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Assessing the Eyes and Ears |
眼、耳評估 |
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Assessment |
評估 |
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1. Ask if client has a history of eye disease, trauma, or vision problems. |
詢問受檢者眼疾、外傷或視力問題史。 |
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2. Ask if client has a history of ear disease, trauma, or hearing problems. |
詢問受檢者耳疾、外傷或聽力問題史。 |
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3. Determine occupational history and use of glasses, contacts, hearing aid, and medications. |
檢查職業(yè)史及眼鏡、隱形眼鏡、助聽器和藥物使用情況。 |
Implementation |
實(shí)施 |
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1. Use Standard Protocol. |
按標(biāo)準(zhǔn)程序開始操作。 |
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2. Test visual acuity: |
視敏度測試。 |
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A. If client wears glasses or contact lenses, ask to read print from newspaper while wearing glasses. Note distance from the eyes that client holds the newspaper. |
帶眼鏡或隱形眼鏡者，可要求其帶眼鏡閱讀報(bào)紙，注意受檢者看報(bào)時(shí)眼睛與報(bào)紙的距離。 |
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B. If client is unable to see print clearly, test each eye separately by placing index card over one eye at a time. |
如受檢者看不清報(bào)紙文字，可用卡紙蓋住眼睛輪流測試兩眼視力。 |
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3. Test visual fields. |
視野測試 |
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A. Have client sit or stand 60 cm (2 feet) away and face you. Your eyes should be at eye level of client. |
病人面對檢查者坐或站于60 cm處。檢查者兩眼與受檢者兩眼同高。 |
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B. Ask client to gently close or cover one eye and to look at your eye directly opposite. Close or cover other eye on side of client's closed eye. |
囑受檢者輕輕遮住或閉上一只眼睛(如右眼)，從對面直視檢查者眼睛。檢查者閉上或遮住異側(cè)眼睛(即左眼)。 |
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C. Fully extend arm midway between client and yourself, then move it centrally with fingers moving. |
檢查者手臂前伸至與受檢者距離中間處，移動手臂并不斷擺動手指。 |
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D. Move finger or object equidistant from you and client outside of own field of vision. Slowly bring it back into field, asking client to state when it is first seen. Repeat procedure for all visual fields and for both eyes. |
在檢查者與受檢者等距離處移動手指或物體至自身視野外。緩緩移進(jìn)視野，要求病人在第一眼看到手或物體時(shí)就告訴檢查者。重復(fù)各個方位，檢查兩眼。 |
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4. Test extraocular movements |
眼外運(yùn)動測試 |
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A. Instruct client to look straight ahead toward you, keeping head motionless throughout examination. |
囑病人直視檢查者，檢查期間頭部保持不動。 |
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B. Hold finger 15 to 30 cm (6 to 12 inches) in front of client's eyes. |
手指放于受檢者前方10-30 cm處。 |
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C. Ask client to follow movement of finger with eyes, keeping head still. Move finger slowly through each of eight cardinal gazes. |
囑受檢者兩眼隨手指移動，頭部不動。按八個方位移動手指。 |
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D. Keep finger within normal field of vision. |
手指停留在正常視野范圍內(nèi)。 |
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E. Observe parallel eye movement, position of upper lid in relation to iris, and presence of nystagmus. |
觀察眼睛平行運(yùn)動、上眼瞼與虹膜對比位置和眼震。 |
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5. Test pupillary reflexes |
瞳孔反射測試 |
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A. Dim room lights to test reaction to light. |
調(diào)暗燈光，測試對光反應(yīng)。 |
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B. As client looks straight ahead, move light source from side of client's face and direct light onto pupil. |
受檢者直視前方，將燈源從受檢者臉部外側(cè)內(nèi)移，燈光直接照射受檢者瞳孔。 |
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C. Observe pupillary response of both eyes. |
觀察兩眼瞳孔反應(yīng)。 |
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D. Note corneal light reflex. |
注意角膜對光反射。 |
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E. Defects along inner margins of the iris may be from surgical correction for glaucoma. |
青光眼手術(shù)矯正會引起虹膜內(nèi)緣缺陷。 |
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6. Test accommodation. |
調(diào)節(jié)能力測試 |
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A. Ask client to look at wall in distance. Quickly bring finger within 10 to 15 cm (4 to 6 inches) of client's nose and ask client to look at finger. |
囑受檢者看遠(yuǎn)處墻壁�？焖賹⑹种敢浦潦軝z者鼻前10-15 cm處，要求受檢者看手指。 |
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B. Move finger smoothly toward nasal bridge; watch for pupil constriction and convergence. |
手指平穩(wěn)地向鼻柱移動，觀察瞳孔收縮會聚情況。 |
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7. Assess external eye. |
外眼評估 |
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A. Inspect eye position with eyes open. Note if any portion of lower conjunctiva is visible. |
受檢者睜蛝，檢查眼睛位置。注意結(jié)膜是否下垂。 |
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B. Ask client to close both eyes; inspect lid position. Raise eyebrows and inspect upper eyelids for color, edema, and presence of lesions. Have client open eyes, and note blink reflex. |
受檢者閉上兩眼，檢查眼瞼位置。揭開眉毛，檢查上眼瞼顏色、浮腫及有無損傷。囑受檢者睜眼，注意瞬目反射。 |
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C. Inspect lacrimal apparatus and note edema or inflammation. Palpate to detect tenderness. (NOTE: Apply gloves if drainage present.) Inspect for excess tearing or edema of inner canthus. |
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D. Inspect conjunctiva for color, edema, or lesions by gently depressing lower lid with thumb pressed against bony orbit. Ask client to look up. |
檢查結(jié)膜顏色、水腫，或拇指靠住眼眶輕輕按壓下眼瞼檢查有無損傷。囑受檢者抬眼。 |
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E. Inspect cornea for opacities by shining light at an angle toward the cornera. Check pupils for size, shape, and equality. Inspect iris for symmetry. |
用手電光斜照角膜，檢查角膜濁斑。檢查瞳孔大小、形狀和對等。檢查虹膜是否對稱。 |
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8. Examine external ear. |
檢查外耳 |
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A. Inspect auricle for placement, size, symmetry, and color. |
檢查耳廓布局、大小、對稱性和顏色。 |
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B. Palpate auricle for texture, tenderness, and presence of lesions. If client complains of pain, gently pull auricle and press on tragus and behind ear over mastoid bone. |
觸碰耳廓檢查質(zhì)地、觸痛，有無損傷。如受檢者叫痛，輕拉耳廓、按耳屏及耳后顳骨乳突部。 |
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C. Observe opening of ear canal for lesions, discharge, swelling, foreign bodies, or inflammation. 醫(yī)學(xué)全在線網(wǎng)站www.med126.com |
觀察耳道口有無損傷、漏液、腫大、異物或炎癥。 |
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D. Inspect canal for buildup of cerumen. If canal is clear, ask how often client usually cleans ears. |
檢查耳道有無耳垢。如耳道干凈，詢問受檢者通常清理時(shí)間。 |
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9. Assess hearing acuity. |
評估聽敏度 |
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A. Ask client to remove hearing aid and close eyes. |
囑受檢者取下助聽器，閉眼。 |
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B. Test one ear at a time |
逐耳檢查。 |
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C. Stand 15 to 60 cm (6 inches to 2 feet) away, exhale fully, and softly whisper a sequence of numbers with two equally accented syllables. |
站于15-60 cm開外，呼氣，輕柔地說出一串?dāng)?shù)字，音節(jié)間重音相等。 |
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D. Ask client to repeat. Repeat in conversational or loud tones if needed. |
囑受檢者重復(fù)。必要時(shí)可用談話語調(diào)或大聲重復(fù)。 |
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10. If hearing loss is suspected, perform a tuning fork test. |
如疑有聽力喪失，可行音叉測試。 |
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A. Weber's test
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韋伯試驗(yàn)
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B. Rinne test
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林納試驗(yàn)
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11. Use Completion Protocol. |
按標(biāo)準(zhǔn)程序完成操作 |
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Evaluation |
評價(jià) |
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1. Compare findings with client's baseline and normal expected findings. |
對比受檢者基線值和正常預(yù)期值。 |
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2. Identify Unexpected Outcomes and Nursing Intervention Record and Report |
確認(rèn)意外結(jié)果和護(hù)理措施 記錄和報(bào)告 |
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1. Assessment findings. |
評估所見 |
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2. Description of abnormalities. |
異常說明 |
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3. Abnormal findings (report to physician). |
異常結(jié)果(報(bào)告醫(yī)生) |
