When performing the otoscopic examination, which of the following indicates an unexpected finding?

Open Resources for Nursing (Open RN)

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.

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. 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

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:

• 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

Assessment	Expected Findings	Unexpected New Findings (Document and notify provider)
Inspection	Eyes 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 immediately		New and sudden problems such as vision loss, blurred vision, eye pain, red eye, ear pain, vertigo, poor balance, or gait change

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Video otoscopy completed by audiology students