Head and Eye assessment

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The head Assessment
Examines skull, face, eyes, ears, nose sinuses, mouth and pharynx.
Techniques used are – inspection, palpation
Procedure: Explain to the client
·         Observe infection control measure
·         Provide privacy
·         Inquire if the client has the following history; Past problems of lumps and bumps
·         Itching, scaling or dandruff, History of loss of consciousness, dizziness, seizures, any known cause of problems, associated symptoms, treatment, recurrences.

Assessment
Normal findings
Deviation from normal
Inspect skull for size, shape & symmetry and contour
Rounded (normocephalic& symmetrical, with frontal, parietal and occipital prominences,)
Lack of symmetry,increased skull size with more prominent nose and forehead
Palpate the skull for nodules /masses & depressions with fingertips with rotating motion with the finger tips
Smooth uniform consistency: absence of nodules and masses
Sebaceous cyst; local deformities from trauma
Inspect the facial features for symmetry of structure & of the distribution of hair
Symmetric slightly asymmetrical facial features. Palpebral fissures symmetrical in size & Symmetric nasolabial folds.
↑ Facial hair, thinning of eyebrows, asymmetric features, exophthalmos, moon face.
Inspect the eyes for edema & hollowness
Periorbital edema, sunkun eyes.
Note symmetry of facial movement
  • Elevate the eyebrow
  • Close the eyes tightly
  • Puff the cheeks
  • Smile and show the teeth
Symmetric facial movement
Eyes cannot be closed, dropping eyelid & mouth, involuntary facial movements

Record the findings.
Normocephailc – normal size, shape.
Exophthalmos- protrusion of eye balls with elevation of upper eyelids- hyperthyroidism
Dry, puffy face with dry skin, thinning of scalp hair and eye brows- hypothyroidism
Increased adrenal hormone production-/ administration- moon face, excessive hair growth on upper lips, chin.
Sunken eyes, cheeks and temples- prolonged illness, starvation, dehydration.
Infants –large head results from congenital anomaly or build-up of CSF
Enlarged jaw and facial bones resulting from acromegaly
Palpate temperomandibular joint

Eye assessment
Examination of eye:
·         Visual acuity
·         Ocular movements
·         Visual fields- area an individual can see when looking straight ahead.
·         External features
Refractive errors
·         Myopia- near sightedness
·         Hyperopia- far sightedness
·         Presbyopia- loss of elasticity of the lens and loss of ability to see close objects. Bifocal lens is used for correction. One for near vision or reading, the other for far vision.
·         Astigmatism- uneven curvature of cornea that prevents horizontal and vertical rays from focusing on the retina is seen in conjunction with refractive errors.
Dacrocystitis- inflammation of the lacrimal sac-(tearing and discharge)
Hordeolum-(sty) redness, tenderness of hair follicles and glands that empty at the edge of the eyelids
Iritis- inflammation of the Iris (pain, tearing, photophobia)
Glaucoma- disturbance in circulation of aqueous fluid which causes   increase in IOP
Cataract-Opacity of lens
Assessing the eye structure and visual acuity
Articles required
·         cotton tip applicator
·         gauze
·         examination glove
·         mm ruler
·         penlight
·         Snellen’s E chart – kinder garten chart, snellen’s standard chart, Snellens E chart
·         Opaque card
Place the client in appropriate room for assessing the eyes and vision.
Explain the procedure to the client. Wash hands, apply gloves and observe appropriate infection control procedures. Provide privacy
Inquire if the client has any history such as family history of diabetes, hypertension, blood dyscrasia, or eye disease, injury or surgery, client’s last visit to an ophthalmologist, current use of eye medications, use of contact lenses or eye glasses etc.

External eye structures
Assessment
Normal findings
Deviations from normal
Inspect the eye brows for hair distribution and alignment and skin quality and movement (ask client to raise and lower the eyebrows)
Hair evenly distributed, skin intact.
Eyebrows symmetrically aligned, equal movement.
Loss of hair, scaling and flakiness of skin.

Unequal alignment and movement eyebrows
Inspect the eyelashes for evenness of distribution and direction of curl.
Equally distributed curled slightly outward
Turned inward
( enteropion)
Inspect the eyelids for surface characteristics (e.g. skin quality and texture), position in relation to the cornea, ability to blink, and frequency of blinking. For proper visual examination of the upper eye lids, elevate the eyebrows with your thumb and index finger, and have the client close the eye.
Inspect the lower eyelids while the client’s eyes are closed.
Skin intact; no discharge; no discoloration
Lids closed symmetrically
Approximately 15 to 20 involuntary blinks per minute; bilaterally blinking
When lids open, no visible sclera above corneas and upper and lower borders of cornea are slightly covered.
 Redness, swelling, flaking, crusting, plaques, discharge, nodules, lesions.
Lids close asymmetrically, incompletely, or painfully
Rapid, monocular, absent, or infrequent blinking.
Ptosis, ectropion, rim of sclera visible between lid and iris.
Inspect the bulbar conjunctiva (that lying over the sclera) for color, texture, and the presence of lesions, retract the eyelids with the thumb and index finger, exerting pressure over the upper and lower bony orbits, and ask the client to look up, down, and from side to side.           
Transparent; capillaries sometimes evident; sclera appears white (yellowish in dark-skinned client)   
Jaundiced sclera (e.g. In liver disease) excessively pale sclera in anemia, reddened sclera, lesions or nodules may indicate damage by mechanical, chemical, allergenic, or bacterial agents.
Inspect the palpabral conjunctiva (that lining the eyelids) by everting the lids. Note color, texture, and the presence of lesions. Evert both lower lids, and ask the client to look up. Then gently retract the lower lids with the index fingers.
Shiny, smooth and pink and red.
External, pale (possible anemia); extremely red (inflammation); nodules or other lesions.

Everting upper eyelid
Articles required- Cotton bud or, Paper clip or Small blunt object, e.g., pen top.
Ask the client to look down while keeping the eyes slightly open. Closing the eyelids contract the orbicular muscle, which prevents lid eversion.  Gently grasp the clients eye lashes with the thumb and index finger. Pull the lashes gently downward. Upward or outward pulling on the eyelashes causes muscle contraction. Place cotton tipped applicator stick about 1cm above the lid margin, and push it gently down ward while holding the eye lashes. These actions evert the lid, that is, flip the lower lid over on top of itself. 
Hold the margin of the everted lid or the eyelash against the ridge of the upper bony orbit with the applicator stick or the thumb.  Inspect the conjunctiva for colour, texture, lesions and foreign bodies. To return the lid to its normal position, gently pull the lashes forward and ask the client to look up and blink.
Assessment of lacrimal gland: Inspect and palpate the lacrimal gland. Observe for evidence of increased tearing. Using the tip of index finger, palpate inside the lower orbital rim near the inner canthus.
Assessment
Normal  findings
Deviations from normal
Inspect and palpate the lacrimal sac and nasolacrimal duct
No edema and tearing
Evidence of increased tearing regurgitation of fluid on palpation of lacrimal sac.
Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold a penlight at an oblique angle to the eye, and move the light slowly across the corneal surface.
In older people, a thin, grayish white ring around the margin, called arcussenilis, may be evident.
Arcussenilis in clients under age 40 is abnormal.
Perform the corneal sensitivity (reflex) test to determine the function of the fifth (trigeminal) cranial nerve. Ask the client to keep both eyes open and look straight ahead. Approach from behind and beside the client, and lightly touch the cornea with a corner of the gauze.
Client blinks when the cornea is touched, indicating that the trigeminal nerve is intact.
One or both eyelids fail to respond.
Inspect the anterior chamber for transparency and depth. Use the same oblique lighting as used to test the cornea.
Transparent
No shadows of light on iris
Depth is about 3mm
Cloudy
Crescent-shaped shadows on far side of iris
Shallow chamber (possible glaucoma)
Inspect the pupils for color, shape, and symmetry of size, pupil charts are available in some agencies.
Black in color; equal in size ; normally 3 to 7mm in diameter ; round, smooth border, iris flat and round.
Cloudiness, mydriasis, miosis, anisocoria, bulging of iris toward cornea.
Assess each pupil’s direct and consensual reaction to light to determine the function of the third (oculomotor) and fourth (trochlear) cranial nerves.
Illuminated pupil constricts (direct response)
Nonilluminated pupil constricts (consensual response)
Neither pupil constricts
Unequal responses
Absent responses
Assess each pupil’s reaction to accommodation
Pupils constrict when looking at near object, pupil dilate when looking at far object, pupil converge when near object is moved toward nose.
One or both pupils fail to constrict, dilate or converge.

Assessing pupil reactions:    
Direct and consensual reaction to light. Partially darken the room. Ask the client to look straight ahead.  Using a penlight or flashlight and approaching from the side, shine a light on the pupil. Observe the response of the illuminated pupil. It should constrict (direct response).
Shine the light on the pupil again, and observe the response of the other pupil. It should also constrict (consensual response).
Reaction to accommodation:
Hold an object (a penlight or pencil) about 10cm (4 inch) from the bridge of the client’s nose.Ask the client to look first at the top of the object and then at a distance object e.g. the far wall) behind the penlight. Alternate the gaze from the near to the far object. Observe the pupil response. The pupils should constrict when looking at the near object and dilate when looking at the far object.
Next, move the penlight or pencil toward the client’s nose. The pupils should converge. To record normal assessment of the pupils, use the abbreviation PERRLA (pupils equally round and react to light and accommodation).

Assessment
Normal findings
Deviation from normal
Assess peripheral visual fields to determine function of the retina and neuronal visual pathways to the brain and second (optic) cranial nerve.
When looking straight ahead, client can see objects in the periphery
Visual field smaller than normal (possible glaucoma) one-half vision in one or both eyes (indicates nerve damage)

Assessing peripheral Visual Fields
Have the client sit directly facing you at a distance of 60 to 90 cm (2to 3 feet). Ask the client to cover the right eye with a card and look directly at your nose.  Cover or close your eye directly opposite the client’s covered eye (i.e., your left eye, and look directly at the client’s nose. Hold an object (e.g. a penlight or pencil) in your fingers, extend your arm, and move the object into the visual field from various points in the periphery. The object should be at an equal distance from the client and yourself. Ask the client to tell you when the moving object is first spotted.
To test the temporal field of the left eye, extend and move your right arm in from the client’s periphery.(Start the object somewhat behind the person) Temporally, peripheral objects can be seen at right angles (90 degree) to the central point of vision.
To test the upward field of the eye, extend and move the right arm down from the upward periphery. The upward field of vision is normally 50 degrees because the orbital ridge is the way.
To test the downward field of the left eye, extend and move the right arm up from the lower periphery. The downward field of vision is normally 70 degrees because the cheekbone is the way.
To test the nasal field of the eye, extend and move your left arm in from the periphery. The nasal field of vision is normally 50 degrees away from the central point of vision because the nose is the in the way. Repeat the above steps for the right eye, reversing the process.
Extra-ocular muscle tests:
Assessment
Normal findings
Deviation from normal
Assess six ocular movements to determine eye alignment and coordination. These can be performed on clients over 6 months of age.
Both eyes coordinated, move in unison, with parallel alignment.
Eye movements not coordinated or parallel, one or both eyes fail to follow a pen-light in specific directions, e.g. strabismus (cross-eye or squint)
Nystagmus (may indicate neurologic impairment)

Assessing the six ocular movements
Stand directly in front of the client and hold the penlight at a comfortable distance, such as 30cm (1ft) in front of the client’s eyes.  Ask the client to hold the head in a fixed position facing you and to follow the movements of the penlight with the eye only.
Move the penlight in a slow, orderly manner through the six cardinal fields of gaze, that is, from the centre of the eye along the cardinal fields of gaze. Stop the movement of the penlight periodically so that nystagmus can be detected
Visual acuity:
Assessment
Normal Findings
Deviations from normal
Assess near vision by providing adequate lighting and asking the client to read from a magazine or newspaper held at a distance of 36cm (14in). if client normally wears corrective lenses should be worn during the test.
Able to read newsprint
Difficulty reading newsprint unless due to aging process
Assess distance vision by asking the client to wear corrective lenses, unless they are used for reading only. That is for distances  of only 36 cm (12 to 14in)
20/20 vision on Snellen chart
Denominator of 40 or more on Snellen chart with corrective.

Assessing Distance Vision- Ask the client to stand or sit 6 m (20ft) from a snellen or character chart. Cover the eye not being tested. And identify the letters or characters on the chart.
Take three readings; right eye, left eye and both eyes.
Record the readings of each eye and both eyes; that is the smallest line from which the person is able to read one half or more of the letters.
At the end of each line of the Snellen chart are standardized numbers (fractions). The top line is 20/200. The numerator (top number) is always 20, the distance the person stands from the chart. The denominator (bottom number) is the distance from which the normal eye can read the chart. Therefore, a person who has 20/40vision, can see at 20 feet from the chart what a normal-sighted person can see at 40 feet from the chart. Visual acuity is recorded as with correction or with correction. Also indicate how many letters were misread in the line.
Performing function vision tests

Assessment
Normal findings
Deviation from normal
Perform functional vision tests if the client is unable to see the top line (20/200)of the snellen chart.
Functional vision only (e.g., light perception, hand movements, counting, counting fingers at 1 ft)
Performing function vision tests:
·         Light perception:Shine a penlight into the client’s eye from a lateral position, and then turn the light off. Ask the client to tell you when the light is on or off. If the Client knows when the light is on or off, the client has light perception, and the vision is recorded as LP.
·         Hand movements:  Hold your hand 30 cm (1ft) from the client’s face and move it slowly back and forth, stopping it periodically. Ask the client to tell you when your hand stops moving. If the client knows when your hand stops moving, record the vision as “H/M 1 ft.”.
Counting fingers C/F  1ft”
Document the findings in the  client record
Ophthalmoscope is used to inspect fundus- retina, choroid, optic nerve, retinal vessels

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notes.nursium.com: Head and Eye assessment
Head and Eye assessment
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