)
-Lens (clear), Cloudiness= cataracts
-PERRLA (CN II & CN III)
-Irises

Front 35

PTOSIS

Back 35

-dropping upper eyelid (covering pupil)

Front 36

EXOPHTHALMOS

Back 36

-bulging eyes
-indicates Hyperthyroidism

Front 37

STRABISMUS

Back 37

-cross eye
-neuromuscular injury or
-inherited

Front 38

Tumor or inflammation of the Orbit causes?

Back 38

abnormal eye protrusion

Front 39

Inability to move eyebrows indicates a facial nerve paralysis. Which CN?

Back 39

CN VII (

Front 40

2 causes of Ptosis?

Back 40

-edema
-impairment of 3rd cranial nerve

Front 41

In older adults Ptosis results from?

Back 41

loss of elasticity

Front 42

ECTROPION

Back 42

-lid margins turn old
-frequently seen in older adults

Front 43

HORDEOLUM

Back 43

-stye
- inflammation of follicle of an eyelash

Front 44

ICTERUS

Back 44

yellow sclera

Front 45

ARCUS SENILIS

Back 45

-fatty deposit around the iris

-common with aging but Abnormal in anyone under 40 y/o

Front 46

Lacrimal Apparatus?

Back 46

secretes & drains tears, which moisten & lubricate eye structures.

Front 47

lubricates the cornea?

Back 47

blink reflex

Front 48

Presence of redness indicates an allergic or infectious?

Back 48

-Conjunctivitis
-highly contagious
-easy to spread the crusty drainage
(wear gloves)

Front 49

Transparent, colorless portion of the eye covering the pupil and iris?

Back 49

-CORNEA

Front 50

What is the Normal size for Pupils?

Back 50

*3 to 7 mm in diameter

Front 51

DILATED pupils are a result of?

Back 51

*glaucoma
*trauma
*neurological d/o
*eye meds (atropine)
* withdrawal from opioids

Front 52

What causes Pupil CONSTRICTION?

Back 52

*inflammation of the iris
*use of drugs(morphine, cocaine, pilocarpine)

Front 53

Common sign of Opioid intoxication?

Back 53

*Pinpoint Pupils

Front 54

Shinning a light through the Pupil and onto the Retina stimulates which CN?

Back 54

CN III (oculomotor)

Front 55

PERRLA

Back 55

*Pupils
*Equal
*Round
*Reflect to Light
*Accommodation

Front 56

How do you test for Light (Pupillary Reflexes)?

Back 56

*dim room
*client looks straight
*bring penlight from side of client face, directing the onto the pupil
*if client looks at the light, there will be a false reaction to accommodation

Front 57

How do you test for Accommodation?

Back 57

*have client gaze at a distant object (far wall), then you hold your finger 4in from bridge of clients nose
*Pupils will dilate to look at an object far away and then converge and constrict to focus on a near object

Front 58

Testing for Accommodation is only important if the client has a _____?

Back 58

*Defect in the pupillary response to light

Front 59

What clients are at greatest need for an eye exam?

Back 59

-hypertension
-diabetes
-intracranial d/o

Front 60

Who does the examination of the Internal Eye Structure exam?

Back 60

*Md

*beyond the scope of new graduate nurses' practice

Front 61

Internal Eye Structure exam includes?

Back 61

*retina
*choroid
*optic nerve disc
*macula
*fovea centralis
*retinal vessels

Front 62

**Client Teaching**

*What are the Teaching Strategies for EYE Assessment?

Back 62

* <40 eye exam every 3-5 y
* >40 every 2 years w/ glaucomascreening
* >65 every year
*describe sx of eye disease
*instruct older adult to be cautious driving at night, increase lighting in the room

Front 63

Examination of the ears include assessment of the?

Back 63

* External-inspect/palpate
* Middle- inspect w/ otoscope
* Internal-Measue clients hearing acuity

Front 64

External ear structures consists of ?

Back 64

* auricle
* outer ear canal
* tympanic membran (eardrum)

Front 65

Air-filled cavity containing 3 bony ossicles (malleus, incus, and stapes)

Back 65

* Middle Ear

Front 66

What connects the middle ear to the nasopharynx/

Back 66

* Eustachian Tube

Front 67

What are some questions the nurse should ask client during EAR assessment?

Back 67

* ear pain, itching, discharge, vertigo, tinnitus(ringing in ears),
* change in hearing
* risk for hearing problems (work, family hx,)
* hearing aid?
* large doses of ASA or ototoxic drugs?
*

Front 68

Ototoxic drugs (aminoglycoside, furosmide, streptomycin) EFFECTS?

Back 68

HEARING LOSS

Front 69

Ototoxicity

Back 69

injury to the auditory nerve
-resulting from high maintenance doses of antibiotics (aminoglycosides)

Front 70

Inspection of the Ear includes:

Back 70

-guarding (children)
-Response to normal voice
-does the patient talk loudly?
-Auricle of pinna-(equal size & level w/ each other)
-objects in ear canal (pink w/ tiny hairs)
-drainage (COCA)
-use Otoscope

Front 71

Appearance of a normal Tympanic Membrane?

Back 71

-translucent
-shiny
-pearly gray

(inspect w/ otoscope)

Front 72

3 types of Hearing Loss

Back 72

-Conduction
-Sensorineural
-Mixed

Front 73

What type of hearing loss Interupts sound waves as they travel from the outer ear to the cochlea of the inner ear?

Back 73

-Conduction Loss

Front 74

What are some examples of causes of Conduction Loss?

Back 74

- swelling of the auditory canal
- tears in the tympanic membrane
- listening to loud music
- in older adult the bones of the middle ear will get stiff

Front 75

What is Sensorineural Loss?

Back 75

- transmission of sound is interrupted at some point beyond the bony ossicles (seen in older adults)
- involves the Inner Ear, Auditory Nerve or Hearing Center of the brain

Front 76

What are some questions the nurse should ask client during EAR assessment?

Back 76

* ear pain, itching, discharge, vertigo, tinnitus(ringing in ears),
* change in hearing
* risk for hearing problems (work, family hx,)
* hearing aid?
* large doses of ASA or ototoxic drugs?
*

Front 77

Ototoxic drugs (aminoglycoside, furosmide, streptomycin) causes?

Back 77

Otitis

Front 78

Ototoxicity

Back 78

injury to the auditory nerve
-resulting from high maintenance doses of antibiotics (aminoglycosides)

Front 79

Inspection of the Ear includes:

Back 79

-guarding (children)
-Response to normal voice
-does the patient talk loudly?
-Auricle of pinna-(equal size & level w/ each other)
-objects in ear canal (pink w/ tiny hairs)
-drainage (COCA)
-use Otoscope

Front 80

Mixed loss

Back 80

combination of Conduction and Sensorineural Loss

Front 81

Cerumen

Back 81

yellow, waxy substance

Front 82

Tuning Fork

Back 82

allows for comparison of hearing by Bone Conduction and Air Conduction

Front 83

Weber Test?

Back 83

1. turning fork place on top of client's heard (ask client if sound is heard best in right/left or both ears equally)

Front 84

Expected findings for a negative WEBER Test?

Back 84

Sounds heard equally in both ears

Front 85

What are some questions the nurse should ask client during EAR assessment?

Back 85

* ear pain, itching, discharge, vertigo, tinnitus(ringing in ears),
* change in hearing
* risk for hearing problems (work, family hx,)
* hearing aid?
* large doses of ASA or ototoxic drugs?
*

Front 86

Ototoxic drugs (aminoglycoside, furosmide, streptomycin) causes?

Back 86

Otitis

Front 87

Ototoxicity

Back 87

injury to the auditory nerve
-resulting from high maintenance doses of antibiotics (aminoglycosides)

Front 88

Inspection of the Ear includes:

Back 88

-guarding (children)
-Response to normal voice
-does the patient talk loudly?
-Auricle of pinna-(equal size & level w/ each other)
-objects in ear canal (pink w/ tiny hairs)
-drainage (COCA)
-use Otoscope

Front 89

*Conduction Deafness

Back 89

-vibration heard best in the AFFECTED ear (ear that has the conduction hearing loss)

Front 90

**Sensorineural Deafness

Back 90

vibration is heard best in the UNAFFECTED ear (hear best on the unaffected side)

Front 91

Normal distance for a Watch-Tick Test

Back 91

5 inches

Front 92

Technique for Whisper Test

Back 92

1. 1 ear is occluded & other ear is tested to see if client can hearwhispered sounds w/o seeing examiner's mouth move
2. Repeat w/ other ear

(30 cm away)

Front 93

Rinne Test?

Back 93

-compares air conduction and bone Bone conduction

-expected findings:
AC>BC; 2 to 1 ratio

Front 94

Technique for Rinne Test

Back 94

1. Stem of vibrating tuning fork against clients Mastoid process
2. count interval
3 client tell you when she no longer hears the sound (note sec)
5 place still vibrating fork beside ear canal
6. client tells you when she no longer hears should
7. compare # of secs the sounds are heard

Front 95

Conduction hearing Loss?

Back 95

AC<BC
(AC is not as long as it should be)