II.

Head and Neck

 Head
-the framework of the head is the skull, which can be divided into two
subsections: the cranium and the face

Cranium- houses and protects the brain and major sensory organs. It
consists of eight bones:

• Frontal (1)
• Parietal (2)
• Temporal (2)
• Occipital (1)
• Ethmoid (1)
• Sphenoid (1)

 Face

Facial bones give shape to the face. The face consists of 14 bones.
Maxilla (2)
• Zygomatic (cheek) (2)
• Inferior conchae (2)
• Nasal (2)
• Lacrimal (2)
• Palatine (2)
• Vomer (1)
• Mandible (jaw) (1)

 NECK

- The structure of the neck is composed of muscles, ligaments, and the

cervical vertebrae.
-Contained within the neck are the hyoid bone, several major blood
vessels, the larynx, trachea, and the thyroid gland, which is in the anterior
triangle of the neck.

 Muscles and Cervical Vertebrae

a. Sternomastoid and trapezius muscles are two of the paired muscles

that allow movement and provide support to the head and neck
b. The eleventh cranial nerve is responsible for muscle movement that
permits shrugging of the shoulders by the trapezius muscles and turning
the head against resistance by the sternomastoid muscles.

 Blood Vessels
-The internal jugular veins and carotid arteries are located bilaterally,
parallel and anterior to the sternomastoid muscles.
 -The external jugular vein lies diagonally over the surface of these
muscles.

 Thyroid Gland
-is the largest endocrine gland in the body. It produces thyroid hormones
that increase the metabolic rate of most body cells.

a.Trachea - through which air enters the lungs, is composed of C-

shaped hyaline cartilage rings. The first upper tracheal ring, called the
cricoid cartilage, has a small notch in it.

b.Thyroid cartilage (“Adam’s apple”) is larger and located just above

the cricoid cartilage. The hyoid bone, which is attached to the tongue,
lies above the thyroid cartilage and under the mandible.

 LYMPH NODES OF THE HEAD AND NECK

Lymph nodes are located in the head and neck.It filter lymph, a clear
substance composed mostly of excess tissue fluid, after the lymphatic vessels
collect it but
before it returns to the vascular system

The most common head and neck lymph nodes are as follows:
• Preauricular
• Postauricular
• Tonsillar
• Occipital
• Submandibular
• Submental
• Superficial cervical
• Posterior cervical
• Deep cervical
• Supraclavicular.

Health Assessment: Collecting Subjective Data

The Nursing Health History

1. History of Present Health Concern - Use of “COLDSPA” mnemonic

 Do you experience neck pain? Be sure to ask about precipitating events

(illness or injury), severity, and associated symptoms.
 Neck pain may accompany muscular problems or cervical spinal cord
problems. Stress and tension may increase neck pain. Sudden head
and neck pain seen with elevated temperature and neck stiffness
may be a sign of meningeal inflammation.
 Do you experience headaches?
 A precise description of the symptoms can help to determine possible
causes of the discomfort. Abnormal Findings 15-1 on page 290 summarizes
typical findings for different headaches. The most common types of
headaches are related to vascular (e.g., migraine), muscle contraction
(tension), traction, or inflammatory causes.

 Do you have any facial pain? Describe.

 Trigeminal neuralgia (tic douloureux) is manifested by sharp, shooting,
piercing facial pains that last from seconds to minutes. Pain occurs over
the divisions of the fifth trigeminal cranial nerve (the ophthalmic,
maxillary, and mandibular areas).

Other Symptoms
 Do you have any difficulty moving your head or neck?
 Tension in muscles, vertebral joint dysfunction, and other disorders
of the head and neck may limit mobility and affect activities of daily
functioning.
 Have you noticed any lumps or lesions on your head or neck that do not
heal or disappear? Describe their appearance. Do you have a cough or
any difficulty swallowing?
 Lumps and lesions that do not heal or disappear may indicate
cancer.
A goiter (an enlarged thyroid gland) may appear as a large swelling
at the base of the neck that the client may notice when shaving or
putting on cosmetics. The client with a goiter may also have a tight
feeling in the throat, cough, hoarseness, difficulty swallowing, or a
hoarse voice (Mayo Clinic, 2011).
 Have you experienced any dizziness, lightheadedness, spinning sensation,
blurred vision, or loss of consciousness? Describe.
 Sudden trouble seeing in one or both eyes or sudden trouble walking,
dizziness, or loss of balance or coordination may be a sign of an
impending stroke (American Stroke Association, 2011).
 Have you noticed a change in the texture of your skin, hair, or nails?
Alterations in thyroid function are manifested in many ways.
Box 15-1 on page 279 discusses signs and symptoms of hypoand
hyperthyroidism.
 Have you noticed a change in the texture of your skin, hair, or nails?
 Alterations in thyroid function are manifested in many ways.
Box 15-1 on page 279 discusses signs and symptoms of hypoand
hyperthyroidism.
 Have you had any weakness or numbness in your face, arms, or legs or
on either side of your body?
 Sudden weakness or numbness in the face, arms, or legs—especially
on one side of the body—may indicate an impending stroke (American
Stroke Association, 2011).
2. Past Health History
 Describe any previous head or neck problems (trauma, injury, falls) you
have had. How were they treated (surgery, medication, physical therapy)?
What were the results?
 Previous head and neck trauma may cause chronic pain and limitation of
movement. This may affect functioning
 Have you ever undergone radiation therapy for a problem in your neck
region?
 Radiation therapy has been linked to the development of thyroid cancer.
Radiation to the neck area may also cause esophageal strictures,
leading to difficulty with swallowing.
The risk of hypothyroidism increases with increased radiation doses
(Vogelius et al., 2011).

3. Family History
 Do you find that you have headaches when you take any of the following
medications?
 Some prescription and nonprescription medicines may cause headaches
as follows:
• Oral contraceptives
• Blood-thinning medicines, such as warfarin, heparin, or aspirin
• Caffeine (or caffeine withdrawal)
• Heart and blood pressure medicines, such as nitroglycerin
• Antihistamines and decongestants
• Corticosteroids, such as prednisone
• Ergotamine (Cafergot) therapy
• Hormone therapy, such as estrogen or progestin
• Medicines to prevent organ transplant rejection
• Certain types of chemotherapy
• Overuse of fat-soluble vitamins, such as vitamin A and vitamin D
• Radiation therapy(MSN, Health, 2010)
 Is there a history of head or neck cancer in your family?
 Genetic predisposition is a risk factor for head and neck
cancers.
 Is there a history of migraine headaches in your family?
 Migraine headaches commonly have a familial association.

4. Lifestyle and Health Practices

 Do you smoke or chew tobacco? If yes, how much?Do you use alcohol or
recreational drugs? Describe the type used and how much.
Tobacco use increases the risk of head and neck cancer. Eighty-fivepercent of
head and neck cancers are linked to tobacco use (smoking
and smokeless tobacco). Symptoms of Head and neck cancer include:
a lump or sore that does not heal, a sore throat that does not go
away, and trouble swallowing (National Cancer Institute [NCI] at the
National Institutes of Health [NIH], 2012).
Alcohol use is also a risk factor for head and neck cancers (NCI,
2012).
 Do you wear a helmet when riding a horse, bicycle, motorcycle, or other
open sports vehicle (e.g., four-wheeler, go-cart)? Do you wear a hard hat
for hazardous occupations?
Failure to use safety precautions increases the risk for head and neck
injury (see Evidence-Based Practice 15-1, p. 280).
 In what kinds of recreational activity do you participate? Describe the
activity.
 Contact or aggressive sports may increase the risk for a head or neck
injury.
 What is your typical posture when relaxing, during sleep, and when
working?
 Poor posture or body alignment can lead to or exacerbate head and
neck discomfort.
 Have any problems with your head or neck interfered with your
relationships with others or the role you occupy at home or at
work?
 Head and neck pain may interfere with relationships or prevent
clients from completing their usual activities of daily living.

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

Preparing the Client

Prepare the client for the head and neck examination by instructing him or
her to remove any wig, hat, hair ornaments, pins, rubber bands, jewelry, and
head or neck scarves.

Equipment
• Small cup of water
• Stethoscope

ASSESSMENT PROCEDURE

INSPECTION AND PALPATION

Head and Face

 Inspect the head. Inspect for size, shape,and configuration
Normal Findings:
Head size and shape vary, especially in accord with ethnicity. Usually the
head is symmetric, round, erect, and in midline and appropriately related to
body size (normocephalic). No lesions are visible.
Abnormal Findings
An abnormally small head is called microcephaly.
The skull and facial bones are larger and
thicker in acromegaly .
Acorn-shaped, enlarged skull bones are seen
in Paget’s disease of the bone.

 Inspect involuntary movement.

Normal Findings
Head should be held still and upright.
Abnormal Findings
Neurologic disorders may cause a horizontal jerking movement. An
involuntary nodding movement may be seen in patients with aortic
insufficiency. Head tilted to one side may indicate unilateral vision or hearing
deficiency or shortening of the sternomastoid muscle.

 Palpate the head. Note consistency

Normal Findings
 The head is normally hard and smooth, without lesions.
Inspect the face. Inspect for symmetry, features, movement, expression, and
skin condition.
Abnormal Findings
Lesions or lumps on the head may indicate recent trauma or a sign of cancer.
Palpate the temporal artery, which is located between the top of the ear and
the eye.
 Inspect the face. Inspect for symmetry, features, movement, expression,
and skin condition.
Normal Findings
 The face is symmetric with a round, oval, elongated, or square
appearance. No abnormal movements noted.
Abnormal Findings

 Asymmetry in front of the earlobes occurs with parotid gland enlargement

from an abscess or tumor. Unusual or asymmetric orofacial movements
may be from an organic disease or neurologic problem, which should be
referred for medical follow-up.

 Drooping, weakness, or paralysis on one side of the face may result from
a stroke (cerebrovascular accident, CVA) and usually is seen with
paralysis or weakness of other parts on that side of the body. Drooping,
weakness, or paralysis on one side of the face may also result from a
neurologic condition known as Bell’s palsy.

 A “mask-like” face marks Parkinson’s disease; a “sunken” face with

depressed
eyes and hollow cheeks is typical of cachexia (emaciation or wasting); and a
pale, swollen face may result from nephrotic syndrome. See Abnormal
Findings 15-2 on page 292 for Bell’s palsy and other abnormalities of the face.

Palpate the temporomandibular joint (TMJ). To assess the TMJ, place your
index finger over the front of each ear as you ask the client to open the
mouth

The Neck
INSPECTION
 Inspect the neck. Observe the client’s slightly extended neck for position,
symmetry, and lumps or masses. Shine a light from the side of the neck
across to highlight any swelling
 Inspect movement of the neck structures. Ask the client to swallow a
small
sip of water. Observe the movement of the thyroid cartilage, thyroid
gland
 Inspect the cervical vertebrae. Ask the client to flex the neck (chin to
chest).
 Inspect range of motion. Ask the client to turn the head to the right and
to the left (chin to shoulder), touch each ear to the shoulder, touch chin
to chest, and lift the chin to the ceiling.

PALPATION
 Palpate the trachea. Place your finger in the sternal notch. Feel each side
of the notch and palpate the tracheal rings (Fig. 15-11). The first upper
ring above the smooth tracheal rings is the cricoid cartilage.
 Palpate the thyroid gland. Locate key landmarks with your index finger
and thumb:
 Hyoid bone (arch-shaped bone that does not articulate directly with
any other bone; located high in anterior neck).
 Thyroid cartilage (under the hyoid bone; the area that widens at the
top of the trachea), also known as the “Adam’s apple.”
 Cricoid cartilage (smaller upper tracheal ring under the thyroid
cartilage).
 To palpate the thyroid, use a posterior approach. Stand behind the client
and ask the client to lower the chin to the chest and turn the neck slightly
to the right. This will relax the client’s neck muscles. Then place your
thumbs on the nape of the client’s neck with your other fingers on either
side of the trachea below the cricoid cartilage. Use your left fingers to
push the trachea to the right. Then use your right fingers to feel deeply in
front of the sternomastoid muscle
 Ask the client to swallow as you palpate the right side of the gland.
Reverse the technique to palpate the left lobe of the thyroid.

AUSCULTATION

 Auscultate the thyroid only if you find an enlarged thyroid gland during
inspection or palpation. Place the bell of the stethoscope over the lateral
lobes of the thyroid gland (Fig. 15-13). Ask the client to hold his or her
breath (to obscure any tracheal breath sounds while you auscultate).

Lymph Nodes of the Head and Neck

 Palpate the lymph nodes.
 Palpate the preauricular nodes (in front of the ear), postauricular nodes
(behind the ears), occipital nodes (at the posterior base of the skull).
 Palpate the tonsillar nodes at the angle of the mandible on the anterior
edge of the sternomastoid muscle.
 Palpate the submandibular nodes located on the medial border of the
mandible.
 Palpate the superficial cervical nodes in the area superficial to the
ternomastoid muscle.
 Palpate the posterior cervical nodes in the area posterior to the
sternomastoid and anterior to the trapezius in the posterior triangle.
 Palpate the deep cervical chain nodes deeply within and around the
sternomastoid muscle
 Palpate the supraclavicular nodes by hookingyour fingers over the
clavicles and feeling deeply between the clavicles and the sternomastoid
muscles.
 Have the client remain seated upright. Then palpate the lymph nodes
with your fingerpads in a slow walking, gentle, circular motion. Ask the
client to bend the head slightly toward the side being palpated to relax
the muscles in that area. Compare lymph nodes that occur bilaterally. As
you palpate each group of nodes, assess their size and shape,
delimitation (whether they are discrete or confluent), mobility,
consistency, and tenderness. Choose a particular palpation sequence. This
chapter presents a sequence that proceeds in a superior to inferior orde.r
 While palpating the lymph nodes, note the following:
• Size and shape
• Delimitation

 Abnormal Findings:Types of Headache

 Sinus Headache
 Cluster Headache
 Tension Headache
 Migraine Headache
 Tumor-related Headache

Abnormalities of the Head and Neck

 Micromegaly
 Cushing Syndrome
 Scleroderma
 Bell’s Palsy
 Hyperthyroidism

IV. Eyes
- transmits visual stimuli to the brain for interpretation and, in doing so,
functions as the organ of vision.

 EXTERNAL STRUCTURES OF THE EYE

a. Eyelids (upper and lower) are two movable structures composed of
skin and two types of muscle: striated and smooth.
 b.Eyelashes are projections of stiff hair curving outward along the
margins of the eyelids that filter dust and dirt from air entering the
eye.

c. Conjunctiva is a thin, transparent, continuous membrane that is

divided into two portions: a palpebral and a bulbar portion.

c.Lacrimal apparatus consists of glands and ducts that

lubricate the eye.

d.Extraocular muscles are the six muscles attached to the outer

surface of each eyeball. These muscles control six different
directions of eye movement.

 INTERNAL STRUCTURES OF THE EYE

a. Eyeball is composed of three separate coats or layers.

 External layer consists of the sclera and cornea.
 Middle layer contains both an anterior portion, which includes the
iris and the ciliary body, and a posterior layer,which includes the
choroid.
 Innermost layer- the retina, extends only to the ciliary body
anteriorly.
 Optic disc is a cream-colored, circular area located on the
retina toward the medial or nasal side of the eye.

 VISION

 Visual Fields and Visual Pathways

a. Visual field refers to what a person sees with one eye. The
visual field of each eye can be divided into four quadrants:upper
temporal, lower temporal, upper nasal, and lower nasal.
b. Visual perception occurs as light rays strike the retina, where
they are transformed into nerve impulses, conducted to the
brain through the optic nerve, and interpreted.

 Visual Reflexes
a. Pupillary light reflex causes pupils immediately to constrict
when exposed to bright light. This can be seen as a direct reflex,in
which constriction occurs in the eye exposed to the light, or as an
indirect or consensual reflex, in which exposure to light in one eye
results in constriction of the pupil in the opposite eye
b. Accommodation is a functional reflex allowing the eyes to
focus on near objects.

Health Assessment: Collecting Subjective Data

The Nursing Health History
1. History of Present Health Concern
 Gather data from the client about his or her current level of eye health.
 Discuss any personal and family history problems that are related to the
eye.
 Collecting data concerning environmental influences on vision as well as
how any problems are influencing or affecting the client’s usual activities
of daily living is also important.

2. History of Present Health Concern

 Describe any recent visual difficulties or changes in your vision that
 you have experienced. Were they sudden or gradual?
 Do you see spots or floaters in front of your eyes?
 Do you experience blind spots? Are they constant or intermittent?
 Do you see halos or rings around lights?
 Do you have trouble seeing at night?
 Do you experience double vision (diplopia)?

Other Symptoms
 Do you have any eye pain or itching? Do you have pain with bright lights
(photophobia)? Describe.
 Do you have any redness or swelling in your eyes?
 Do you experience excessive watering or tearing of the eye? If so, is it
in one eye or both eyes?
 Have you had any eye discharge? Describe.
 Describe any past treatments you have received for eye problems
(medication, surgery, laser treatments, corrective lenses). Were these
successful? Were you satisfied?
 What types of medications do you take?
 When was your last eye examination?
 Do you perform the test for macular degeneration using the Amsler’s
chart? How do you use this chart and how often? What do you see when
you use it?
 Do you have a prescription for corrective lenses (glasses or contacts)?
 Do you wear them regularly? If you wear contacts, how long do you
 wear them? How do you clean them?
 Have you ever been tested for glaucoma? What were the results?

3. Family History

 Is there a history of eye problems or vision loss in your family?

 Are you exposed to conditions or substances in the workplace or home
that may harm your eyes or vision (e.g., chemicals, fumes, smoke, dust,
or flying sparks)? Do you wear safety glasses during exposure to harmful
substances?
 Do you wear sunglasses during exposure to the sun?
 Has your vision loss affected your ability to care for yourself? To
 work?
 What visual aids do you use to assist you with your visual loss
(magnifying glasses, audiotapes, CDs, special glasses for viewing
television, arge-numbered phones, large-print checks, large print books)?
 Describe your typical diet. What have you eaten in the last 24 hours?
 Do you take any vitamins or supplements?
 Do you smoke? How many packs and for how long?

Collecting Objective Data: Physical Examination

 Preparing the Client

 Explain each vision test thoroughly to guarantee accurate results.
 Position the client to be seated comfortably.
 To ease any client anxiety, explain in detail what you will be doing
and answer any questions the client may have.

 Equipment
 Snellen or E chart (Assessment Guide 16-1)
 Hand-held Snellen card or near-vision screener
 Penlight
 Opaque cards
 Ophthalmoscope

Physical Assessment
Before performing eye examination, review and recognize
structures and functions of the eyes. While performing the
examination, remember these key points:
• Administer vision tests competently and record the results.
• Use the ophthalmoscope correctly and confidently.
• Recognize and distinguish normal variations from abnormal findings.

A. Vision Chart
- Snellen Chart- Used to test distant visual acuity, the Snellen
chart consists of lines of different letters stacked one above the
other.
-Jaeger Test -Near vision is assessed in clients over 40 years of
age by holding the pocket screener (Jaeger test) or newspaper
print 14 I inches from the eye. Clients who have decreased
accommodation to view closer print will have to move the card or
newspaper further away to see it.

B. Opthalmoscope -is a hand-held instrument that allows the

examiner to view the fundus of the eye by the projection of light
through a prism that bends the light 90 degrees.
 Evaluating Vision

-Test distant visual acuity.

-Test near visual acuity.
-Test visual fields for gross peripheral vision.
-Perform corneal light reflex test
-Perform cover test.
-Perform the positions test

Assessment Procedure
Evaluating Vision
 Test distant visual acuity. Position the client 20 feet from the Snellen or E
chart
 and ask her to read each line until she cannot decipher the letters or their
direction Document the results.
 During the vision test, note any client behaviors (i.e., leaning forward,
head tilting, or squinting) that could be unconscious attempts to see
better.
 Test near visual acuity. Use this test for middle-aged clients and others
who complain of difficulty reading.
 Give the client a hand-held vision chart (e.g., Jaeger reading card, Snellen
card, or comparable chart) to hold 14 inches from the eyes. Have the
client cover one eye with an opaque card before reading from top (largest
print) to bottom (smallest print). Repeat test for other eye.
 Test visual fields for gross peripheral vision. To perform the confrontation
test, position yourself approximately 2 feet away from the client at eye
level. Have the client cover the left eye while you cover your right eye.
Look directly at each other with your uncovered eyes. Next, fully extend
your left arm at midline and slowly move one finger (or a pencil) upward
from below until the client sees your finger. Test the remaining three
visual fields of the client’s right eye (i.e., superior, temporal, and nasal).
Repeat the test for the opposite eye.

TESTING EXTRAOCULAR MUSCLE FUNCTION

 Perform corneal light reflex test. This test assesses parallel alignment of
the eyes. Hold a penlight approximately 12 inches from the client’s face.
Shine the light toward the bridge of the nose while the client stares
straight ahead. Note the light reflected on the corneas.
 Perform cover test. The cover test detects deviation in alignment or
strength and slight deviations in eye movement by interrupting the fusion
reflex that normally keeps the eyes parallel
 Ask the client to stare straight ahead and focus on a distant object. Cover
one of the client’s eyes with an opaque card.As you cover the eye,
observe the uncovered eye for movement. Now remove the opaque card
and observe the previously covered eye for any movement. Repeat test
on the opposite eye.
 Perform the positions test, which assesses eye muscle strength and
cranial nerve function.
 Instruct the client to focus on an object you are holding (approximately
12 inches from the client’s face). Move the object through the six cardinal
positions of gaze in a clockwise direction, and observe the client’s eye
movements.

External Eye Structures

Inspection and Palpation

Inspect the eyelids and eyelashes.

 Note width and position of palpebral fissures.

 Assess ability of eyelids to close.
 Note the position of the eyelids in comparison with the eyeballs. Also note
any unusual
• Turnings
• Color
• Swelling
• Lesions
• Discharge
 Observe for redness, swelling, discharge, or lesions.
 Observe the position and alignment of the eyeball in the eye socket.
 Inspect the bulbar conjunctiva and sclera. Have the client keep the head
straight while looking from side to side then up toward the
ceiling.Observe clarity, color, and texture.
 Inspect the palpebral conjunctiva
 Put on gloves for this assessment procedure.First inspect the palpebral
conjunctiva of the lower eyelid by placing your thumbs bilaterally at the
level of the lower bony orbital rim and gently pulling down to expose the
palpebral conjunctiva. Avoid putting pressure on the eye. Ask the client to
look up as you observe the exposed areas.
 Evert the upper eyelid. Ask the client to look down with his or her eyes
slightly open. Gently grasp the client’s upper eyelashes and pull the lid
downward.
 Place a cotton-tipped applicator approximately 1 cm above the eyelid
margin and push down with the applicator while still holding the
eyelashes.
 Hold the eyelashes against the upper ridge of the bony orbit just below
the eyebrow, to maintain the everted position of the eyelid. Examine the
palpebral conjunctiva for swelling, foreign bodies, or trauma. Return the
eyelid to normal by moving the lashes forward and asking the client to
look up and blink. The eyelid should return to normal.
 Inspect the lacrimal apparatus. Assess the areas over the lacrimal glands
(lateral aspect of upper eyelid) and the puncta (medial aspect of lower
eyelid).
 Palpate the lacrimal apparatus. Put on disposable gloves to palpate the
nasolacrimal duct to assess for blockage. Use one finger and palpate just
inside the lower orbital rim
 Inspect the cornea and lens. Shine a light from the side of the eye for an
oblique view. Look through the pupil to inspect the lens.
 Inspect the iris and pupil. Inspect shape and color of iris and size and
shape of pupil. Measure pupils against a gauge if they appear larger or
smaller than normal or if they appear to be two different sizes.

Test pupillary reaction to light.

 Test for direct response by darkening the room and asking the client to
focus on a distant object. To test direct pupil reaction, shine a light
obliquely into one eye and observe the pupillary reaction. Shining the
light obliquely into the pupil and asking the client to focus on an object in
the distance ensures that pupillary constriction is a reaction to light and
not a near reaction.
 Assess consensual response at the same time as direct response by
shining a light obliquely into one eye and observing the pupillary reaction
in the opposite eye.
 Test accommodation of pupils. Accommodation occurs when the client
moves his or her focus of vision from a distant point to a near object,
causing the pupils to constrict. Hold your finger or a pencil about 12 to 15
inches from the client. Ask the client to focus on your finger or pencil and
to remain focused on it as you move it closer in toward the eyes.

INTERNAL EYE STRUCTURES

 Using an ophthalmoscope inspect the internal eye. To observe the red
reflex, set the diopter at 0 and stand 10 to 15 inches from the client’s
right side at a 15-degree angle. Place your free hand on the client’s head,
which helps limit head movement. Shine the light beam toward the
client’s pupil.
Inspect the optic disc. Keep the light beam focused on the pupil and
move closer to the client from a 15-degree angle.
 You should be very close to the client’s eye (about 3 to 5 cm), almost
touching the eyelashes. Rotate the diopter setting to bring the retinal
structures into sharp focus. The diopter should be zero if neither the
examiner nor the client has refractive errors. Note shape, color, size, and
physiologic cup.
 Inspect the retinal vessels. Remain in the same position as described
previously. Inspect the sets of retinal vessels by following them out to the
periphery of each section of the eye. Note the number of sets of arterioles
and venules.
 Also note color and diameter of the arterioles.
 Observe the arteriovenous (AV) ratio.
 Look at AV crossings.
 Inspect retinal background. Remain in the same position described
previously and search the retinal background from the disc
 to the macula, noting the color and the presence of any lesions.
 Inspect fovea (sharpest area of vision) and macula. Remain in the same
position described previously. Shine the light beam toward the side of the
eye or ask the client to look directly into the light. Observe the fovea and
the macula that surrounds it.
 Inspect anterior chamber. Remain in the
 same position and rotate the lens wheel slowly to +10, +12, or higher to
inspect the anterior chamber of the eye.

ASSESSING EYE TRAUMA

In the event of an eye trauma in in which the client is experiencing eye pain,
discomfort, or feels something is in the eye, observe for:
• Foreign body that remains after gentle washing
• Perforated globe
• Blood in eye

In the case of blunt eye trauma, observe for:

• Lid swollen shut
• Blood in anterior chamber
• White/hazy cornea
• Irregularly shaped, fixed, dilated, or constricted pupil

Abnormal Findings: Visual Field Defects

 Unilateral blindness (e.g., blind right eye)

 Bitemporal hemianopia (loss of vision in both temporal fields)
 Left superior quadrant anopia or similar loss of vision (homonymous) in
quadrant of each field
 Right visual field loss—right homonymous hemianopia or similar loss of
vision in half of each field

Abnormal Findings: Extraocular Muscle

DYSFUNCTION
Abnormalities found during an assessment of extraocular muscle function are
as follows:

CORNEAL LIGHT REFLEX TEST ABNORMALITIES

 Pseudostrabismus- Normal in young children, the pupils will appear at the
inner canthus (due to the epicanthic fold)
 Strabismus (or Tropia)A constant malalignment of the eye axis,
strabismus is defined according to the direction toward which the eye
drifts and may cause amblyopia.
 Esotropia (eye turns inward).
 Exotropia (eye turns outward)

COVER TEST ABNORMALITIES

 Phoria (Mild Weakness)- Noticeable only with the cover test, phoria is less
likely to cause amblyopia than strabismus. Esophoria is an inward drift
and exophoria an outward drift of the eye.
 The uncovered eye is weaker; when the strongereye is covered, the
weaker eye moves to refocus.
 When the weaker eye is covered, it willdrift to a relaxed position.Once the
eye is uncovered, it will quicklymove back to reestablish fixation.

POSITIONS TEST ABNORMALITIES

 Paralytic Strabismus

Abnormalities of the External Eye

 Ptosis
 Extropion
 Conjunctivitis
 Exophthalmos
 Chalazion
 Hordeolum (stye).
 Entropion
 Blepharitis
 Diffuse episcleritis

Abnormalities of the Cornea

 Corneal Scar
 Early pterygium,

Abnormalities of the Lens

 Nuclear Cataract
 Peripheral /Cataract

Abnormalities of the Iris

 IRREGULARLY SHAPED IRIS-

Abnormalities of the Iris

 Miosis
 Anisocoria
 Mydriasis

Abnormalities of the Optic Disc

 Papilledema
 Glaucoma
 Optic Atrophy

Abnormalities of the Retinal Vessels and Background

 Constricted Arteriole
 Copper Wire Arteriole
 Silver Wire Arteriole
 Arteriovenous Nicking
 Arteriovenous Tapering
 Arteriovenous Banking
 Cotton Wall Patches
 Hard Exudate
 Superficial (Flame-Shaped)Retinal Hemorrhages
 Deep (Dot-shaped) Retinal Hemorrhages
 Microaneurysms

IV. Ears
- the sense organ of hearing and equilibrium. It consists of three distinct
parts: the external ear, the middle ear, and the inner ear.

a. External Ear is composed of the auricle, or pinna, and the

external auditory canal
b. Middle Ear or tympanic cavity, is a small, air-filled chamber in
the temporal bone.
c. Inner Ear or labyrinth, is fluid filled and made up of the bony
labyrinth and an inner membranous labyrinth.

 HEARING
-Sound vibrations traveling through air are collected by and funneled
through the external ear, causing the eardrum to vibrate.

Health Assessment
Collecting Subjective Data: Nursing Health History

1. History of Present Health Concern

 Describe any recent changes in your hearing.

 Are you ever concerned that you may be losing your ability to hear well?
 Are all sounds affected with this change or just some sounds?

Other Symptoms:
 Do you have any ear drainage? Describe the amount and any odor.
 Do you have any ear pain? If the client answers yes, use COLDSPA to
explore the symptom.
 Do you experience any ringing, roaring or crackling in your ears?
 Do you ever feel like you are spinning or that the room is spinning? Do
you ever feel dizzy or unbalanced?
2. Personal Health History
 Have you ever had any problems with your ears such as infections,
trauma, or earaches?
 Describe any past treatments you have received for ear problems
(medication, surgery, hearing aids). Were these successful? Were you
satisfied?

3. Family History
 Is there a history of hearing loss in your family

4. Lifestyle and Health Practices

 Do you work or live in an area with frquent or continuous loud noise?
How do you protect your ears from the noise?
 Do you spend a lot of time swimming or in water? How do you protect
your ears
 when you swim?
 Has your hearing loss affected your ability to care for yourself? To work?
 Has your hearing loss affected your socializing with others?
 When was your last hearing examination?
 Do you wear a hearing aid?
 How do you care for your ears? Describe how you clean your ears

COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION

The purpose of the ear and hearing examination is to evaluate the condition
of the external ear, the condition and patency of the ear canal, the status of
the tympanic membrane, bone and air conduction of sound vibrations,
hearing acuity, and equilibrium.

Preparing the Client

 Make sure that the client is seated comfortably during the ear
examination. This helps to promote the client’s participation, which is very
important in this examination.
 The test should be explained thoroughly to guarantee accurate results. To
ease any client anxiety, explain in detail what you will be doing. Also,
answer any questions the client may have.
 As you prepare the client for the ear examination, carefully note how the
client responds to your explanations.

Equipment
• Watch with a second hand for Romberg test
• Tuning fork (512 or 1024 Hz)
• Otoscope

Physical Assessment
Before performing the examination, make sure to:
• Recognize the role of hearing in communication and adaptation to the
environment, particularly in regard to aging.
• Know how to use the otoscope effectively when performing
the ear examination (Assessment Guide 17-1).
• Understand the usefulness and significance of basic hearing
test

Asessment Procedure

External Ear Structures

Inspection and Palpation
Inspect the auricle, tragus, and lobule. Note size, shape, and position.
Continue inspecting the auricle, tragus, and lobule. Observe for lesions,
discolorations, and discharge.
Palpate the auricle and mastoid process.

Internal Ear: Otoscopic Examination

Inspection
 Inspect the external auditory canal.
 Use the otoscope .Note any discharge along with the color and
consistency of cerumen (earwax)
 Observe the color and consistency of the ear canal walls and inspect the
character of any nodules
 Inspect the tympanic membrane (eardrum). Note color, shape,
consistency, and landmarks.
 To evaluate the mobility of the tympanic membrane, perform pneumatic
otoscopy with a bulb insufflator attached by using an otoscope with bulb I
nsufflators. Observe the position of the tympanic membrane when the
bulb is inflated and again when the air is released.

Hearing and Equilibrium Tests

 Perform the whisper test
 Perform Weber’s Test
 Perform the Rinne test
 Perform the Romberg test

Hearing Loss and Testing

 Sensorineural Hearing and Hearing Loss
 Conductive Hearing and Loss
Abnormalities of the External Ear and Ear Canal
 Malignant lesion
 Building of cerumen in ear canal
 Otitis media
 Polyp
 Exostosis.

Abnormalities of the Tympanic Membrane

 Acute Otitis Media
 Blue/Dark Red Tympanic Membrane
 Perforated Tympanic Membrane
 Serous Otitis Media
 Scarred Tympanic Membrane
 Retracted Tympanic Membrane