Health Assessment - Lecture

Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lesson title: THE EYES Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to:
1. Identify the components and function of the eye; References:
2. Collect an accurate health history of the eye;
3. Describe the physical examination techniques performed to Hogan-Quigley, B., Palm, M. L., & Bickley, L.
evaluate the eye; (2012). Bates’ nursing guide to physical
4. Identify the measures for prevention or early detection of examination and history taking (2nd ed.)
eye disease, infections, or vision loss; and, Philadelphia, PA: Lippincott Williams &
5. Perform a complete eye examination. Wilkins.

A. LESSON PREVIEW/REVIEW

Let us have a quick review of what you have learned from the previous session. Kindly answer the posted question on the
space provided. You may use the back page of this sheet, if necessary. Here is the question:

As a nursing student, describe what you have learned in performing an assessment in the head and neck.

B. MAIN LESSON

COMMON OR CONCERNING SYMPTOMS IN THE EYES:

 Changes in vision:
o Hyperopia – is a refractive error, which means that the eye does not bend or refract light properly to a
single focus to see images clearly. In hyperopia, distant objects look somewhat clear, but close objects
appear more blurred.
o Presbyopia – is when your eyes gradually lose the ability to see things clearly up close. It is a normal part
of aging. In fact, the term “presbyopia” comes from a Greek word which means “old eye”. You may start to
notice presbyopia shortly after age 40.
o Myopia – is a common vision condition in which you can see objects near to you clearly, but objects
farther away are blurry. It occurs when the shape of your eye causes light rays to bend (refract)
incorrectly, focusing images in front of your retina instead of on your retina.
o Scotomas – is an area of partial alteration in field of vision consisting of a partially diminished or entirely
degenerated visual acuity that is surrounded by a field of normal–or relatively well-preserved– vision.
 Double vision or diplopia
 Strabismus – is when your eyes are not lined up properly and they point in different directions
 Blurring
 Redness
 Itching
 Discharge
 Pain
 Tearing
 Edema
 Lesions
 Visual disturbances
 Photophobia

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 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Areas of History Interview

• Eye History
• Family History
• Lifestyle Habits

PHYSICAL EXAMINATION
The components of the eye examination include:
• Vision tests: distal, near, and peripheral Inspection of the eye, eyebrows, lids, conjunctiva and sclera, cornea,
lens, iris, and pupils Inspection and palpation of the lacrimal apparatus.
• Extraocular movements: assessment of cardinal fields, convergence, corneal light test, cover–uncover test.

Equipment for Examination

• Snellen chart or “E” card • Penlight
• Rosenbaum, near-vision card • Ophthalmoscope
• Index card

Visual Acuity
• This is expressed as two numbers (e.g., 20/30): the numerator indicates the distance of the patient from the chart
and this number should always be 20 unless the patient moved closer to see, and the denominator is the distance
at which a normal eye can read the line of letters.

Near Vision
• Testing near vision with a special hand-held card, the Rosenbaum chart, helps identify the need for reading
glasses or bifocals in patients older than 45 years. This card can be utilized to test visual acuity at the bedside.
Held 14 inches from the patient’s eyes, the card simulates a Snellen chart. However, patients may choose their
own distance.

External Eye Examination

• Position and Alignment of the Eyes. Stand in front of the patient and survey the eyes for position and alignment. If
one or both eyes seem to protrude, assess them from above.
• Eyebrows. Inspect the eyebrows, noting their quantity and distribution and any scaliness of the underlying skin.
• Eyelids. Note the position of the lids in relation to the eyeballs.

Inspect for the following:

• Width of the palpebral fissures — open area between the upper and lower eyelids
• Edema of the lids
• Color of the lids
• Lesions
• Condition and direction of the eyelashes
• Adequacy with which the eyelids close. Look for this especially when the eyes are unusually prominent, when
there is facial paralysis, or when the patient is unconscious.

Internal Eye Examination

• Cornea and Lens. With oblique lighting, inspect the cornea of each eye for opacities and note any opacity in the
lens that may be visible through the pupil.
• Iris. At the same time, inspect each iris. The markings should be clearly defined. With your light shining directly
from the temporal side, look for a crescentic shadow on the medial side of the iris. Because the iris is normally
fairly flat and forms a relatively open angle with the cornea, this lighting casts no shadow.
• Pupils. Inspect the size, shape, and symmetry of the pupils. If the pupils are large (5 mm), small (<3 mm), or
unequal, measure them. A pupil guide with black circles of varying sizes facilitates measurement.

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 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

• Test the pupillary reaction to light. Ask the patient to look into the distance, and shine a bright light obliquely into
each pupil in turn.

Ophthalmic Examination
• The nurse would examine the patient’s eyes without dilating the pupils. The view is therefore limited to the
posterior structures of the retina.
• To see more peripheral structures, to evaluate the macula well, or to investigate unexplained visual loss,
ophthalmologists dilate the pupils with mydriatic drops unless this is contraindicated.

Extraocular Muscles
• The normal conjugate movements of the eyes in each direction, or any deviation from normal
• Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme lateral gaze are normal.
If you see it, bring your finger in to within the field of binocular vision and look again.
• Lid lag as the eyes move from up to down.

Special Techniques
• Nasolacrimal Duct Obstruction. This test helps identify the cause of excessive tearing. Ask the patient to look up.
Press on the lower lid close to the medial canthus, just inside the rim of the bony orbit — this compresses the
lacrimal sac. Look for fluid regurgitated out of puncta into the eye. Avoid this test if area is inflamed and tender.

Health Promotion, Disease Prevention and Education

• Vision screening
• Eye protection
• Care of contact lenses

Vision Screening
• Changes in vision shift with age. Amblyopia, also known as “lazy eye”, affects approximately 2–4% or preschool
children. This loss of vision is due to an alteration in neural pathways in the developing brain which in turn
decreases use of the affected eye.
• Strabismus is eye misalignment; these are found most frequently in infants and children up to 5 years old.
Screening tests for detecting strabismus and amblyopia include simple inspection, the cover uncover test, corneal
light reflex and visual acuity tests.

Eye Protection
• Eye injuries and trauma can occur in the home, during recreational activities, and in the place of employment.
Protective eyewear should be utilized when there is a chance of injury to the eye.
• Eye injury can result from numerous causes, for example: chemical splashes from cleaning supplies, metal
shards or rocks flying when mowing the lawn, sports (e.g., lacrosse) injuries, body fluids entering the eye—the list
is endless. The activities and environment in which people work and play should be assessed and precautions
taken to avoid eye injury and promote healthy habits.

Care of Contact Lenses

• Infections can occur and injure the eye if contact lenses are not taken care of properly. Patients should remember
to wash their hands when inserting or removing lenses, to wear and remove them as prescribed by the health
care provider, and to keep them clean and not share contacts.
• If patients are using solutions, they should discard unused portions at the expiration date.

Variations and Abnormalities of the Eyelids

• Ptosis • Ectropion
• Entropion • Lid retraction and exophthalmos

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Opacities of the Cornea and Lens

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 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Check for Understanding

After studying the main lesson, you may now answer the following multiple choice questions and provide the rationale for
each item.

1. Which of the following structures of the eye regulates the amount of light entering the eye?
a. Pupil
b. Iris
c. Cornea
d. Lens
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

2. Which of the following vitamins is deficient in a patient who is experiencing xerophthalmia?

a. Vitamin C
b. Vitamin K
c. Vitamin D
d. Vitamin A
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

3. A patient who can see objects that are near but is not able to see objects from afar has which of the following
conditions?
a. Hyperopia
b. Presbycusis
c. Myopia
d. Astigmatism
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

4. The patient can be declared legally blind if the patient has a visual acuity of:
a. 20/150
b. 20/100
c. 20/180
d. 20/200
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

5. Excessive tearing of the eyes can be commonly caused by which of the following?
a. Nasolacrimal duct obstruction
b. Retinal detachment
c. Cataract
d. Presbyopia
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

6. A nurse is assessing a patient who has Bell’s palsy has observed for the drooping of the eyelid of the affected side.
The nurse must note this as:
a. Ectropion
b. Entropion
c. Ptosis
d. Pterygium
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

7. When the nurse is assessing a 4-year old child, she has noticed that the child has an eye misalignment. She should
note this as:
a. Strabismus
b. Amblyopia
c. Presbyopia
d. Exophthalmos
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

8. When teaching a patient who is going to use contact lenses for the first time, the nurse must teach the patient that
prior to the application of the contact lenses the patient must:
a. Look at a bright light
b. Do handwashing
c. Clean the contact lenses
d. Ask assistance from a family member in the application of the contact lenses
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

This document is the property of PHINMA EDUCATION

 Health Assessment - Lecture
Module #9 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

9. This is the fine rhythmic oscillations of the eyes:

a. Amblyopia
b. Presbyopia
c. Nystagmus
d. Exophthalmos
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

10. A patient who has hyperthyroidism can have which of the following eye conditions?
a. Ptosis
b. Exophthalmos
c. Ectropion
d. Entropion
Answer: ________
Rationale:
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________

C. LESSON WRAP-UP

Thinking about Learning

THE OUTCOME SENTENCES STRATEGY

This strategy is an excellent way to show your grasp of learning and to give you time to reflect about what you have
learned. Complete each phrase with what you have deemed to express:

 I was surprised that _____________________________________________________________________________

 I have a question about __________________________________________________________________________
 I would still like to know more about _________________________________________________________________
 I learned a great deal about _______________________________________________________________________
 Today, I understood _____________________________________________________________________________
 I am still confused about __________________________________________________________________________

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 Health Assessment - Lecture
Module #10 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lesson title: EARS, NOSE, MOUTH, AND THROAT Materials:

Electronic gadget, pen, & notebook
Learning Targets:
At the end of the module, students will be able to:
1. Identify the structures and function of the ear, nose, mouth,
and throat; References:
2. Collect an accurate health history of the ear, nose, mouth,
and throat; Hogan-Quigley, B., Palm, M. L., & Bickley, L.
3. Describe the physical examination techniques performed to (2012). Bates’ nursing guide to physical
evaluate the ear, nose, mouth, and throat; and, examination and history taking (2nd ed.)
4. Perform a complete ear, nose, mouth, and throat Philadelphia, PA: Lippincott Williams &
examination. Wilkins.

A. LESSON PREVIEW/REVIEW

Let us have a quick review of what you have learned from the previous session. Kindly answer the posted question on the
space provided. You may use the back page of this sheet, if necessary. Here is the question:

As a nursing student, describe what you have learned in performing an assessment of the eyes.

B. MAIN LESSON

COMMON OR CONCERNING SYMPTOMS OF THE EARS:

 Hearing loss  Tinnitus
 Earache  Vertigo
 Discharge

Hearing Loss
 Try to distinguish between two basic types of hearing impairment: conductive loss, which results from problems in
the external or middle ear, and sensorineural loss, from problems in the inner ear, the cochlear nerve, or its
central connections in the brain.
 Hearing loss may also be congenital, from single gene mutations
 People with sensorineural loss have particular trouble understanding speech, often complaining that others
mumble; noisy environments make hearing worse. In conductive loss, noisy environments may help.
 Medications that affect hearing include aminoglycosides, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs),
quinine, furosemide, and others.
 Symptoms associated with hearing loss, such as earache or vertigo; help you to assess likely causes. In addition,
inquire specifically about medications that might affect hearing and ask about sustained exposure to loud noise.

Earache
 Complaints of earache, or pain in the ear, are especially common. Ask about associated fever, sore throat, cough,
and concurrent upper respiratory infection.
 Pain suggests a problem in the external ear, such as otitis externa, or, if associated with symptoms of respiratory
infection, in the inner ear, as in otitis media.2 It may also be referred from other structures in the mouth, throat, or
neck.

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 Health Assessment - Lecture
Module #10 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Discharge
 Ask about discharge from the ear, especially if associated with earache or trauma.
 Unusually soft wax, debris from inflammation or rash in the ear canal, or discharge through a perforated eardrum
may be secondary to acute or chronic otitis media.

Tinnitus
 Tinnitus is a perceived sound that has no external stimulus and commonly is heard as musical ringing or a
rushing or roaring noise. It can involve one or both ears. Tinnitus may accompany hearing loss and often remains
unexplained.
 Occasionally, popping sounds originate in the temporomandibular joint, or vascular noises from the neck may be
audible.
 Tinnitus is a common symptom, increasing in frequency with age. When associated with hearing loss and vertigo,
it suggests Ménière’s disease.

Vertigo
 Vertigo refers to the perception that the patient or the environment is rotating or spinning. These sensations point
primarily to a problem in the labyrinths of the inner ear, peripheral lesions of cranial nerve (CN) VIII, or lesions in
its central pathways or nuclei in the brain.

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 Health Assessment - Lecture
Module #10 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

Lumps on the Ear; Abnormalities of the Eardrum; and Patterns of Hearing Loss (The student will read and check the
illustrations about this topic in textbook or as presented and discussed by the instructor.)

Past History (Ear)

 Congenital hearing loss  Infection
 Removal of cerumen  Exposure to hazardous noise levels (work,
 Ear surgery home, war)
 Trauma or injury to your ear(s)  History of syphilis, rubella, meningitis

Family History
 Hearing loss  Allergies
 Otitis media  Smoking or exposure to cigarette smoke

COMMON OR CONCERNING SYMPTOMS OF THE NOSE AND SINUSES

Rhinorrhea
 This refers to drainage from the nose and is often associated with nasal congestion, a sense of stuffiness or
obstruction. These symptoms are frequently accompanied by sneezing, watery eyes, and throat discomfort, and
also by itching in the eyes, nose, and throat.
 Causes include viral infections, allergic rhinitis (“hay fever”), and vasomotor rhinitis.
 Itching favors an allergic cause.
 Relation to seasons or environmental contacts suggests allergy.
 Excessive use of decongestants can worsen symptoms, causing rhinitis medicamentosa.

Congestion
 The symptoms usually appear after an upper respiratory infection. Together these suggest acute bacterial
sinusitis. Sensitivity and specificity are highest for symptoms appearing after a URI (90% and 80%).

Epistaxis
 Epistaxis means bleeding from the nose. The blood usually originates from the nose itself, but may come from a
paranasal sinus or the nasopharynx.
 Local causes of epistaxis include trauma (especially nose picking), inflammation, drying and crusting of the nasal
mucosa, tumors, and foreign bodies.
 Bleeding disorders may contribute to epistaxis.

Change in Sense of Smell

Ask the patient for the following:
 Trigger  Any injury to the nose and head
 Illness prior to the symptom  If the symptom is constant or intermittent

Past History
 Sinus infections  Nasal or sinus surgery
 Upper respiratory infections  Polyps
 Allergies  Dental history
 Trauma or injury

Family History
 Allergies  Cancer of the nose or sinus
 Asthma

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 Health Assessment - Lecture
Module #10 Student Activity Sheet

Name: _________________________________________________________ Class number: _______

Section: ____________ Schedule: ___________________________________ Date: _______________

COMMON OR CONCERNING SYMPTOMS OF THE MOUTH AND THROAT

 Sore throat  Bleeding gums
 Hoarseness  Toothache
 Lesions  Dysphagia
 Sore tongue

Sore Throat
 Sore throat is a frequent complaint, usually associated with acute upper respiratory symptoms.
 Fever, pharyngeal exudates, and anterior lymphadenopathy, especially in the absence of cough, suggest
streptococcal pharyngitis, or strep throat

Hoarseness
 Hoarseness refers to an altered quality of the voice, often described as husky, rough, or harsh. The pitch may be
lower than before. Hoarseness usually arises from inflammation or infection of the larynx but may also develop as
extralaryngeal lesions press on the laryngeal nerves.
 Check for overuse of the voice, allergy, smoking or other inhaled irritants, and any associated symptoms.

Bleeding from Gums

 Bleeding from the gums is a common symptom, especially when brushing teeth. It can also be caused by
gingivitis. Ask what type of toothbrush is used? Hard or soft? Ask about local lesions and any tendency to bleed
or bruise elsewhere.

Dysphagia
 The patient has difficulty of swallowing, whether it is food or fluids.

Abnormalities of the Lips; Findings in the Palate, Pharynx, and the Oral Mucosa; Findings in the Gums and
Teeth; Findings in or under the Tongue (The student will read and check the illustrations about this topic in textbook or
as presented and discussed by the instructor.)

Past History
 Sore throat
 Loss of voice
 Dental, mouth, or throat surgery
 Trauma or injury to teeth, mouth, or throat
 History of infections
 Oral cancer
 Sexually transmitted disease

Family History
 Allergies
 Smoking or exposure to cigarette smoke
 Stroke
 Tuberculosis

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