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EYE AND EAR ASSESSMENT AND PROCEDURES
CHAPTER 6 EYE AND EAR ASSESSMENT AND PROCEDURES
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PRETEST True or False The outer layer of the eye is composed of white connective tissue known as the sclera. A person who is farsighted has a condition known as myopia. An optometrist can perform eye surgery. The Snellen eye test is conducted at a distance of 20 feet. The eustachian tube connects the nasopharynx to the inner ear.
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PRETEST, CONT. True or False
An eye instillation may be performed to treat an eye infection. The function of cerumen is to inhibit the growth of pathogens. The most specific type of hearing test is the tuning fork test. Serous otitis media can result in a conductive hearing loss. An ear instillation may be performed to treat an ear infection.
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Content Outline Introduction to Eye and Ear Assessment
MA is responsible for performing a variety of eye and ear assessments and procedures Visual acuity test: screening test to detect deficiencies in vision Hearing test: use of tuning fork or audiometer Audiometer: instrument that emits sound waves at various frequencies MA should be alert to signs that indicate the patient might be having difficulty hearing What are signs that would alert the MA that a patient has a hearing problem?
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Introduction to Eye and Ear Assessment, cont.
Color vision assessment Requires specially prepared colored plates Color blindness: inability to distinguish certain colors Red and green most common Why is it important for a person to see red and green colors?
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Introduction to Eye and Ear Assessment, cont.
Eye and ear irrigations and instillations Irrigation: washing a body canal with a flowing solution Instillation: dropping a liquid into a body cavity Why would we irrigate an eye? 6
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The Eye Structure of the Eye Eye has three layers: Sclera: outer layer
Composed of tough, white, fibrous connective tissue Front of sclera is modified to form cornea Cornea: transparent covering over the colored part of the eye What is a corneal abrasion? 7
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Structure of the Eye From Applegate EJ: The anatomy and physiology learning system, ed 2, Philadelphia, 2000, Saunders.
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Structure of the Eye, cont.
Choroid: middle layer Composed of many blood vessels and is highly pigmented Blood vessels: nourish the eye Pigment: absorbs stray light rays Front part of choroid specialized into: Ciliary body: muscles that control shape of the lens Suspensory ligaments: suspend lens in place Lens: focuses light rays on the retina Can we see the choroid just by looking at a person’s eye? 9
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Structure of the Eye, cont.
Iris: colored part of the eye that controls size of the pupil Pupil: opening in the eye that permits entrance of light rays Retina: inner layer Light rays come to a focus on the retina Transmitted to brain by optic nerve to be interpreted Define retinal detachment. 10
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Structure of the Eye, cont.
Chambers of the eye Anterior chamber: area between cornea and iris Posterior chamber: area between iris and lens Aqueous humor: fills both anterior and posterior chambers Vitreous humor: transparent jellylike material Fills eyeball between lens and retina Function: maintains the shape of the eyeball See slide 8 for structure. 11
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Structure of the Eye, cont.
Conjunctiva: membrane that lines eyelids and covers front of the eye, except for the cornea Conjunctiva covering the sclera: transparent Allows white sclera to show through See slide 8 for structure. 12
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Visual Acuity Visual acuity: acuteness or sharpness of vision
Normal visual acuity: Can see clearly Able to distinguish fine details Both close up and at a distance Normal visual acuity is 20/20. 13
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Errors of Refraction Errors of refraction: most common cause of defects in visual acuity Refraction: bending of the parallel light rays coming into the eye so they can be focused on the retina Notice the point of focus on the slide.
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Errors of Refraction, cont.
Error of refraction: light rays are not being bent properly: Are not focused on retina adequately Cause: defect in the shape of eyeball Can be improved with corrective lenses What are the types of lenses available for a patient? Is there a corrective surgery available for errors of refraction? 15
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Myopia Myopia (nearsighted): eyeball too long from front to back
Causes light rays to focus in front of retina Difficulty seeing objects at a distance May squint and have HA from eye strain Corrective lenses (eyeglasses, contact lenses) or laser surgery: can correct condition Cause light rays to focus on retina In school children, what is another problem they may have besides squinting? 16
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Myopia, cont. Notice the point of focus.
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Hyperopia Hyperopia (farsighted): eyeball too short from front to back
Causes light rays to focus behind the retina Difficulty viewing objects at a reading or working distance May have blurring, headache, and eye strain while performing close-up tasks Corrective lenses can correct condition Cause light rays to focus on retina A convex plus lens is used in corrective glasses. 18
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Hyperopia, cont. Notice the point of focus.
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Presbyopia Presbyopia: decrease in elasticity of lens
Usually begins after age 40 Results in a decreased ability to focus clearly on close objects Are corrective lenses used for this condition? 20
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Eye Specialists Types of eye specialists
Ophthalmologist: medical doctor specializing in diagnosis and treatment of diseases and disorders of the eye Prescribes ophthalmic and systemic medications Performs eye surgery List one type of eye surgery. 21
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Eye Specialists, cont. Optometrist: licensed primary health care provider who has expertise in measuring visual acuity and prescribing corrective lenses Can diagnose and treat of disorders and diseases of the eye Prescribes ophthalmic medications Not a physician: cannot prescribe systemic medications or perform eye surgery Optician: professional who interprets and fills prescription for eyeglasses and contact lenses What is a systemic medication? 22
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Assessment of Distance Visual Acuity (DVA)
Used to diagnose myopia Along with other tests Snellen eye chart: most often used 23
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Assessment of Distance Visual Acuity (DVA), cont.
Types of charts Letters in decreasing sizes Used for school-aged children and adults The MA should explain the test to the patient before the procedure.
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Assessment of Distance Visual Acuity (DVA), cont.
Capital letter E in decreasing sizes (arranged in different directions) Used for preschool children, non-English-speaking people, nonreaders Pictures of familiar objects Used for preschoolers Less accurate because some children are unable to identify objects How would the patient explain to us what direction the E is facing? 25
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Snellen Big E Chart
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Conducting a Snellen Test
Perform in a well-lit room free from distractions Performed at a distance of 20 feet Mark off with paint or tape on floor Why would we use a well-lit area? Why would we perform this test at 20 feet away? 27
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Conducting a Snellen Test, cont.
Two numbers next to each row of letters Number above line: distance at which test is conducted (20 feet) Number below line: distance from which a person with normal visual acuity can read the row of letters Normal DVA: 20/20 Person can read what supposed to read at 20 feet How would we explain 20/25? 28
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Conducting a Snellen Test, cont.
DVA: 20/30 Smallest line the individual could read at 20 feet People with normal acuity can read this line at 30 feet DVA: 20/15 Indicates above-average DVA People with normal acuity can read at 15 feet 29
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Conducting a Snellen Test, cont.
Acuity of each eye measured separately Traditionally beginning with right eye If patient wears eyeglasses or contact lenses (except reading glasses) Keep them on during test Record in chart that corrective lenses were worn Also record if corrective lenses were not being worn How would you chart if corrective lenses were worn? 30
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Snellen Eye Test
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Conducting a Snellen Test, cont.
Eye occluder: held over eye not being tested Patient's hand should not be used; may encourage peaking through fingers Instruct patient to leave eye not being tested open Closing eye: causes squinting of eye being tested What would the MA use to clean the eye occluder? What does squinting do to our vision temporarily? 32
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Conducting a Snellen Test, cont.
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Snellen Eye Chart
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Assessing Distance Visual Acuity in Preschoolers
Snellen Big E chart used Completely explain procedure to child Tell child you will be playing a pointing game Do not force child: results will be inaccurate How would we communicate with a child who is too shy and refuses to perform the exam? 35
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Assessing Distance Visual Acuity in Preschoolers, cont.
Draw a capital E on an index card Teach child to point in the direction of the open part of the E Phrases to describe open part of E: "fingers" or "legs of table" Allow child to practice Praise child when correct Parent may need to help child hold occluder in place Some offices give the child an award such as a sticker when the test is complete. 36
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Snellen Big E Chart
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What Would You Do? What Would You Not Do?
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What Would You Do? What Would You Not Do?
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Assessment of Near Visual Acuity (NVA)
Assesses patient's ability to read objects close up Used to detect hyperopia and presbyopia NVA card: contains different sizes of type: Ranging from size of newspaper headline down to very small print The physician may order a visual acuity test if there has been an injury to the eye. 40
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Assessment of Near Visual Acuity (NVA)
Available in variety of forms: Printed paragraphs Printed words Pictures Which one would you use for a child? 41
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Assessment of Near Visual Acuity (NVA), cont.
To perform NVA testing: Perform test in well-lit room free of distractions Patient holds card at a distance of 14 to 16 inches Reading glasses should be worn (if patient uses them) Each eye tested separately Why would the patient keep the reading glasses on for this test? 42
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Assessment of Near Visual Acuity (NVA), cont.
To perform NVA testing, cont.: Eye occluder held over eye not being tested Instruct patient to keep covered eye open Closing causes squinting of eye being tested Patient asked to read each line or paragraph If the patient fails the NVA test, where would we refer the patient? 43
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Assessment of Near Visual Acuity (NVA), cont.
Observe patient for unusual symptoms Squinting, tilting of head, watering of eyes Indicates patient having difficult reading card Patient continues until reaching smallest line that can be read How would you chart the symptoms observed? 44
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Assessment of Near Visual Acuity (NVA), cont.
Record results as smallest type patient could read with each eye Recording based on type of test card used Also record: Date and time If corrective lenses worn Unusual symptoms exhibited by patient 45
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Near Visual Acuity Chart
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Assessment of Color Vision
Classification of defects in color vision: Congenital defect: most common Inherited (present at birth) Most often affects males Acquired defect: acquired after birth Eye injury Disease Certain drugs Retinal disease or optic nerve disease may cause color vision. 47
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Assessment of Color Vision, cont.
Color vision tests detect congenital color vision defects Often performed in medical office Basic color vision screening test: Ask patient to identify red and green lines on Snellen chart How would you ask the patient to identify lines? 48
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Ishihara Test Detects:
Total congenital color blindness Red-green color blindness Series of plates: colored dots forming a numeral against a background of dots of contrasting colors Patients with normal color vision: read appropriate numeral How would you explain to the patient how to perform the test? 49
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Ishihara Color Plates Identify the numbers in the circles.
From Ishihara J: Tests for color blindness, Tokyo, 1920, Kanehara.
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Ishihara Test, cont. Patients with defects read dots as:
Not forming a number at all Forming a different number 51
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Ishihara Test, cont. First plate can be read correctly by all patients
Used to explain test procedure to patient Plates with winding colored lines: For patients unable to identify numbers by name Patient asked to trace line formed by the dots Used for preschoolers and non-English-speaking persons Patients should use a cotton-tipped applicator instead of their finger to trace the lines. 52
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Ishihara Test, cont. Conduct test in quiet room
Illuminated by natural daylight Bright sunlight can change shades of color on plates Can cause inaccurate test results Can use electric light Should adjust to resemble natural daylight Some offices have natural daylight light bulbs for this purpose. 53
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Ishihara Test, cont.
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Ishihara Test, cont. Test consists of 14 color plates:
Basic test: Plates 1-11 Further assessment of patient's with red-green deficiency: Plates 12, 13, and 14 From Ishihara J: Tests for color blindness, Tokyo, 1920, Kanehara. 55
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Ishihara Test, cont. Interpretation of results
Normal color vision: 10 or more plates read correctly Color vision deficiency: 7 or fewer plates read correctly Defect in color vision: patient referred to ophthalmologist or optometrist For additional assessment Use of more precise color vision tests How would you chart the results? 56
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Eye Irrigation Washing the eye with a flowing solution Purpose
Cleanse the eye by washing away: Foreign particles Ocular discharges Harmful chemicals Relieve inflammation though application of heat Apply an antiseptic solution For what types of foreign particles might we irrigate? 57
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Eye Irrigation, cont.
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Eye Instillation Dropping of a liquid into lower conjunctival sac
Purpose Treat eye infections (with medications) Soothe an irritated eye Dilate the pupil Anesthetize during eye examination or treatment Describe where the lower conjunctival sac is. 59
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Eye Instillation, cont. Locate the conjuctival sac.
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Eye Instillation, cont. Medications instilled in eye may come in the form of: Liquid (ophthalmic drops) Usually dispensed in a flexible bottle with an attached dropper Ointment Dispensed in a small metal tube with tip for applying medication The tip of the medication should not come in contact with the eye. Give examples of ophthalmic medications. 61
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What Would You Do? What Would You Not Do?
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What Would You Do? What Would You Not Do?
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The Ear Structure of the Ear
Functions in hearing and maintaining equilibrium Consists of three divisions: External ear Auricle (pinna): flap of cartilage covered with skin that Projects from side of head Receives and collects sound waves and directs them toward the external auditory canal What is equilibruim? Can we still hear without an auricle? 64
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Structure of the Ear, cont.
External auditory canal: extends from auricle to tympanic membrane Also known as external ear canal External auditory meatus: opening of canal 1 inch long in adult Lined with skin that contains nerve endings, fine hairs, glands Glands secrete cerumen: lubricates and protects ear canal Can we have too much cerumen in our ears? Can we have too little cerumen in our ears? 65
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Structure of the Ear, cont.
Canal has an S-shaped curve as it leads inward Canal must be straightened during: Tympanic membrane: located at end of the canal Pearly gray semitransparent membrane Receives sound waves Otoscopic examination Ear instillation Ear irrigation Aural temperature measurement You should not clean your ears with a cotton-tipped applicator. This could puncture the tympanic membrane. 66
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Structure of the Ear, cont.
From Applegate EJ: The anatomy and physiology learning system, ed 2, Philadelphia, 2000, Saunders.
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Structure of the Ear, cont.
Middle ear: air-filled cavity Contains three small bones (ossicles) Malleus Incus Stapes Eustachian tube: connects middle ear to the nasopharynx Stabilizes air pressure between the external atmosphere and the middle ear If a patient has a eustachian tube dysfunction, it may cause dizziness. 68
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Structure of the Ear, cont.
Inner ear Cochlea: essential organ of hearing Semicircular canals: maintain equilibrium Cochlear implants are used for deaf and severely hard-of-hearing patients. 69
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Assessment of Hearing Acuity
Part of complete PE Person can have hearing loss and not be aware of it Early detection and treatment: may prevent permanent hearing loss If a patient is not aware of the problem, usually a family member recognizes it. 70
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Assessment of Hearing Acuity
Person with normal hearing: can hear frequencies of normal speech Ranges from 300 to 4000 Hz (hertz or cycles per second) Patients who exhibit hearing loss: a. Referred to otolaryngologist or audiologist ENT stands for ear, nose, and throat. 71
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Conductive Hearing Loss
Conductive hearing loss: results when there is a physical interference with normal conduction of sound waves through external and middle ear Most common type of hearing loss Amount of sound reaching inner ear is less than normal What is prescribed for hearing loss? 72
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Conductive Hearing Loss, cont.
Conductive loss in external ear Caused by an obstruction of external ear canal: Impacted cerumen External otitis (swimmer's ear) Foreign bodies Benign growths (polyps) What is ordered for impacted cerumen? 73
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Conductive Hearing Loss, cont.
Conductive loss in middle ear Caused by an obstruction in middle ear: Serous otitis media (fluid in middle ear) Acute otitis media (infection in middle ear) Perforated tympanic membrane Otosclerosis What could be prescribed for acute otitis media? 74
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Conductive Hearing Loss, cont.
Cause of conductive loss: often detected by examining the ear canal with otoscope Hearing frequently restored by: Removing obstruction (e.g., cerumen) Treating the disorder (e.g., serous otitis media) A disposable speculum is used when examining the ear with an otoscope to prevent cross-contamination. 75
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Sensorineural Hearing Loss
Sensorineural hearing loss: results from damage to inner ear or auditory nerve Sound is conducted normally through outer and middle ear structures Problem with perception of sound waves: results in a hearing deficit Meniere’s disease can cause this type of hearing loss. 76
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Sensorineural Hearing Loss, cont.
Causes Hereditary factors Intense noise exposure over period of time Tumors Changes from normal aging process Ototoxicity caused by certain medications Infectious diseases (measles, mumps, meningitis) Mixed hearing loss: combination of both conductive and sensorineural loss Name some employees that might be exposed to increased intense noise. 77
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What Would You Do? What Would You Not Do?
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What Would You Do? What Would You Not Do?
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Hearing Acuity Tests Include: Simple gross screening test
Qualitative tests: tuning fork Highly sensitive tests: audiometry 80
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Hearing Acuity Tests, cont.
Important to test only one ear at a time Hearing deficit may exist only in one ear Ear not being tested: blocked by an earplug or masked Masking: presentation of sound to ear not being tested So patient's response is based only on hearing in ear being tested How would you explain the test to the patient? 81
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Gross Screening Test Gross Screening Test
Used to identify a very large hearing impairment Whisper test: patient asked to repeat simple word or series of numbers Whispered from a distance of 1 to 2 feet If the whisper test is performed, the patient may be asked to plug one ear and then the other. 82
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Tuning Fork Tests Tuning Fork Tests
Provide a general assessment of hearing acuity Use of tuning fork with frequency of 512 or 1024 Hz These frequencies fall within range of normal speech How would you clean the tuning fork? 83
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Weber Test Weber test: useful when one ear hears better than other
Fork set in vibration Base of fork placed on center of patient's head Patient indicates where sound is heard best How do you set the fork into vibration? 84
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Weber Test, cont.
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Weber Test, cont. Results of Weber test:
Normal hearing: patient hears sounds equally in both ears Conductive hearing loss: patient hears sound better in problem ear Sensorineural hearing loss: patient does not hear the sound as well in problem ear How would we record the results? 86
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Rinne Test Rinne test: compares the duration of sound perception by air conduction with that of bone conduction Fork is set in vibration Base of fork placed against bone of mastoid process Patient indicates when sound is no longer heard Prongs of fork (still vibrating) placed in the air: 1 inch from opening of ear Where is the mastoid process located? 87
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Rinne Test, cont.
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Rinne Test, cont. Results of Rinne test:
Normal hearing: patient hears sound twice as long through air conduction as through bone conduction Conductive hearing loss: patient hears the sound longer by bone conduction than by air conduction Sensorineural hearing loss: sound is reduced; patient also hears sound longer through air conduction than through bone conduction, but not twice as long How would the results be charted? 89
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Audiometry Audiometry: measurement of hearing acuity using an audiometer Audiometer: an instrument that quantitatively measures the various frequencies of sound waves Provides information on: How extensive hearing loss is Which frequencies are involved How would you explain the procedure to the patient? 90
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Audiometer Courtesy GSI [Grayson-Stadler], Milford, NH.
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Audiometry, cont. To perform test: Conduct test in quiet room
Headphones placed snugly over ears Each ear assessed separately Audiometer delivers a single frequency at a time Starts with low frequencies (250 to 500 Hz) and goes to high frequencies (6000 to 8000 Hz) Patient signals when sound is heard Results plotted on a graph (audiogram) How should the patient signal when the sound is heard? 92
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Audiometry, cont. Courtesy GSI [Grayson-Stadler], Milford, NH
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Tympanometry Tympanometry: helps determine cause of hearing loss
Not a hearing test Tympanometer: earpiece attached to an electronic device This is a diagnostic test. Courtesy GSI [Grayson-Stadler], Milford, NH
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Tympanometry, cont. Earpiece placed snugly in patient's ear
Low-frequency sound waves are directed against eardrum While pressure is applied in ear canal Instruct the patient to remain still and quiet. Courtesy GSI [Grayson-Stadler], Milford, NH.
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Tympanometry, cont. Normal ear: eardrum exhibits mobility in response to pressure Fluid present in middle ear: eardrum will not move (remains stiff) Used to diagnose serous otitis media Common cause of temporary hearing loss in children Results printed on a graphic readout: tympanogram Fluid in the middle ear is usually not treated. If infection is present, antibiotics are prescribed. 96
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Ear Irrigation Washing of the external auditory canal with a flowing solution The solution to use is ordered by the physician.
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Ear Irrigation, cont. Performed to:
Cleanse external ear canal to remove: Cerumen Discharge Foreign body Relieve inflammation by applying antiseptic solution Apply heat to ear When irrigating the ear, the syringe should be inserted toward the roof of the ear to prevent tympanic membrane injury. 98
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Ear Irrigation, cont. Impacted cerumen must be softened before removal: By instilling warm mineral oil or hydrogen peroxide (10 to 15 minutes) Do not perform irrigation if tympanic membrane is perforated Could result in severe irritation or infection of middle ear The ear canal must be straightened to reach all areas of the canal. 99
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Ear Instillation Dropping of a liquid into the external auditory canal
a. Usually dispensed in a flexible plastic container with an attached dropper 2. Performed to: Soften impacted cerumen Combat infection with antibiotic eardrops Relieve pain A moistened cotton wick may be used after instillation. Why would we want to moisten the wick? 100
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Ear Instillation, cont. Do not touch the ear with the tip of the applicator if this is a multi-dose bottle. Why would we want to avoid this?
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POSTTEST True or False The function of the lens is to permit the entrance of light rays into the eye. Visual acuity refers to sharpness of vision. Presbyopia is a decrease in the elasticity of the lens due to the aging process. An optician fills prescriptions for eyeglasses. The Snellen Big E chart is used with school-aged children.
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POSTTEST, CONT. True or False
The most common color vision defects are congenital in nature. The cochlea functions in maintaining equilibrium. The range of frequencies for normal speech is 300 to 4000 Hz. Intense noise can result in a sensorineural hearing loss. Tympanometry is used to diagnose patients with auditory nerve damage.
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