chapter 16
vision acuity tests
Snellen Chart (Distance Vision)
– Client stands 20 ft away; reads smallest visible line
– Normal: 20/20; 20/200 or worse = legal blindness
– Top number = distance from chart; bottom = distance a person with normal vision can read that line
Jaeger Card (Near Vision)
– Held 14 inches from eyes
– Normal: reads without hesitation or glasses (if prescribed)
Amsler Grid (Macular Degeneration Screening)
– Focus on center dot, one eye at a time
– Report any blurry, gray, or missing lines
– Used to detect central vision loss
Confrontation Test (Peripheral Vision)
– Cover opposite eyes (client and examiner), bring finger in from periphery
– Tests for peripheral vision loss or blind spots
structure and function
External Ear: Includes the auricle (pinna) and external auditory canal. Funnels sound to tympanic membrane. Produces cerumen (wax) for protection.
Middle Ear: Contains malleus, incus, stapes (ossicles). Transfers sound vibrations to inner ear. Connected to nasopharynx by eustachian tube.
Tympanic Membrane: Separates external and middle ear. Normal appearance: pearly gray, concave, translucent, visible malleus, and cone of light.
Inner Ear: Includes cochlea (hearing), vestibule, and semicircular canals (balance). Fluid-filled. Contains Organ of Corti. Cranial Nerve VIII (vestibulocochlear) transmits sound and balance info to brain.
hearing tests
Whisper Test: Stand 2 ft behind, occlude opposite ear, whisper two-syllable word. Normal: Correctly repeats. Abnormal: Suggests hearing loss.
Weber Test:
Tuning fork on forehead.
Normal: Sound heard equally both ears.
Conductive loss: Sound lateralizes to poor ear.
Sensorineural loss: Sound lateralizes to good ear.
Rinne Test:
Compare bone vs. air conduction (mastoid vs. front of ear).
Normal: AC > BC.
Conductive loss: BC ≥ AC.
Sensorineural loss: AC > BC but shorter than normal.
Romberg Test: Eyes closed, feet together, observe for sway. Positive = vestibular issue (loss of balance).
mouth
Includes lips, cheeks, palate (hard/soft), uvula, tongue, teeth, and gums. Begins digestion and aids in speech.
Tongue: Muscle attached to hyoid bone, connected to floor by frenulum; assists in chewing, swallowing, and speech.
Salivary glands:
Parotid (Stensen ducts)
Submandibular (Wharton ducts)
Sublingual
Secrete saliva (contains amylase to digest carbs)
objective data normal findings
lips: pink, moist, smooth
teeth and gums: 28–32 aligned white teeth; pink, firm gums.
buccal mucosa: pink, moist, smooth
tongue: midline, moist, pink with papillae; visible veins underneath
tonsils: pink, symmetric, may be 1+ (Grading:)
1+ Visible
2+ Midway to uvula
3+ Touching uvula
4+ Touching each other
uvula and palate: uvula midline, soft palate rises with "ahh" (CN X)
nose: midline, nontender; pink mucosa; septum intact
sinuses: nontender on palpation/percussion
objective data normal findings
– Eyelids: symmetric, no redness/swelling
– Sclera: white; Conjunctiva: pink, moist
– Pupils: equal (2–6 mm), round, reactive to light and accommodation
– Eye movement: smooth in 6 cardinal fields, no nystagmus
– Accommodation: pupils constrict & eyes converge when focusing near
types of hearing loss
Conductive: Problem in outer or middle ear (e.g., cerumen impaction, otitis media, perforated tympanic membrane, otosclerosis). Sound is blocked before reaching inner ear.
Sensorineural: Problem in inner ear, cochlear nerve, or brain (e.g., presbycusis, Meniere’s disease, ototoxic drugs, noise exposure, jaundice, birth complications). Sound reaches inner ear but cannot be processed correctly.
Mixed: Both conductive and sensorineural components.
Presbycusis: Gradual sensorineural hearing loss with aging, especially high-frequency sounds.
Otosclerosis: Abnormal bone growth in the middle ear that impairs sound transmission.
Bone conduction: Sound bypasses outer/middle ear by traveling through bones of skull.
older adult considerations
Presbycusis: Gradual sensorineural loss, begins ~age 50. Loss of high-frequency first.
External ear: Elongated lobes, drier cerumen, coarse hair.
TM: May appear cloudy; landmarks more prominent due to atrophy.
Hearing aids: May be underused due to stigma or discomfort.
Throat (pharynx)
Muscular passage for food and air.
Includes nasopharynx, oropharynx, laryngopharynx.
Tonsils: Lymphoid tissue — palatine, lingual, pharyngeal (adenoids)
objective data: abnormal
Lips: pallor (anemia), cyanosis (hypoxia), lesions, cheilosis, cold sores, carcinoma
Teeth & Gums: abnormal: Caries, missing teeth, swollen/bleeding gums (gingivitis), receding gums (periodontitis), hyperplasia (meds, pregnancy)
Buccal Mucosa: abnormal: Leukoplakia (white patch), thrush (Candida), Koplik spots (measles), leukoedema (benign)
Tongue: abnormal: Smooth/shiny (B12/iron deficiency), black hairy tongue, ulcers (cancer), enlarged tongue (hypothyroid, Down), fasciculations (CN XII damage)
Tonsils: abnormal: Redness, swelling, white/yellow exudate (tonsillitis)
Uvula & Palate: abnormal: Deviation (CN X lesion or stroke), cleft palate
Breath Odor: fruity (DKA), ammonia (renal), foul (infection), sulfur (liver), fecal (bowel obstruction)
Nose: abnormal: Red/swollen mucosa (URI), pale/gray mucosa (allergies), polyps, septal perforation (trauma, cocaine)
Sinuses: abnormal: Tenderness, crepitus → sinusitis
objective data abnormal findings
External Eye
– Ptosis: drooping upper eyelid
– Entropion: inward turning of lower lid
– Ectropion: outward turning of lower lid
– Conjunctivitis: redness, discharge
– Blepharitis: crusted eyelid margin
– Chalazion: painless nodule on lid
– Hordeolum (stye): red, painful lump at lash line
– Scleral jaundice: yellow sclera (liver issue)
– Subconjunctival hemorrhage: bright red scleral patch
– Exophthalmos: bulging eyes (seen in hyperthyroidism)
Pupils
– Miosis: pinpoint pupils
– Mydriasis: fixed, dilated pupils
– Anisocoria: unequal pupil sizes
Eye Movement / Muscle Control
– Strabismus (tropia): constant eye misalignment
– Pseudostrabismus: normal in infants
– Phoria: slight misalignment revealed on cover test
– Paralytic strabismus: paralysis of eye muscle
– Nystagmus: rhythmic, involuntary eye movement
– Limited movement: possible cranial nerve dysfunction
subjective data
Hearing changes: Sudden loss = emergency (could be cerumen, infection, or nerve damage).
Ear pain (otalgia): Associated with otitis media, otitis externa, sinus or dental issues.
Drainage (otorrhea):
Purulent/bloody: Otitis externa or TM rupture
Yellow/green: Infection
Tinnitus: Ringing, buzzing. Causes: excessive cerumen, high BP, ototoxic meds, Meniere’s disease.
Vertigo: Inner ear disturbance; BPPV, infection, Meniere’s. Room or self spins.
Past history: Frequent infections may cause scarring or hearing loss.
Family history: Hearing loss can be genetic. Otosclerosis runs in families.
Noise exposure: Prolonged exposure (>85 dB) = risk for NIHL.
Ear care: Using foreign objects to clean ears may cause trauma or cerumen impaction.
Lifestyle questions: Work setting, swimming habits, ototoxic medications, hearing aid use, communication difficulties—all help identify risks.
disorders
Otitis Externa: Redness, discharge, pain with tragus/pinna movement. “Swimmer’s ear.”
Otitis Media: Middle ear infection, common in children. TM red/bulging. Pain, fever.
Cerumen Impaction: Conductive hearing loss. Often in older adults.
Tinnitus: Ringing in ears. Can be due to noise, ototoxic drugs, high BP.
Vertigo/BPPV: Inner ear issue, crystals dislodged. Spinning sensation.
Cholesteatoma: Chronic middle ear infection leads to skin growth in middle ear.
Sinuses
Frontal, maxillary (palpable); ethmoid, sphenoid (deep).
Air-filled, reduce skull weight, resonate sound, trap debris.
sinusitis
Acute: <4 weeks, often viral → bacterial Chronic: >12 weeks despite treatment
Symptoms
Yellow-green nasal discharge
Facial pain, sinus pressure
Frontal headache, fever, bad breath, ↓ smell
Risk Factors
Nasal polyps, allergies, asthma, deviated septum, immunosuppression, chronic rhinitis
glaucoma (two types)
– Damage to optic nerve, usually due to increased IOP
– 2nd leading cause of blindness
– Vision loss is permanent but preventable if caught early
Open-Angle Glaucoma
– Patchy peripheral vision loss
– Tunnel vision in late stages
Acute Angle-Closure Glaucoma
– Severe headache, eye pain, nausea, halos, redness
– Medical emergency
Risk Factors
– Age > 40 (especially African Americans)
– Family history, diabetes, hypertension, corticosteroids
– Farsightedness, thin cornea, high IOP
– Eye trauma/surgery, East Asian or Inuit ethnicity
Screening
– 40–54: every 1–3 yrs
– 55–64: every 1–2 yrs
– 65+: every 6–12 months
Client Education
– Get regular eye exams
– Wear eye protection
– Eat leafy greens, maintain healthy weight
– Manage BP, blood sugar
Inspection and palpation: outer ear
Normal: Symmetrical, aligned with eyes, no lumps/lesions, no discharge, non-tender.
Abnormal:
Otitis externa: Pain with tragus/pinna movement
Tophi: Gout-related nodules
Polyps: Associated with chronic infection
Microtia/Macrotia: Congenital deformities
Exostoses: Bone growths from cold water exposure ("surfer’s ear")
Malignant lesion: Ulcerated nodule that doesn’t heal
HEALTH PROMOTION: HEARING LOSS
Goal: Reduce prevalence and impact of hearing disorders.
Risks: Loud noise, aging, genetics, ototoxic meds, ear infections.
Prevention:
Use ear protection in noisy areas
Avoid inserting objects in ears
Get hearing checked routinely (especially >50 yrs)
Immunizations (e.g., rubella, meningitis)
Prompt treatment for infections
Avoid bottle-feeding infant lying flat
Monitor use of ototoxic medications
nose
Filters, warms, moistens air. Receptors for CN I (smell). Contains septum and turbinates.
OROPHARYNGEAL CANCER
Common Sites
Tongue, tonsils, floor of mouth, gums
Risk Factors
Smoking, alcohol, HPV, sun exposure, poor oral hygiene
Early Signs
Non-healing ulcers
Red/white patches
Lump/thickening
Trouble chewing/speaking/swallowing
Screening
Dental exams for high-risk patients
Nurses can assess if dental care is missed
cataracts
Definition
– Clouding of the lens causing blurred or foggy vision
– Leading cause of blindness worldwide
– Often age-related; progresses slowly
– Common after age 65
Symptoms
– Blurry vision, glare, halos, poor night vision
– Colors fade, double vision in one eye
– Frequent prescription changes
Risk Factors
– Age, diabetes, UV light, smoking, alcohol
– Steroid use, eye injury, obesity, high BP
– Family history, previous eye surgery or inflammation
Screening
– Adults 65+: every 1–2 years even if asymptomatic
– Early detection improves outcomes
Client Education
– Wear sunglasses (UV-B protection)
– Stop smoking, limit alcohol
– Eat antioxidant-rich diet (fruits, veggies)
– Use eye protection
– Treat inflammation or injuries early
– Maintain healthy weight and exercise
Otoscopic Exam – Canal and Tympanic Membrane
Canal: No redness, swelling, or discharge; cerumen present (color varies by ethnicity).
Abnormal canal:
Foul discharge: External otitis
Bloody/purulent: Otitis media with rupture
Watery blood: Skull fracture (emergency)
Obstruction: Cerumen impaction, foreign body
Tympanic Membrane (TM):
Normal: Pearly gray, intact, cone of light at 5 o’clock (R) or 7 o’clock (L)
Abnormal:
Acute otitis media: Red, bulging, no light reflex
Serous otitis media: Yellow TM, bubbles
Perforated TM: Hole, possible drainage
Blue/dark red TM: Trauma/bleeding
Scarred TM: White patches
Retracted TM: Prominent landmarks from eustachian tube dysfunction
Cholesteatoma: White, cheesy mass from chronic infection
Tympanostomy tube: Inserted for chronic otitis media
subjective data
Mouth & Throat
Sores >2 weeks → malignancy concern
Gum bleeding, redness → gingivitis/periodontitis
Pain or tooth loss → affects nutrition and speech
Difficulty swallowing (dysphagia) → cancer, stroke, GERD
Hoarseness >2 weeks → laryngeal involvement
Nose & Sinuses
Sinus pressure/pain → sinusitis (acute vs. chronic)
Nosebleeds (epistaxis) → trauma, dryness, HTN, coagulopathy
Loss of smell/taste → COVID, neuro, aging, zinc deficiency
Discharge:
Clear → allergies or CSF leak
Yellow/green → infection
Health Practices
Smoking/alcohol → ↑ oral cancer risk
Poor hygiene → gingivitis, periodontitis
Vitamin deficiencies → affect oral tissues (e.g., B12, C)
health promotion
Avoid tobacco and alcohol
Maintain oral hygiene (brush/floss, dentist visits)
HPV vaccine for prevention
Manage sinus issues and allergies
Avoid excessive nasal spray use
Encourage hydration and nutrition