HEALTH ASSESSMENT

EYES AND EARS

ASSESSMENT
Module 12

PETER ARNOLD T. TUBAYAN, RN, MAN

Instructor
OVERVIEW/INTRODUCTION:

 The eye and the ear are sensory structures

that connect us with the environment. They
allow us to perceive our surroundings
through sight and sound. Disorders of the
eye and the ear can range from minor
annoyances to life-threatening problems.
Most problems do not result in acute illness;
however, they may be associated with
more serious neurological conditions such as
brain tumor, stroke, or head injury.
 OVERVIEW/INTRODUCTION:

 No matter what the cause, visual and hearing

problems can have a major impact on
physiological functioning as well as psychological
and social well-being. Early detection reduces the
likelihood of problems related to social interaction.
Determining whether a patient has adequate
vision and hearing is crucial before assessing
mental status or providing instructions. The eyes
and the ears are common sites of injury; they also
exhibit structural variations as a result of age,
cultural background, and genetic influences.
OVERVIEW/INTRODUCTION:

 Assessment of vision provides important

information about the client’s ability to interact
with the environment because healthy eyes are
essential for vision and to perform activities of
daily living. Vision informs our lives, permits
mobility, and assists learning. People without
vision are handicapped indeed. Changes in
vision often occur gradually and go
unrecognized by clients until a severe problem
develops. Thus, an accurate history and exam
are essential to detect any abnormalities.
OVERVIEW/INTRODUCTION:

 The sense organ of hearing and equilibrium

is the ear, which consists of the external ear,
the middle ear, and the inner ear. Healthy
ears are essential to effective
communication and balance. When the
nurse first meets the client, cues of hearing
ability provides important information about
the client’s interaction with others and the
environment.
 LEARNING OUTCOMES:
At the end of the module, students should be able to:
1. Describe the structures and functions of the eyes and
ears.
2. Practice a client interview for an accurate nursing
history of the eyes and ears.
3. Demonstrate a physical assessment of the eyes and
ears using the correct techniques.
4. Differentiate between normal and abnormal findings
of the eyes and ears.
5. Analyze data from the interview and physical
assessment of the eyes and ears.
EYE ASSESSMENT
STRUCTURE & FUNCTION

 Eye
Transmit stimuli to the brain
for interpretation
Organ of vision
 EXTERNAL STRUCTURE

 Eyelid (upper & lower)

2 movable structures
composed of skin and
2 types of muscles (striated & smooth)
 Protects the eye from foreign bodies
 Limits the amount of light entering the eye
 Serveto distribute tears that lubricates the
surface of the eye.
EXTERNAL STRUCTURE

 Upper eyelid – larger, more mobile

and contains tarsal plates made up of
connective tissue
 Tarsal plates contains
meibomian glands
which secretes an
oily substance
that lubricates
the eyelid.
 EXTERNAL STRUCTURE

The eyelids join at two points:

1. Lateral (outer) canthus
2. Medial (inner) canthus
Inner canthus contains:
a. PUNCTA (two small openings
that allow drainage of tears into
lacrimal system
b. Caruncle – a small fleshy
mass that contains sebaceous
glands.
 EXTERNAL STRUCTURE
1
 Palpebral fissure – white space between the open
eyelids 2

 Eyelashes – projections of stiff hair curving outward 3

along the margins of the eyelids.
4
 it
filters dust and dirt from air entering the eye.
 Conjunctiva – thin, transparent, continuous 5
membrane that is divided into two portions:
1. Palpebral conjunctiva – lines the inside of the
6
eyelids
2. Bulbar conjunctiva – covers most of the anterior
eye merging with the cornea at the limbus.
 EXTERNAL STRUCTURE
1
 Lacrimal apparatus – consist of glands and ducts
2
that lubricates the eye
1. Lacrimal gland – located in the upper outer 3
corner of the orbital cavity just above the eye
- produces tears 4
2. Excretory ducts of lacrimal gland - Punctu
5
3. Lacrimal sac
4. Lacrimal canal
5. Nasolacrimal sac 6
6. Nasolacrimal duct
7. Nasal meatus
EXTERNAL STRUCTURE
 EXTRAOCULAR MUSCLES

1. Superior rectus 5 1
2. Inferior rectus
3. Medial rectus
3
4. Lateral rectus 4
5. Superior oblique
6. Inferior oblique 6
2
EXTRAOCULAR MUSCLES

 Extraocular Muscles – 6 muscles attached to

the outer surface of each eyeball.
 control six different directions of eye
movement
 the 4 rectus are responsible for straight
movement
 the 2 oblique are responsible for diagonal
movement
 innervated by Cranial Nerve III
(Oculomotor), CN IV(Trochlear) and CN VI
(Abducens)
INTERNAL STRUCTURES:

Three (3) layers:

1. External layer
(Sclera)
2. Middle layer
(Choroid)
3. Innermost layer
(Retina)
 INTERNAL STRUCTURES:

1. SCLERA (EXTERNAL LAYER)

– a dense protective, white,
covering that physically
supports the internal eye
structure.
 it continues anteriorly forming
the CORNEA (window of the
eye) which permits the
entrance of light, well
supplied with nerve endings,
making it responsive to pain
and touch.
 INTERNAL STRUCTURES:

2. MIDDLE LAYER (CHOROID)

 Anterior portion
 Iris – circular disc of muscle
containing pigment that determines
the color of the eye.
 Ciliary body – holds the lens
 Posterior portion
 Choroid – contains vascularity necessary
to provide nourishment
 Pupil – central aperture of the iris
 Lens – a biconvex, transparent, avascular, encapsulated
structure located immediately posterior to the iris.
 refracts light (bend) rays onto the retina
 INTERNAL STRUCTURES:
3. RETINA (INNER LAYER) – extends only to the
ciliary body anteriorly
 contains numerous layers of nerve cells
often referred as “PHOTORECEPTORS”
because they are responsive to light.
 Rods – highly sensitive to light, regulate black
and white vision and functions in dim light.
 Cones – functions in bright light and are
sensitive to color.
 Optic disc – is a cream-colored, circular area
located on the retina toward the medial or
nasal side of the eye where the optic nerve
enters the eyeball.
 Retinal vessel – four sets of arterioles and
venules.
 EYEBALL CHAMBERS
Eyeball contains chambers that serves to
maintain structure, protects against injury
and transmits light rays. 1 2 3
1. Anterior chamber
 Located between the cornea and iris
2. Posterior chamber
 Located between the iris and the lens
Anterior/posterior chamber – contains
AQUEOUS HUMOR, a clear liquid
produced by the ciliary body
3. Vitreous chamber
 Located in the area behind the lens to
the retina
 contains VITREOUS HUMOR, a clear
gelatinous liquid.
 Larger chamber
 VISION
 Visual fields – is the entire area (field of vision) that
can be seen when the eyes are focused on a single
point. In addition to what can be seen straight
ahead, the visual field includes what can be seen
above, below, and to either side of the point the
eyes are focused on.
 Four (4) quadrants of visual field:
1. Upper temporal
2. Lower temporal
3. Upper nasal
4. Lower nasal
 VISUAL PERCEPTION
 occurs when light
rays strike the
retina, where they
are transformed
into nerve
impulses,
conducted to the
brain through the
optic nerve and
interpreted.
 VISUAL PERCEPTION
 Transparent media where
light passes:
1. Cornea
2. Aqueous humor
3. Lens
4. Vitreous humor  Retina
 Optic disc  optic
nerve  brain for
interpretation
 Image projected on the
retina is upside down and
reversed right to left from the
actual image.
 VISUAL REFLEXES
1. Pupillary light reflexes – causes pupils
immediately to constrict when exposed to bright
light. Mediated by the Oculomotor nerve.
a. Direct – constriction occurs in the eye exposed
to light
b. Indirect – results when exposure to light in one
eye causes constriction of the opposite eye.
2. Accommodation – normally there is
convergence of the eyes and constriction of
pupils occurring simultaneously when object is
brought near the eyes.
 COLLECTING
SUBJECTIVE DATA
 NURSING HEALTH HISTORY

 History of present health concern

 Use COLDSPA
 Questions:

 Visual Problems
1. Describe any recent changes in your vision?
Were they sudden or gradual?
2. Do you see spots or floaters in front of your eyes?
3. Do you experience blind spots? Are they
constant or intermittent?
 NURSING HEALTH HISTORY
 INTERPRETATION:
1. Sudden changes in vision are associated with acute
problems such as head trauma, or increased ICP. Gradual
changes may be associated with AGING, DM, HPN,
neurologic disorders.
2. Spots or floaters are common among clients with MYOPIA
(nearsightedness) or in clients with over age 40.
3. Scotoma is a blind spot that is surrounded by either normal
or slightly diminished peripheral vision. It maybe be due to
glaucoma.
4. Intermittent blind spot may be associated with vascular
spasm (ophthalmic migraine), or pressure on the optic
nerve by a tumor or intracranial pressure.
5. Consistent blind spots may indicate retinal detachment.
 NURSING HEALTH HISTORY

4. Do you see halos or rings around lights?

 associated with narrow angle glaucoma
5. Do you have trouble seeing at night?
6. Do you experience double vision?
 Other symptoms:
1. Do you have any eye pain or itching? Describe.
2. Do you have any redness or swelling in your eyes?
3. Do you experience watering or tearing of the eye?
 NURSING HEALTH HISTORY

4. Have you had any eye discharge?

Describe.
5. Have you ever had problems with
your eyes or vision?
6. Have you ever had eye surgery?
7. Describe any past treatments
received for eye problems.
NURSING HEALTH HISTORY

 Family History
 Is there any history of eye problem or
vision loss in your family?
 Lifestyle and Health Practices
 Exposure to conditions or substances in
workplace or home that may harm eyes
or vision? Wearing of safety glasses
during exposure?
NURSING HEALTH HISTORY

 Wearing of sunglasses during exposure to

sun?
 Has vision loss affect ability to care for
self? work?
 When was last eye examination?
 Prescription and use of corrective lenses?
 COLLECTING
OBJECTIVE DATA
 PHYSICAL EXAMINATION

 Purpose is to identify any changes in vision or

signs of eye disorder to initiate early
treatment.
 Equipment includes:
1. Snellen or E chart
2. Hand held snellen card or near vision
screener
3. Penlight
4. Opaque cards
5. Ophthalmoscope
6. Disposable gloves
PHYSICAL EXAMINATION

 Evaluating Vision
 TestDistant vision
acuity
Normal: Normal
distant vision acuity
is 20/20.
Abnormal: Myopia
(nearsightedness)
PHYSICAL EXAMINATION
 Test for distant vision acuity – Position the client 20
feet from the snellen chart or E chart and ask her to
read each line until she cannot decipher the letters
or their direction.
 20/20 means the client can distinguish what the
person with normal vision can distinguish from 20 feet
away.
 Myopia – impaired far vision (20/40). The higher the
second number, the poorer the vision.
 20/200 – considered legally blind.
 During this vision test, note any client behaviors
(leaning forward, head tilting or squinting) that could
be unconscious attempts to see better.
PHYSICAL EXAMINATION

 TEST NEAR VISION ACUITY

 Normal: Normal near
vision acuity is 14/14
 Abnormal: Presbyopia
and Hyperopia
(farsightedness)
 PHYSICAL EXAMINATION
 Test Near Vision acuity: 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.
 14/14 – this means a client can read what a normal
eye can read from a distance of 14 inches.
 Presbyopia – (impaired near vision) is indicated when
the client moves the chart away from the eyes to
focus on the print. It is caused by decreased
accommodation. It is common in clients over age 45.
 TEST VISUAL FIELDS FOR
GROSS PERIPHERAL VISION
 Normal: the client sees the examiner’s finger
at the same time the examiner sees it.
Normal visual field degrees are as follows:
 Inferior: 70 degrees
 Superior: 50 degrees
 Temporal: 90 degrees
 Nasal: 60 degrees
 Abnormal: Delayed or absent
perception of the examiner’s finger indicates
reduced peripheral vision.
 TEST VISUAL FIELDS FOR
GROSS PERIPHERAL VISION
 Test visual fields for gross peripheral vision/confrontation
test: Position yourself approximately 2 feet away from
the client at eye level. Have the client cover his 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. Then, test the remaining 3 visual fields of the client
right eye(Superior, temporal, nasal).
 Abnormalities: Unilateral blindness – (e.g. right blind
eye), Bitemporal hemianopia (loss of vision in both
temporal fields), homonymous hemianopia (similar loss
of vision in half of visual field)
 TESTING EXTRAOCULAR
MUSCLES FUNCTION
 PERFORM CORNEAL LIGHT REFLEX
 Normal: Parallel alignment.
The reflection of light of the
corneas should be in the
exact same spot on each eye
 Abnormal: Asymmetric
position of light reflex
indicates deviated alignment
of the eyes.
 TESTING EXTRAOCULAR
MUSCLES FUNCTION
 Perform corneal light reflex – 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.
Abnormal :
 Pseudostrabismus – normal in young children, the pupils will
appear at the inner canthus.
 Strabismus/Tropia – a constant misalignment of the eye
axis. Stabismus is defined according to the direction
toward which the eye drifts and may cause amblyopia/
lazy eye  poor eye sight
 PERFORM COVER TEST

 Normal: The uncovered eye

should remain fixed straight
ahead. The covered eye
should remain fixed straight
ahead after being uncovered.
 Abnormal: The uncovered eye
will move to establish focus
when opposite eye is covered.
When covered eye is
uncovered, movement to
establish focus occurs.
 PERFORM COVER TEST

 Cover test detects deviation in alignment or strength

and slight deviation in eye movement by interrupting
fusion reflex normally keeps the eyes parallel.
 Ask the client to stare straight ahead and focus on a
distant vision. Cover one of the clients eye with an
opaque card. As you cover the eye, observe the
uncovered eye for movement.
 Abnormal: Phoria – is a term used to describe
misalignment that occurs only when fusion reflex is
blocked.
 Strabismus – is a constant misalignment of the eyes.
 Tropia – is a specific type of misalignment.
PERFORM THE POSITION TEST
(6 CARDINAL GAZES)

 Normal: Eye movement

should be smooth and
symmetric throughout all
six directions.
 Abnormal: Failure of eye
to follow movement
symmetrically in any or all
directions. Nystagmus
(the eyes make repetitive,
uncontrolled movements)
 6 CARDINAL FIELD GAZES

Superior rectus Inferior oblique

(CN III) (CN III)

Lateral Rectus Medial rectus

(CN VI) (CN III)

Inferior rectus Superior oblique

(CN III) (CN IV)
 Paralytic Strabismus – result of the
weakness or paralysis of one or more
extraocular muscles.
 6th nerve paralysis – eye cannot look to the
outer side
 4th nerve paralysis – eye cannot look down
when turned inward.
 3rd nerve paralysis – upward, downward
and inward movements are lost. Ptosis and
dilation may also occur.
 PERFORM THE POSITION TEST
(6 CARDINAL GAZES)

 Position test assesses eye muscle strength and cranial

nerve function.
 Instruct the client to focus on an object you are holding
(approximately 12 inches from the clients face). Move
object through the six cardinal gazes in a clockwise
direction and observe the client’s eye movements.
 Abnormal: Failure of eye to follow movement
symmetrically in any or all directions indicates a weakness
in one or more extraocular muscles or dysfunction of the
cranial nerve that innervates the particular muscles.
 Nystagmus – an oscillating (shaking) movement of the
eye may be associated with an inner ear disorder, multiple
sclerosis, brain lesions or narcotics use.
Clockwise direction: up, side, down, down, side , up
EXTERNAL EYE STRUCTURES

INSPECTION AND PALPATION

 Inspect the eyelids and eyelashes
 Normal: Upper lid margin should
be between the upper margin of
the iris and upper margin of the
pupil. Lower lid margin rest on the
lower border of the iris. No white
sclera is seen above the or below
the iris.
 Abnormal: Ptosis, Retracted lid
margins
 EXTERNAL EYE STRUCTURES

INSPECTION AND PALPATION

Note for width and position of palpebral
fissure.
 Normal: palpebral fissure should be
horizontal.
 Abnormal: Ptosis – drooping of the
upper lid maybe attributed to
oculomotor nerve damage,
myasthenia gravis, weakened muscle
or tissue or a congenital disorder.
 Retracted lid margins – which allows
for viewing of the sclera when the are
open , suggest hyperthyroidism.
EXTERNAL EYE STRUCTURES

 Assessfor ability of
eyelids to close
 Normal: upper and
lower lids close easily
and meet completely
when closed.
 Abnormal: Failure of
lids to close
EXTERNAL EYE STRUCTURES

 Failure of lids to close

completely puts clients at
risk for corneal damage.
 Xanthelasma – raised
yellow plaques located
most often near the inner
canthus, are normal
variation associated with
increasing age and high
lipid level.
 EXTERNAL EYE STRUCTURES

 Note the position of the eyelids in

comparison with the eyeballs.
 Normal: Lower lid is upright with no
inward or outward turning. Eyelashes
evenly distributed and curve
outward along with lid margins.
 Abnormal: Entropion – inverted lower
lid which may cause pain and injured
the cornea as the eyelashes brushes
against the conjunctiva and cornea.
Ectropion – everted lower eyelid results
in drying of the conjunctiva.
EXTERNAL EYE STRUCTURES

 Observe for redness,

swelling, discharges or
lesion
 Normal: Absent redness,
swelling, lesions
 Abnormal: Redness and
crusting along the lid
margins, Hordeolum
(Stye), Chalazion,
 EXTERNAL EYE STRUCTURES

 Abnormal: Redness and crusting

along the lid margins suggest
SEBORRHEA or BLEPHARITIS, an
infection caused by Staph. aureus
 Hordeolum(Stye) – a hair follicle
infection causes local redness,
swelling, and pain.
 Chalazion – infection of the
meibomian gland (located in the
eyelid) may produce extreme
swelling of the lid, moderate redness
but minimal pain.
 EXTERNAL EYE STRUCTURES

 Observe the position and alignment

of the eyeball in the eye socket.
 Normal: Eyeballs are symmetrically
aligned in socket without protruding
or sinking
 Abnormal: Exophthalmos, sunken
appearance of the eyes.
Exophthalmos – protrusion of the
eyeballs accompanied by
retracted eyelid margins is a
characteristic of Graves diseases
(hyperthyroidism)
EXTERNAL EYE STRUCTURES

 Inspect the bulbar conjunctiva and sclera

 Normal: Bulbar conjunctiva is clear, moist and
smooth, underlying structures are clearly visible.
Sclera is white.
 Abnormal: Generalized redness of conjunctiva,
areas of dryness, Episcleritis
Inspect the bulbar conjunctiva and sclera: have
the client keep her head straight while looking
from the side to side then up toward the ceiling.
Observe the clarity, color and texture.
 EXTERNAL EYE STRUCTURES

 Pinguecula – yellowish nodules on the

bulbar conjunctiva are common in
older clients. Appear first on the medial
side of the iris, then on the lateral side.
 Conjunctivitis – generalized redness
of the conjunctiva
 Eye dryness suggest allergies/ trauma
 Episcleritis – local, non-infectious
inflammation of the sclera
characterized by either nodular
appearance or by redness with dilated
vessels.
 EXTERNAL EYE STRUCTURES

 Inspect the palpebral conjunctiva (both upper &

lower)
 Normal: lower and upper palpebral conjunctiva
are clear and free from swelling or lesions, foreign
bodies or trauma.
 Abnormal: Cyanosis of the lower lid suggest a
heart or lung disorder
Inspect the palpebral conjunctiva: This procedure is
stressful and uncomfortable for the client and only done
if the client complains of pain or “something in the eye”
EXTERNAL EYE STRUCTURES

Inspect the lacrimal apparatus.

Normal: No swelling or redness over
lacrimal gland, puncta is visible with
swelling or redness and is turned
slightly towards the eye.
Abnormal: Swelling, redness, and
excessive tearing expressed drainage
from the puncta on palpation suggest
duct blockage.
EXTERNAL EYE STRUCTURES

 Inspect the lacrimal

apparatus: Assess the
areas over the lacrimal
glands (lateral aspect of
upper eyelid) and puncta
(medial aspect of lower
eyelid)
 Swelling maybe caused by
blockage, infection or
inflammatory condition
EXTERNAL EYE STRUCTURES

 Inspect the cornea and lens.

 Normal: Cornea is transparent with no
opacities. Oblique view shows a smooth
and overall moist surface; lens is free from
opacities.
 Abnormal: Areas of roughness or dryness on
cornea suggest injury or allergies; opaque
lens
EXTERNAL EYE STRUCTURES

 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.
 Arcus Senilis – a normal condition in older clients,
appears as a white arc around the limbus. It has no
effect in vision.
 Keratitis – redness and swelling of the cornea
 Pterygium – pinkish tissue growth on the cornea
 Pinguecula – whitish/ yellowish spot tissue near the
cornea
 Cataract – cloudy/ opacity of the lens
EXTERNAL EYE STRUCTURES

 Inspect the iris and the pupil

 Normal: Iris is typically round, flat & evenly
colored. Pupil , round with regular border
and is centered in the iris. Pupils are
normally equal in size (3 to 5mm)
 Abnormal: Irregularly shaped irises, miosis
(excessive constriction of the pupil),
mydriasis (unusual dilation or widening of
the pupils), and anisocoria (pupil of one eye
differs in size from the pupil of the other eye)
 EXTERNAL EYE STRUCTURES

 Inspect the Iris and the pupil: Inspect

shape, color of iris and size and
shape of pupil. Measure pupil against
a gauge if they appear larger or
smaller than normal or if they appear
to be two different sizes.
TEST FOR PUPILLARY
REACTION TO LIGHT
 Direct response
Normal: constriction of pupil
Abnormal: No pupillary response
 Consensual response
Normal: constriction of pupils in both eyes
Abnormal: Pupils do not react with light
 TEST FOR PUPILLARY
REACTION TO LIGHT
 Test for direct response by darkening the room and
asking the client to focus on a distant object. Shine
a light obliquely into one eye and observe pupillary
reaction.
 Use a pupillary gauge to measure the constricted
pupil. Then document the finding in mm.
 For consensual response: Place your hand or
another barrier to light between the client’s eyes to
avoid inaccurate findings.
TEST FOR ACCOMMODATION
OF PUPILS
 Normal: Constriction of pupils and
convergence of eye when focusing on near
object.
 Abnormal: Pupils do not constrict and eyes
do not converge.
TEST FOR ACCOMMODATION
OF PUPILS
 Accommodation occurs when the client
moves his focus of vision from a distant point
to a near object causing the pupils to
constrict.
 Hold your finger or 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 towards the eye.
INTERNAL EYE STRUCTURE

 Inspect the optic disc

 Inspect the retinal vessel
 Inspect the retinal background
 Inspect the fovea and macula
 Inspect the anterior chamber
Done using the ophthalmoscope.
INTERNAL EYE STRUCTURE

 Papilledema – swelling of optic disc

 Optic atrophy – evidence by the disc being
white in color and a lack of disc vessel
 Hyphemia – RBC/blood at the lower half of
the anterior chamber
 Hypopyon – WBC accumulate in the
anterior chamber and produces cloudiness
in front of the iris.
 Glaucoma – increase pressure in the anterior
chamber
 EAR
ASSESSMENT
 STRUCTURE AND FUNCTION
 Ear
Earis the sense organ of
hearing and equilibrium.
Has 3 distinct parts:
1. External ear
2. Middle ear
3. Inner ear
STRUCTURES OF THE EAR
STRUCTURES OF THE EAR
 STRUCTURES OF THE EAR
• The external auditory canal – is S-shaped in adult. The
outer part of the canal curves up and back and the
inner part curves down and forward.
• Modified sweat glands secretes CERUMEN, a wax like
substance that keeps the tympanic membrane soft.
• CERUMEN has a bacteriostatic properties and its sticky
consistency serves as a defense against foreign bodies.
• Tympanic membrane/Eardrum – has a translucent
pearly, gray appearance and this separates the external
ear fro middle ear.
- is concave and located at the end of the auditory canal in a
tilted position such that the top of the membrane is closer to the
auditory meatus than the bottom.
STRUCTURES OF THE EAR
MIDDLE EAR/
TYMPANIC CAVITY
 Middle ear – is a small, air filled chamber in the
temporal bone. It is separated from the external
ear by eardrum and from the inner ear by a bony
partition, containing two openings, the ROUND and
OVAL windows.
 The 3 ossicles are responsible for transmitting sound
waves from the eardrum to the inner ear through
the oval window.
 Eustachian tube – equalizes the air pressure on both
sides of the tympanic membrane, it also connects
the middle ear to the nasopharynx.
INNER EAR/LABYRINTH

 Inner ear – is fluid filled and is made up of

the bony labyrinth and inner membranous
labyrinth
 Bony labyrinth
1. Cochlea – contains the Spiral Organ of
Corti – sensory organ of hearing
2. Vestibule
3. Semicircular canals
 Membranous labyrinth
 HEARING

 Conductive Hearing
 transmission of sound waves
through external and middle ear
 Sensorineural Hearing
transmission of sound waves in
the ear
 HEARING
 Sound vibration  funneled through external ear 
causing eardrum to vibrate  sound waves are then
transmitted through auditory ossicles: (malleus, incus,
stapes)  stapes vibrates at the oval window  sound
waves are passed to the fluid in the inner ear 
stimulation of hair cells of the SPIRAL ORGAN OF CORTI 
initiates nerve impulses to the brain via ACOUSTIC NERVE
 Conductive Hearing Loss (Impacted cerumen, otitis
media, externa, foreign object, perforated eardrum,
drainage in the middle ear, otosclerosis
 Sensorineural Hearing Loss – (dysfunction of the organ
of Corti, CN VIII, temporal lobe)
 TRANSMISSION OF SOUND

a. Air conduction
b. Bone conduction
 COLLECTING
SUBJECTIVE DATA
COLLECTING
SUBJECTIVE DATA
 First
note for any signs of
hearing loss:
 inappropriate answers
 frequent request for repetition
 Head tilted nearer to the one
speaking
THE NURSING HEALTH HISTORY

 History of present health concern

 Use COLDSPA
 Questions
CHANGES IN HEARING
1. Describe any recent changes in your
hearing.
2. Are all sounds affected with this change or
just one sound?
 OTHER SYMPTOMS
1. Do you have any ear drainage? Describe
amount and any odor.
 NURSING HEALTH HISTORY

 A sudden decrease in ability to hear in one

ear may be associated with otitis media.
 Presbycusis – a gradual hearing loss is
common among age 50 up.
- caused by a degeneration of the cochlea
and vestibulocochlear nerve.
 Presbycusis often begins with a loss of the
ability to hear high-frequency sounds.
 NURSING HEALTH HISTORY

Other symptoms:
 Drainage (Otorrhea) usually indicates infection.
 Purulent bloody drainage suggest an infection
of the external ear (otitis externa)
 Purulent drainage associated with pain and a
popping sensation is characteristic of otitis
media with perforation of tympanic membrane.
Earache (OTALGIA) can occur with ear
infections, cerumen blockage, sinus infections,
or teeth and gum problems.
NURSING HEALTH HISTORY

3. Do you have any ear pain? If so, do you

have an accompanying sore throat,
sinus infection or problem with your
teeth or gums?
4. Do you experience any ringing or
crackling in your ears?
5. Do you ever feel like you are spinning or
that the room is spinning? Do you ever
feel dizzy or unbalanced?
NURSING HEALTH HISTORY

 Ringing in the ears (TINNITUS) may be

associated with excessive ear wax buildup,
HPN, or certain OTOTOXIC medications
(streptomycin, gentamicin, kanamycin,
neomycin, furosemide, indomethacin or aspirin)
 Vertigo (true spinning motion) may be
associated with an inner ear problem.
 Subjective vertigo – when clients feels that he is
spinning around.
 Objecitve vertigo – when clients feels that the
room is spinning around him.
 PAST HEALTH HISTORY
1. Have you ever had problems with your ears
such as infections, trauma or earaches?
2. Describe any past treatment you have
received for ear problems?
3. Is there a history of hearing loss in your
family?
 A history of repeated infections can affect
the tympanic membrane and hearing.
 In many cases, hearing loss is hereditary.
 LIFESTYLE AND HEALTH
PRACTICES
 Do you work or live in an area with frequent 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?
 Has your hearing loss affected your ability to
care for yourself? Work?
 Has your hearing loss affected your socializing
with others?
 When was your last hearing examination?
 How do you care for your ears?
 COLLECTING
OBJECTIVE DATA
EQUIPMENT:

1. Watch with a second-hand

for Romberg test
2. Tuning fork
3. Otoscope
PHYSICAL ASSESSMENT

 INSPECTION AND PALPATION

 Inspectthe auricle, tragus, and lobule.
Note for size, shape & location.
 Normal: Ears are equal in size bilaterally (4-
10cm). Auricle aligns with the corner of each
eye & within 10 degree angle of the vertical
position.
 Abnormal:Ears are smaller than 4cm or larger
than 10cm. Malaligned or low set ears
PHYSICAL ASSESSMENT

 Ears are smaller than 4cm or larger than

10cm. Malaligned or low set ears may be a
sign of genitourinary disorders or
chromosomal defects.

 Older client often has elongated earlobes

with linear wrinkles.
 PHYSICAL ASSESSMENT

 Observe for lesions,

discolorations and
discharges.
 Normal: Skin is smooth with
no lesions, lumps or
nodules. Color is consistent
with facial color. No
discharges, Darwin’s
tubercle may be present.
 PHYSICAL ASSESSMENT
 Observe for lesions, discolorations and discharges.
 Abnormal: Enlarged pre-auricular and post-auricular
lymph nodes - INFECTION
 Tophi – non-tender, hard, cream-colored nodules on
the helix or antihelix containing uric acid crystals –
GOUT
 Blocked sebaceous glands – POST-AURICULAR CYST
 Ulcerated, crusted nodules that bleed – SKIN
CANCER (most commonly seen on the helix because
of skin exposure)
 Redness, swelling, scaling or itching – OTITIS EXTERNA
 Pale blue ear lobe - FROSTBITE
 PHYSICAL ASSESSMENT
 Palpate the auricle and mastoid
process
 Normal: Non-tender
 Abnormal: Painful auricle or tragus,
Tenderness over mastoid process,
tenderness behind the ear
 Painfulauricle or tragus – OTITIS EXTERNA
or POST AURICULAR CYST
 Tenderness over mastoid process –
MASTOIDITIS
 Tenderness behind the ear – OTITIS MEDIA
INTERNAL EAR: OTOSCOPIC
EXAMINATION
 INSPECTION
 Inspect the external auditory canal.
 Normal:A small amount of odorless
cerumen
 Abnormal: Foul-smelling, sticky, yellow
discharge
Bloody, purulent discharge
Blood or watery drainage
Impacted cerumen
INTERNAL EAR: OTOSCOPIC
EXAMINATION
 A small amount of odorless cerumen is the only
discharge normally present. Cerumen maybe
yellow, orange, red, brown, gray, or black and soft,
moist, dry, flaky, or even hard.
 ABNORMAL: Foul-smelling, sticky, yellow discharge
– OTITIS EXTERNA or IMPACTED FOREIGN BODY
 Bloody, purulent discharge – OTITIS MEDIA with
ruptured tympanic membrane
 Blood or watery drainage – SKULL TRUAMA (CSF)
 Impacted cerumen – CONDUCTIVE HEARING LOSS
PHYSICAL ASSESSMENT
 Observe the color and consistency of the ear
canal walls and inspect the character of any
nodules.
 Normal: Canal walls should be pink & smooth
and without nodules
 Abnormal: Reddened, swollen canals, Exostoses,
Polyps
 Reddened, swollen canals – OTITIS EXTERNA
 Exostosis (non-malignant nodular swelling)
 Polyps - abnormal tissue growths
 PHYSICAL ASSESSMENT
 Inspect the tympanic membrane (eardrum)
 Normal: Pearly, gray, shiny, and translucent with no
bulging or retraction. It is slightly concave, smooth and
intact.
 Abnormal: -Red, bulging eardrum and distorted,
diminished or absent light reflex
-Yellowish, bulging membrane
with bubbles behind
- Bluish or dark red color
- White spots
- Perforations
- Prominent landmarks
- Obscured or absent land marks
 PHYSICAL ASSESSMENT
 Inspect the tympanic membrane (eardrum):
Note for color shape, consistency and
landmarks
 Cone-shaped reflection of the otoscope
light is normally seen at 5 o’clock at right ear
and at 7 o’clock in the left ear. The short
process and handle of the malleus and
umbo are clearly visible.
 OLDER clients ear drum appears cloudy,
tympanic membrane atrophy
 PHYSICAL ASSESSMENT
 ABNORMAL:
 Red, bulging eardrum and distorted, diminished or
absent light reflex – ACUTE OTITIS MEDIA
 Yellowish, bulging membrane with bubbles behind –
SEROUS OTITIS MEDIA
 Bluish or dark red color – BLOOD BEHIND the EARDRUM
from skull trauma
 White spots – SCARRING FRON INFECTION
 Perforations - TRUAMA
 Prominent landmarks – EARDRUM RETRACTION FROM
NEGATIVE EAR PRESSURE
 Obscured or absent land marks – EARDRUM
THICKENING from chronic otitis media
 HEARING &
EQUILIBRIUM TEST
 Weber test (use tuning fork)
 Normal: Vibrations are heard
equally well in both ears. No
lateralization of sound to either ear.
 Abnormal:
 Lateralization of sound to the
poor ear (Conductive Hearing
Loss)
 Lateralization of sound to the
good ear (Sensorineural
Hearing Loss)
 HEARING &
EQUILIBRIUM TEST
 Perform WEBER test if the client reports diminished or
lost hearing in one ear.
 Weber’s test – helps to evaluate the conduction of
sound waves through the bones.
 Distinguishes CONDUCTIVE HEARING (sound waves
transmitted by the external and middle ear) and
SENSORINEURAL HEARING (sound waves transmitted by
the inner ear.)
 WEBER’S TEST: STRIKE a tuning fork softly with the back of
your hand and place it in the center of the client’s
head or forehead. ASK WHETHER THE CLIENT HEARS THE
SOUND BETTER IN ONE EAR or THE SAME IN BOTH EARS.
WEBER’S TEST
RINNE’S TEST
 Normal : Air conduction sound is normally
heard longer than bone conduction sound
(AC>BC)
 Abnormal:
 Bone conduction sound is heard longer
than or equally as long as air conduction
(BC≥AC) – Conductive Hearing Loss
 Air conduction sound is heard longer than
bone conduction sound (AC>BC) –
Sensorineural Hearing Loss
 RINNE’S TEST
 Perform the Rinne’s test: compares air
conduction and bone conduction sound.
 STRIKE a tuning fork and place the base of
the fork on the client’s mastoid process. ASK
THE CLIENT TO TELL YOU WHEN THE SOUND IS
NO LONGER HEARD.
 MOVE the prongs of the tuning fork to the
front of the external auditory canal. ASK THE
CLIENT TO TELL YOU IF THE SOUND IS AUDIBLE
AFTER THE FORK IS REMOVED.
RINNE’S TEST
 ROMBERG TEST

Perform the Romberg test: tests the

client equilibrium
Normal: Client maintains position for
20 second without swaying or with
minimal swaying
Abnormal: Client moves feet apart
to prevent falls or starts to fall from
loss of balance.
 ROMBERG TEST
 Perform the Romberg test: tests the client
equilibrium
 ASK the client to stand with feet together
and arms at sides and eyes open and then
with eyes closed. (Put your arms around the
client without touching him or her to
prevent falls.
 129

ASSESSMENT/S
QUIZZES/ ACTIVITY/ EXERCISES/
DEMONSTRATION
CASE STUDY
130

 Refer
to Health Assessment Lab
Manual
QUIZZES
131

 Refer
to Health Assessment Lab
Manual
 132

RELATED  Demonstration
and return
LEARNING demonstration of
the skill
EXPERIENCE competency using
the laboratory
(LAB) worksheet.
RESOURCES: 133
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 Barbara Timby (2009). Fundamental Nursing Skills and Concepts. 9th ed. Philippines:
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 Carol Taylor and carol Lillis et al (2008). Fundamentals of Nursing: The Art and
Science of Nursing Care. 6th ed. Philippines: Lippincott Williams & Wilkins
 Carolyn Jarvis (2004). Physical Examination and Health Assessment. 4th ed.
Singapore: Elsevier Ple. Ltd
 Donita D’Amico and Colleen Barbarito (2000). Health and Physical Assessment in
Nursing. 1st ed. Singapore: Pearson Education Ple. Ltd
 Helen Ballestas and Julie Calvery et al (2009). Nursing Know-How: Evaluating Signs
& Symptoms. Philippines: Lippincott Williams & Wilkins
 Janet Weber and Jane Kelley (2007). Health Assessment in Nursing. 3rd ed.
Philippines: Lippincott Williams & Wilkins
 Joyce LeFever Kee (2006). Laboratory and diagnostic Test with Nursing
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 Marily Shelley Leasia and Frances Donovan Monahan (1997). A Practical Guide to
Health Assessment. USA: W.B. Saunders Company.
 Patricia Dillon (2007). Nursing Health Assessment: Clinical Pocket Guide. 2nd ed.
Thailand: Group Press Co. Ltd
 Patricia Potter and Anne Griffin Perry (20017). Basic Nursing: Essential for Practice.
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