U.S. flag

An official website of the United States government

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2023.

Cover of Nursing Skills

Nursing Skills [Internet]. 2nd edition.

Show details

Chapter 8 Eye and Ear Assessment

8.1. EYE AND EAR ASSESSMENT INTRODUCTION

Learning Objectives

• Perform an eye and ear assessment, including visual acuity, extraocular motion, and hearing acuity

• Modify assessment techniques to reflect variations across the life span

• Document actions and observations

• Recognize and report significant deviations from norms

The ability to see, hear, and maintain balance are important functions of our eyes and ears. Let’s begin by reviewing the anatomy of the eye and ear and their common disorders.

8.2. EYE AND EAR BASIC CONCEPTS

Anatomy of the Eye

Our sense of vision occurs due to transduction of light stimuli received through the eyes. The eyes are located within either orbit in the skull. See Figure 8.1[1] for an illustration of the eye. The eyelids, with lashes at their leading edges, help to protect the eye from abrasions by blocking particles that may land on the surface of the eye. The inner surface of each lid is a thin membrane known as the conjunctiva. The conjunctiva extends over the white areas of the eye called the sclera, connecting the eyelids to the eyeball. The iris is the colored part of the eye. The iris is a smooth muscle that opens and closes the pupil, the hole at the center of the eye that allows light to enter. The iris constricts the pupil in response to bright light and dilates the pupil in response to dim light. The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. The cornea, with the anterior chamber and lens, refracts light and contributes to vision. The cornea can be reshaped by surgical procedures such as LASIK. The innermost layer of the eye is the retina that contains the nervous tissue and specialized cells called photoreceptors for the initial processing of visual stimuli. Two types of photoreceptors within the retina are the rods and the cones. The cones are sensitive to different wavelengths of light and provide color vision. These nerve cells of the retina leave the eye and enter the brain via the optic nerve (cranial nerve II).[2]

Figure 8.1

Figure 8.1

The Eye

Tears are produced by the lacrimal gland that is located beneath the lateral edges of the nose. Tears flow through the lacrimal duct to the medial corner of the eye and flow over the conjunctiva to wash away foreign particles. Movement of the eye within the orbit occurs by the contraction of six extraocular muscles that originate from the bones of the orbit and insert into the surface of the eyeball. The extraocular muscles are innervated by the abducens nerve, the trochlear nerve, and the oculomotor nerve (cranial nerves III, IV, and V).[3] See the illustration of the extraocular muscles in Figure 8.2.[4]

Figure 8.2

Figure 8.2

Extraocular Muscles

Video Review for Anatomy of the Eye[5]

Image ch8eyeandear-Image001.jpg

Common Disorders of the Eye

Eye disorders that nurses commonly see in practice include myopia, presbyopia, color blindness, dry eye, conjunctivitis, styes, cataracts, macular degeneration, and glaucoma.

Myopia

Myopia is impaired vision, also known as nearsightedness that makes far-away objects look blurry. It happens when the eyeball grows too long from front to back or when there are problems with the shape of the cornea or the lens. These problems make light focus in front of the retina, instead of on it, causing blurriness. See Figure 8.3[6] for a simulated image of a person’s vision with myopia. Nearsightedness usually becomes apparent between ages 6 and 14. It is corrected with glasses, contacts, or LASIK surgery.[7]

Figure 8.3

Figure 8.3

Simulated Vision with Myopia

Presbyopia

Presbyopia is impaired near vision. It commonly occurs in middle-aged and older adults, making it difficult to clearly see objects up close. As people age, the lens in the eye gets harder and less flexible and stops focusing light correctly on the retina.[8] Presbyopia can be corrected with glasses and/or contacts. See Figure 8.4[9] for a simulated image of a person’s vision with presbyopia.

Figure 8.4

Figure 8.4

Simulated Vision with Presbyopia

Color Blindness

Color blindness makes it difficult to differentiate between certain colors. Color blindness can occur due to damage to the eye or to the brain. There’s no cure for color blindness, but special glasses and contact lenses can help people differentiate between colors. Most people who have color blindness are able to use visual strategies related to color selection and don’t have problems participating in everyday activities.[10]

Dry Eye

Dry eye is a very common eye condition that occurs when the eyes don’t make enough tears to stay wet or the tears don’t work correctly. Symptoms of dry eye include a scratchy feeling, stinging, and burning. Treatment includes over-the-counter and prescription eye drops, as well as lifestyle changes to decrease the dryness of the eyes.[11]

Conjunctivitis

Conjunctivitis is a viral or bacterial infection that causes swelling and redness in the conjunctiva and sclera. See Figure 8.5[12] for an image of conjunctivitis. The eye may feel itchy and painful with crusty yellow drainage present. Conjunctivitis is very contagious, so the nurse should educate the patient and family caregivers to wash hands frequently. Additionally, the patient should not share items like pillowcases, towels, or makeup. Bacterial conjunctivitis is treated with antibiotic eye drops.[13]

Figure 8.5

Figure 8.5

Conjunctivitis

Stye

A stye is a bacterial infection of an oil gland in the eyelid, causing a red, tender bump at the edge of the eyelid. See Figure 8.6[14] for an image of a stye. Treatment includes applying warm compresses to the eyelid and prescription eyedrops.[15]

Cataracts

A cataract is a cloudy area on the lens of the eye. Cataracts are very common in older adults. Over half of all Americans age 80 or older either have cataracts or have had surgery to remove cataracts. See Figure 8.7[16] for an image of a cataract. Cataracts develop slowly and symptoms include faded colors, blurred or double vision, halos around light, and trouble seeing at night. See Figure 8.8[17] for a simulated image of a person’s vision with cataracts. Decreased vision due to cataracts may result in trouble reading and driving and increases the risk of falling. Patients often undergo surgery for cataracts. During cataract surgery, the doctor removes the clouded lens and replaces it with a new, artificial lens.[18]

Figure 8.7

Figure 8.7

Cataracts

Figure 8.8

Figure 8.8

Simulated Vision with Cataracts

Macular Degeneration

Age-related macular degeneration is a common condition that causes blurred central vision. It is the leading cause of vision loss for people 50 and older. See Figure 8.9[19] for a simulated image of a person’s vision with macular degeneration. There are two types of macular degeneration: dry (nonexudative) and wet (exudative). During dry macular degeneration, cellular debris called drusen accumulates and scars the retina. In the wet (exudative) form, which is more severe, blood vessels grow behind the retina that leak exudate fluid, causing hemorrhaging and scarring. There is no treatment for dry macular degeneration, but laser therapy can be used to help treat wet (exudative) macular degeneration.[20]

Figure 8.9

Figure 8.9

Simulated Vision with Macular Degeneration

Glaucoma

Glaucoma is a group of eye diseases that causes vision loss by damaging the optic nerve due to increased intraocular pressure. Treatment includes prescription eye drops to lower the pressure inside the eye and slow the progression of the disease. If not treated appropriately, glaucoma can cause blindness. Symptoms of glaucoma include gradual loss of peripheral vision. See Figure 8.10[21] for a simulated image of a person’s vision with glaucoma. Because the loss of vision occurs so slowly, many people don’t realize they have symptoms until the disease is well-progressed or it is discovered during an eye exam.[22]

Figure 8.10

Figure 8.10

Simulated Vision with Glaucoma

Screening Tools for Eye Exams

Common screening tools used during an eye exam are the Snellen chart, a near vision chart, and Ishihara plates. Nurses working in outpatient settings or school settings use these tools when screening patients for vision problems. If a vision problem is identified, the patient is referred to an optometrist for further testing. When performing a vision assessment, be sure to provide adequate lighting.

Snellen Chart

Distant vision is tested by using the Snellen chart. See Figure 8.11[23] for an image of the Snellen chart. Place the patient 20 feet away from the Snellen chart. Ask them to cover one eye and read the letters from the lowest line they can see clearly. Record the corresponding fraction in the furthermost right-hand column. Repeat with the other eye. If the patient is wearing glasses or contact lens during this assessment, document the results as “corrected vision” when wearing these assistive devices.

Figure 8.11

Figure 8.11

Snellen Chart

A person with no visual impairment is documented as having 20/20 vision. A person with impaired vision has a different lower denominator of this fraction. For example, a vision measurement of 20/30 indicates the patient can see letters clearly at 20 feet that a person with normal vision can see clearly at 30 feet.[24] Alternative charts are also available for children or adults who can’t read letters in English. See Figure 8.12[25]for an alternative eye chart.

Figure 8.12

Figure 8.12

Alternative Eye Chart

Near Vision

Near vision is assessed by having a patient read from a prepared card that is held 14 inches away from the eyes. If a card is not available, the patient can be asked to read from a newspaper as an alternative quick screening tool. See Figure 8.13[26] for an image of a prepared card used to assess near vision.

Figure 8.13

Figure 8.13

Assessing Near Vision

Ishihara Plates

Ishihara plates are commonly used to assess color vision. Each of the colored dotted plates shows either a number or a path. See Figure 8.14[27] for an example of Ishihara plates. A person with color blindness is not able to distinguish the numbers or paths from the other colored dots on the plate.

Figure 8.14

Figure 8.14

Ishihara Color Test Plates

Anatomy of the Ear

Hearing is the transduction of sound waves into a neural signal by the structures of the ear. See Figure 8.15[28] for an image of the anatomy of the ear. The large, fleshy structure on the lateral aspect of the head is known as the auricle. The C-shaped curves of the auricle direct sound waves toward the ear canal. At the end of the ear canal is the tympanic membrane, commonly referred to as the eardrum, that vibrates after it is struck by sound waves. The auricle, ear canal, and tympanic membrane are referred to as the external ear. The middle ear consists of a space with three small bones called the malleus, incus, and stapes, the Latin names that roughly translate to “hammer,” “anvil,” and “stirrup.” The malleus is attached to the tympanic membrane and articulates with the incus. The incus, in turn, articulates with the stapes. The stapes is attached to the inner ear, where the sound waves are transduced into a neural signal. The middle ear is also connected to the pharynx through the Eustachian tube that helps equilibrate air pressure across the tympanic membrane. The Eustachian tube is normally closed but will pop open when the muscles of the pharynx contract during swallowing or yawning. The inner ear is often described as a bony labyrinth because it is composed of a series of semicircular canals. The semicircular canals have two separate regions, the cochlea and the vestibule, that are responsible for hearing and balance. The neural signals from these two regions are relayed to the brain stem through separate fiber bundles. However, they travel together from the inner ear to the brain stem as the vestibulocochlear nerve (cranial nerve VIII).[29]

Figure 8.15

Figure 8.15

The Ear

Hearing

Sound waves cause the tympanic membrane to vibrate. This vibration is amplified as it moves across the malleus, incus, and stapes and into the cochlea. Within the inner ear, the cochlear duct contains sound-transducing neurons. As the frequency of a sound changes, different hair cells within the cochlear duct are sensitive to a particular frequency. In this manner, the cochlea separates auditory stimuli by frequency and sends impulses to the brain stem via the cochlear nerve. The cochlea encodes auditory stimuli for frequencies between 20 and 20,000 Hz, the range of sound that human ears can detect.[30]

Balance

Along with hearing, the inner ear is also responsible for the sense of balance. Semicircular canals in the vestibule have three ring-like extensions. One extension is oriented in the horizontal plane, and the other two are oriented in the vertical plane. Hair cells within the vestibule sense head position, head movement, and body motion. By comparing the relative movements of both the horizontal and vertical planes, the vestibular system can detect the direction of most head movements within three-dimensional space. However, medical conditions affecting the semicircular canals cause incorrect signals to be sent to the brain, resulting in a spinning type of dizziness called vertigo.

Video Review of Anatomy of the Ear[31]

Image ch8eyeandear-Image002.jpg

Common Ear Disorders

HEARING LOSS

Hearing loss is classified as conductive hearing loss or sensorineural hearing loss. Conductive hearing loss occurs when something in the external or middle ear is obstructing the transmission of sound. For example, cerumen impaction or a perforated tympanic membrane can cause conductive hearing loss. Sensorineural hearing loss is caused by pathology of the inner ear, cranial nerve VIII, or auditory areas of the cerebral cortex. Presbycusis is sensorineural hearing loss that occurs with aging due to gradual nerve degeneration. Ototoxic medications can also cause sensorineural hearing loss by affecting the hair cells in the cochlea.

ACUTE OTITIS MEDIA

Acute otitis media is the medical diagnosis for an middle ear infection. Ear infections are a common illness in the pediatric population. Children between the ages of 6 months and 2 years are more susceptible to ear infections because of the size and shape of their Eustachian tubes. Acute otitis media typically occurs after an upper respiratory infection when the Eustachian tube becomes inflamed and the middle ear fills with fluid, causing ear pain and irritability. This fluid can become infected, causing purulent fluid and low-grade fever. Acute otitis media is diagnosed by a health care provider using an otoscope to examine the tympanic membrane for bulging and purulent fluid. If not treated, acute otitis media can potentially cause perforation of the tympanic membrane. Treating early acute otitis media with antibiotics is controversial in the United States due to the effort to prevent antibiotic resistance. However, the treatment goals are to control pain and treat infection with antibiotics if a bacterial infection is present.[32]

Some children develop recurrent ear infections that can cause hearing loss affecting their language development. For children experiencing recurring cases, a surgery called myringotomy surgery is performed by an otolaryngologist. During myringotomy surgery, a tympanostomy tube is placed in the tympanic membrane to drain fluid from the middle ear and prevent infection from developing. If a child has a tympanostomy tube in place, it is expected to see clear fluid in their ear canal as it drains out of the tube. See Figure 8.16[33] for an image of a tympanostomy tube in the ear.[34]

Figure 8.16

Figure 8.16

Tympanostomy Tube

OTITIS EXTERNA

Otitis externa is the medical diagnosis for external ear inflammation and/or infection. See Figure 8.17[35] for an image of otitis externa. It is commonly known as “swimmer’s ear” because it commonly occurs in swimmers, especially in summer months. Otitis externa can occur in all age groups and causes an erythematous and edematous ear canal with associated yellow, white, or grey debris. Patients often report itching in the ear canal with pain that is worsened by pulling upwards and outwards on the auricle. Otitis externa is treated with antibiotic drops placed in the ear canals.[36]

Figure 8.17

Figure 8.17

Otitis Externa

CERUMEN IMPACTION

Cerumen impaction refers to a buildup of earwax causing occlusion of the ear canal. This occlusion often causes symptoms such as hearing loss, ear fullness, and itching. See Figure 8.18[37] for an image of cerumen impaction. Cerumen can be removed via irrigation of the ear canal, ear drops to dissolve the wax, or manual removal.[38] In outpatient settings, nurses often assist with ear irrigation to remove cerumen impaction according to agency policy. See Figure 8.19[39] for an image of an ear irrigation procedure.

Figure 8.18

Figure 8.18

Cerumen Impaction

Figure 8.19

Figure 8.19

Ear Irrigation to Remove Cerumen Impaction

TINNITUS

Tinnitus is a ringing, buzzing, roaring, hissing, or whistling sound in the ears. The noise may be intermittent or continuous. Tinnitus can be caused by cerumen impaction, noise trauma, or ototoxic medications, such as diuretics or high doses of aspirin. Military personnel have a high incidence of tinnitus due to noise trauma from loud explosions and gunfire. There are no medications to treat tinnitus, but patients can be referred to an otolaryngologist for treatment such as cognitive therapy or noise masking.[40]

VERTIGO

Vertigo is a type of dizziness that is often described by patients as, “the room feels as if it is spinning.” Benign positional vertigo (BPV) is a common condition caused by crystals becoming lodged in the semicircular canals in the vestibule of the inner ear that send false movement signals to the brain. BPV can be treated by trained professionals using a specific set of maneuvers that guide the crystals back to the chamber where they are supposed to be in the inner ear.[41]

References

1.
2.
Giddens, J. (2007). A survey of physical examination techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education , 46(2), 83-87. ↵. [PubMed: 17315568]
3.
This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.
4.
5.
Forciea, B. (2015, May 12). Anatomy of the eye (v2.0). [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/HmKGyJUcRLw ↵.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
“Cataract in human eye.png” by Rakesh Ajuja, MD is licensed under CC BY-SA 3.0 ↵.
17.
18.
19.
20.
21.
22.
23.
“Snellen chart.jpg” by Jeff Dahl is licensed under CC BY-SA 3.0 ↵.
24.
Sue, S. (2007). Test distance vision by using a Snellen chart. Community Eye Health , 20(63), 52. https://www​.ncbi.nlm​.nih.gov/pmc/articles/PMC2040251/ ↵. [PMC free article: PMC2040251] [PubMed: 17971914]
25.
26.
“111012-F-ZT401-067.JPG” by Airman 1st Class Brooke P. Beers for U.S. Air Force is in the Public Domain​. Access for free at https://www​.pacaf.af​.mil/News/Article-Display​/Article/593609​/keeping-sight-all-right/ ↵.
27.
This work is derivative of “Ishihara 9.png” and "Ishihara_1​.png" by Shinobu Ishihara are in the Public Domain ↵.
28.
29.
This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.
30.
This work is a derivative of Anatomy & Physiology by OpenStax and is licensed under CC BY 4.0. Access for free at https://openstax​.org​/books/anatomy-and-physiology​/pages/1-introduction ↵.
31.
Forciea, B. (2105, May 12). Anatomy of the ear (v2.0). [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/A2ji_Vd8cuE ↵.
32.
This work is a derivative of StatPearls by Danishyar and Ashurst and is licensed under CC BY 4.0 ↵.
33.
“Ear Tube.png” by BruceBlaus is licensed under CC BY-SA 4.0 ↵.
34.
This work is a derivative of StatPearls by Danishyar and Ashurst and is licensed under CC BY 4.0 ↵.
35.
“Otitis externa.gif” by S. Bhjimji MD is licensed under CC BY 4.0. Access for free at https://www​.ncbi.nlm​.nih.gov/books/NBK556055/ ↵.
36.
This work is a derivative of StatPearls by Medina-Blasini and Sharman and is licensed under CC BY 4.0 ↵.
37.
“Ear Wax.JPG” by Anand2202 is licensed under CC BY-SA 4.0 ↵.
38.
This work is a derivative of StatPearls by Mankowski and Raggio and is licensed under CC BY 4.0 ↵.
39.
“150915-F-GO352-025.jpg” by Staff Sgt. Jason Huddleston for U.S. Air Force is licensed under CC0​. Access for free at https://www​.59mdw.af​.mil/News/Article-Display​/Article/647342​/photo-essay-559th-medical-group-at-a-glance/ ↵.
40.
This work is a derivative of StatPearls by Grossan and Peterson and is licensed under CC BY 4.0 ↵.
41.
Woodhouse, S. (n.d.). Benign paraoxysmal positional vertigo (BPPV). Vestibular Disorders Association. https://vestibular​.org​/article/diagnosis-treatment​/types-of-vestibular-disorders​/benign-paroxysmal-positional-vertigo-bppv/ ↵.

8.3. EYE AND EAR ASSESSMENT

Now that we have reviewed the anatomy of the eyes and ears and their common disorders, let’s discuss common eye and ear assessments performed by nurses.

Subjective Assessment

Nurses collect subjective information from the patient and/or family caregivers using detailed questions and pay close attention to what the patient is reporting to guide the physical exam. Focused interview questions include inquiring about current symptoms, as well as any history of eye and ear conditions. See Table 8.3a for suggested interview questions related to the eyes and ears.

Table 8.3a

Suggested Interview Questions for Subjective Assessment of the Eyes and Ears

Interview Questions
Eye
Have you had any difficulty seeing or experienced blurred vision?
Do you wear glasses or contact lenses?
When was your last vision test?
Have you had any redness, swelling, watering, or discharge from the eyes?
Have you ever been diagnosed with an eye condition such as cataracts, glaucoma, or macular degeneration?
Are you currently using any medication, eye drops, or supplements for your eyes?
Ear
Have you had any trouble hearing? If so, do you wear hearing aids?
Have you had any symptoms like ringing in the ears, drainage from the ears, or ear pain?
Do you ever feel dizzy, off-balance, or like the room is spinning?
Have you ever been diagnosed with an ear condition such as an infection, tinnitus, or vertigo?
Are you currently using any medications, ear drops, or supplements for your ears?

Life Span Considerations

Pediatric

When collecting subjective data from children, information is also obtained from parents and/or legal guardians. Children aged 2-24 months commonly experience ear infections. Vision impairments may become apparent in school-aged children when they have difficulty seeing the board from their seats. Additional subjective data may be obtained by asking these questions:

  • Have you or your child’s teachers noticed your child experiencing any problems seeing or hearing?
  • Has your child experienced frequent ear infections or had tubes placed in their ears? If so, have you noticed any effects on their language development?

Older Adults

The aging adult experiences a general slowing in nerve conduction. Vision, hearing, fine coordination, and balance may also become impaired. Older adults may experience presbyopia (decreased near vision), presbycusis (hearing loss), cataracts, macular degeneration, or glaucoma. They may also experience feelings of dizziness or feeling off-balance, which can result in falls. Read more about these conditions in the “Eye and Ear Basic Concepts” section earlier in this chapter.

Image ch8eyeandear-Image003.jpg

Tip: Educate all patients to have yearly eye examinations.

Objective Assessment

A routine assessment of the eyes and ears by registered nurses in inpatient and outpatient settings typically includes external inspection of eyes and ears for signs of a medical condition, as well as screening for vision and hearing problems. A vision screening test, whispered voice hearing test, and assessment of pupillary response are often included in the physical exam based on the setting.[1] Additional assessments may be performed if the patient’s status warrants assessment of the cranial nerves.

Inspection

EYES

Begin the assessment by inspecting the eyes. The sclera should be white and the conjunctiva should be pink. There should not be any drainage from the eyes. The patient should demonstrate behavioral cues indicating effective vision during the assessment.

EARS

Inspect the ears. There should not be any drainage from the ears or evidence of cerumen impaction. The patient should demonstrate behavioral cues indicating effective hearing.

Vision Tests

See more information about procedures for assessing vision in the “Eye and Ear Basic Concepts” section earlier in this chapter. Assess far vision using the Snellen eye chart. In outpatient settings, near vision may be assessed using a prepared card or a newspaper. Color vision may be assessed using a book containing Ishihara plates.

Hearing Test

Nurses perform a basic hearing assessment during conversation with the patient. For example, the following patient cues during normal conversation can indicate hearing loss:

  • Lip-reads or watches your face and lips closely rather than your eyes
  • Leans forward or appears to strain to hear what you are saying
  • Moves head in a position to catch sounds with the better ear
  • Misunderstands your questions or frequently asks you to repeat
  • Uses an inappropriately loud voice
  • Demonstrates garbled speech or distorted vowel sounds[2]
WHISPER TEST

The whispered voice test is an effective screening test used to detect hearing impairment if performed accurately. Complete the following steps to accurately perform this test:[3]

  • Stand at arm’s length behind the seated patient to prevent lip reading.
  • Test each ear individually. The patient should be instructed to occlude the nontested ear with their finger.
  • Exhale before whispering and use as quiet a voice as possible.
  • Whisper a combination of numbers and letters (for example, 4-K-2), and then ask the patient to repeat the sequence.
  • If the patient responds correctly, their hearing is considered normal; if the patient responds incorrectly, the test is repeated using a different number/letter combination.
  • The patient is considered to have passed the screening test if they repeat at least three out of a possible six numbers or letters correctly.
  • The other ear is assessed similarly with a different combination of numbers and letters.

Pupillary Response, Extraocular Movement, and Cranial Nerves

When a patient is suspected of experiencing a neurological disease or injury, their pupils are assessed to ensure they are bilaterally equal, round, and responsive to light and accommodation (PERRLA). Extraocular movement and other cranial nerves may also be assessed that affect vision, hearing, and balance. For more information about how to assess PERRLA, extraocular eye movement, and other cranial nerves, go to the “Assessing Cranial Nerves” section in the “Neurological Assessment” chapter.

See Table 8.3b for a comparison of expected versus unexpected findings when assessing the eyes and ears.

Table 8.3b

Expected Versus Unexpected Findings on Eyes or Ears Assessment

AssessmentExpected FindingsUnexpected New Findings (Document and notify provider)
InspectionEyes
Sclera are white.
Lens is clear.
Conjunctiva are pink.
Eyelids do not have redness, swelling, lumps, or discharge.
No drainage is present from the eyes.
Patient displays behavioral cues of effective vision.
Eyes appear appropriately placed in orbits.
Ears
No drainage or cerumen is present in the ear canals.
Conversation includes behavioral cues of effective hearing.
During the whispered voice test, the patient correctly reports at least three out of a possible six numbers for both ears.
Patient demonstrates good balance and a coordinated gait.		Eyes
Yellow sclera may indicate liver dysfunction. Cloudy lens indicates cataracts.
Red conjunctiva or drainage can indicate conjunctivitis.
Redness or crusting on the eyelids can indicate blepharitis.
A tender lump on the eye can indicate a stye.
Patient displays behavioral cues indicating vision loss that is not already corrected with glasses or contacts.
Sunken eyes can indicate dehydration.
Ears
Purulent drainage is present in ear canal. Cerumen impaction is present.
Conversation indicates behavioral cues of uncorrected hearing loss.
During the whispered voice test, the patient reports fewer than three out of a possible six numbers or letters correctly for both ears.
Patient demonstrates poor balance or an uncoordinated gait.
*CRITICAL CONDITIONS to report immediatelyNew and sudden problems such as vision loss, blurred vision, eye pain, red eye, ear pain, vertigo, poor balance, or gait change

References

1.
Giddens, J. (2007). A survey of physical examination techniques performed by RNs: Lessons for nursing education. Journal of Nursing Education, 46(2), 83-87. ↵ [PubMed: 17315568]
2.
Jarvis, C. (2015). Physical examination and health assessment (7th ed.). Saunders. p. 330. ↵
3.
Pirozzo, S., Papinczak, T., & Glasziou, P. (2003). Whispered voice test for screening for hearing impairment in adults and children: Systematic review. BMJ (Clinical research ed.), 327(7421), 967.  ↵10.1136/bmj.327.7421.967 [PMC free article: PMC259166] [PubMed: 14576249] [CrossRef]

8.4. SAMPLE DOCUMENTATION

Sample Documentation of Expected Findings

The patient reports no previous history of ear or eye conditions. Eyes have white sclera and pink conjunctiva with no drainage present. Corrected vision with glasses using Snellen chart is 20/20 bilaterally. Ear canals are clear bilaterally. Whispered voice test indicates effective hearing with the patient reporting five out six numbers correctly for both ears. Patient demonstrates good balance and coordinated gait.

Sample Documentation of Unexpected Findings

The patient reports awakening with an irritated left eye and crusty drainage but no change in vision. The sclera in the left eye is pink, the conjunctiva is red, and yellow, crusty drainage is present. The patient is able to read the newspaper without visual impairment. Dr. Smith was notified and she evaluated the patient at 1400. A new order for antibiotic eye drops was received and administered. The patient and their family members were educated to wash hands frequently to avoid contagion.

8.5. CHECKLIST FOR EYE AND EAR ASSESSMENT

Use the checklist below to review the steps for completing an “Eye and Ear Assessment.”

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1.

Gather supplies: penlight, Ishihara plates, Snellen chart, Rosenbaum card, or a newspaper to read.

2.

Perform safety steps:

  • Perform hand hygiene.
  • Check the room for transmission-based precautions.
  • Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain the process to the patient and ask if they have any questions.
  • Be organized and systematic.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure the patient’s privacy and dignity.
  • Assess ABCs.
3.

Use effective interview questions to collect subjective data about eye or ear problems.

4.

Inspect the external eye. Note any unexpected findings.

5.

Assess that pupils are equally round and reactive to light and accommodation (PERRLA).

6.

Assess extraocular movement.

7.

Inspect the external ear. Note any unexpected findings.

8.

Assess distance vision acuity using the Snellen eye chart and proper technique.

9.

Assess near vision acuity using a prepared card or newspaper.

10.

Asses for color blindness using the Ishihara plates.

11.

Assess hearing by accurately performing the whisper test.

12.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

13.

Ensure five safety measures when leaving the room:

  • CALL LIGHT: Within reach
  • BED: Low and locked (in lowest position and brakes on)
  • SIDE RAILS: Secured
  • TABLE: Within reach
  • ROOM: Risk-free for falls (scan room and clear any obstacles)
14.

Perform hand hygiene.

15.

Document the assessment findings. Report any concerns according to agency policy.

8.6. SUPPLEMENTARY VIDEO ON EYE ASSESSMENT

Video Review for Eye Assessment[1]

Image ch8eyeandear-Image004.jpg

References

1.
RegisteredNurseRN. (2017, November 16). Eye assessment nursing | How to assess eyes for head-to-toe assessment. [Video]. YouTube. All rights reserved. Video used with permission. https://youtu​.be/pgSj3l9iV6k ↵.

8.7. LEARNING ACTIVITIES

Learning Activities

(Answers to “Learning Activities” can be found in the ‘”Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

When conducting the general survey and patient health history, a nurse can look for many assessment cues that may indicate that the patient has hearing difficulty. Describe three different cues that the nurse might identify to reflect an auditory challenge.

Image ch8eyeandear-Image005.jpg

Image ch8eyeandear-Image006.jpg

Image ch8eyeandear-Image007.jpg

VIII. GLOSSARY

Acute otitis media

The medical diagnosis for a middle ear infection.

Auricle

The large, fleshy structure of the ear on the lateral aspect of the head.

Cerumen impaction

A buildup of earwax causing occlusion of the ear canal.

Conductive hearing loss

Hearing loss that occurs when something in the external or middle ear is obstructing the transmission of sound.

Conjunctiva

Inner surface of the eyelid.

Conjunctivitis

A viral or bacterial infection in the eye causing swelling and redness in the conjunctiva and sclera.

Cornea

The transparent front part of the eye that covers the iris, pupil, and anterior chamber.

Eustachian tube

The tube connecting the middle ear to the pharynx that helps equilibrate air pressure across the tympanic membrane.

Extraocular muscles

Six muscles that control the movement of the eye within the orbit. Extraocular muscles are innervated by three cranial nerves, the abducens nerve, the trochlear nerve, and the oculomotor nerve.

Iris

Colored part of the eye.

Lacrimal duct

Tears produced by the lacrimal gland flow through this duct to the medial corner of the eye.

Lens

An inner part of the eye that helps the eye focus.

Myopia

Impaired vision, also known as nearsightedness, that makes far-away objects look blurry.

Optic nerve

Cranial nerve II that conducts visual information from the retina to the brain.

Otitis externa

The medical diagnosis for external ear inflammation and/or infection.

Ototoxic medications

Medications that cause the adverse effect of sensorineural hearing loss by affecting the hair cells in the cochlea.

Presbycusis

Sensorineural hearing loss that occurs with aging due to gradual nerve degeneration.

Presbyopia

Impaired near vision that commonly occurs in middle-aged and older adults.

Pupil

The hole at the center of the eye that allows light to enter.

Retina

The nervous tissue and photoreceptors in the eye that initially process visual stimuli.

Sclera

White area of the eye.

Sensorineural hearing loss

Hearing loss caused by pathology of the inner ear, cranial nerve VIII, or auditory areas of the cerebral cortex.

Snellen chart

A chart used to test far vision.

Tinnitus

Ringing, buzzing, roaring, hissing, or whistling sound in the ears.

Tympanic membrane

The membrane at the end of the external ear canal, commonly called the eardrum, that vibrates after it is struck by sound waves.

Vertigo

A type of dizziness often described by patients as “the room feels as if it is spinning.”

Vestibulocochlear nerve

Cranial nerve VIII that transports neural signals from the cochlea and the vestibule to the brain stem regarding hearing and balance.

Copyright Notice

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/.

Bookshelf ID: NBK596724
Contents

Views

In this Page

Other titles in this collection

Related Items in Bookshelf

Bulk Download

Related information

  • PMC
    PubMed Central citations
  • PubMed
    Links to PubMed

Recent Activity

ClearTurn OffTurn On

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

See more...