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.
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Assessment
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Normal findings
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Deviation from normal
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Inspect skull for size,
shape & symmetry and contour
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Rounded (normocephalic&
symmetrical, with frontal, parietal and occipital prominences,)
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Lack of symmetry,increased skull size with more
prominent nose and forehead
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Palpate the skull for
nodules /masses & depressions with fingertips with rotating motion with
the finger tips
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Smooth uniform
consistency: absence of nodules and masses
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Sebaceous cyst; local
deformities from trauma
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Inspect the facial
features for symmetry of structure & of the distribution of hair
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Symmetric slightly
asymmetrical facial features. Palpebral fissures symmetrical in size &
Symmetric nasolabial folds.
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↑ Facial hair, thinning of
eyebrows, asymmetric features, exophthalmos, moon face.
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Inspect the eyes for edema
& hollowness
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Periorbital edema, sunkun
eyes.
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Note symmetry of facial
movement
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Symmetric facial movement
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Eyes cannot be closed,
dropping eyelid & mouth, involuntary facial movements
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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.
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External features
Refractive errors
Refractive errors
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Myopia- near sightedness
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Hyperopia- far
sightedness
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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
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Snellen’s E chart –
kinder garten chart, snellen’s standard chart, Snellens E chart
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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
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Assessment
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Normal findings
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Deviations from normal
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Inspect the eye brows for hair distribution and
alignment and skin quality and movement (ask client to raise and lower the
eyebrows)
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Hair evenly distributed, skin intact.
Eyebrows symmetrically aligned, equal movement.
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Loss of hair, scaling and flakiness of skin.
Unequal alignment and movement eyebrows
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Inspect the eyelashes for evenness of distribution
and direction of curl.
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Equally distributed curled slightly outward
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Turned inward
( enteropion)
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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.
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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.
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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.
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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.
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Transparent; capillaries sometimes evident; sclera
appears white (yellowish in dark-skinned client)
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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.
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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.
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Shiny, smooth and pink and red.
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External, pale (possible anemia); extremely red
(inflammation); nodules or other lesions.
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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.
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Assessment
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Normal findings
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Deviations from normal
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Inspect and palpate the lacrimal sac and
nasolacrimal duct
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No edema and tearing
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Evidence of increased tearing regurgitation of fluid
on palpation of lacrimal sac.
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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.
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In older people, a thin, grayish white ring around
the margin, called arcussenilis, may be evident.
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Arcussenilis in clients under age 40 is abnormal.
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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.
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Client blinks when the cornea is touched, indicating
that the trigeminal nerve is intact.
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One or both eyelids fail to respond.
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Inspect the anterior chamber for transparency and
depth. Use the same oblique lighting as used to test the cornea.
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Transparent
No shadows of light on iris
Depth is about 3mm
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Cloudy
Crescent-shaped shadows on far side of iris
Shallow chamber (possible glaucoma)
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Inspect the pupils for
color, shape, and symmetry of size, pupil charts are available in some
agencies.
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Black in color; equal in
size ; normally 3 to 7mm in diameter ; round, smooth border, iris flat and
round.
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Cloudiness, mydriasis,
miosis, anisocoria, bulging of iris toward cornea.
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Assess each pupil’s direct
and consensual reaction to light to determine the function of the third
(oculomotor) and fourth (trochlear) cranial nerves.
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Illuminated pupil
constricts (direct response)
Nonilluminated pupil constricts
(consensual response)
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Neither pupil constricts
Unequal responses
Absent responses
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Assess each pupil’s
reaction to accommodation
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Pupils constrict when
looking at near object, pupil dilate when looking at far object, pupil
converge when near object is moved toward nose.
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One or both pupils fail to
constrict, dilate or converge.
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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).
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Assessment
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Normal findings
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Deviation from normal
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Assess peripheral visual fields to determine
function of the retina and neuronal visual pathways to the brain and second
(optic) cranial nerve.
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When looking straight ahead, client can see objects
in the periphery
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Visual field smaller than normal (possible glaucoma)
one-half vision in one or both eyes (indicates nerve damage)
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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:
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Assessment
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Normal findings
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Deviation from normal
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Assess six ocular movements to determine eye
alignment and coordination. These can be performed on clients over 6 months
of age.
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Both eyes coordinated, move in unison, with parallel
alignment.
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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)
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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:
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Assessment
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Normal
Findings
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Deviations
from normal
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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.
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Able to read newsprint
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Difficulty reading newsprint unless due to aging
process
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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)
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20/20 vision on Snellen chart
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Denominator of 40 or more on Snellen chart with
corrective.
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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
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Assessment
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Normal
findings
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Deviation
from normal
|
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Perform functional vision tests if the client is
unable to see the top line (20/200)of the snellen chart.
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Functional vision only (e.g., light perception, hand
movements, counting, counting fingers at 1 ft)
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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
MYDRIASIS, MIOSIS,
ANISOCORIA:
COMMENTS