Assessing the Eyes and Ears

眼、耳评估

Assessment

评估

1. Ask if client has a history of eye disease, trauma, or vision problems.

询问受检者眼疾、外伤或视力问题史。

2. Ask if client has a history of ear disease, trauma, or hearing problems.

询问受检者耳疾、外伤或听力问题史。

3. Determine occupational history and use of glasses, contacts, hearing aid, and medications.

检查职业史及眼镜、隐形眼镜、助听器和药物使用情况。

Implementation

实施

1. Use Standard Protocol.

按标准程序开始操作。

2. Test visual acuity:

视敏度测试。

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.

带眼镜或隐形眼镜者，可要求其带眼镜阅读报纸，注意受检者看报时眼睛与报纸的距离。

B. If client is unable to see print clearly, test each eye separately by placing index card over one eye at a time.

如受检者看不清报纸文字，可用卡纸盖住眼睛轮流测试两眼视力。

3. Test visual fields.

视野测试

A. Have client sit or stand 60 cm (2 feet) away and face you. Your eyes should be at eye level of client.

病人面对检查者坐或站于60 cm处。检查者两眼与受检者两眼同高。

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.

嘱受检者轻轻遮住或闭上一只眼睛(如右眼)，从对面直视检查者眼睛。检查者闭上或遮住异侧眼睛(即左眼)。

C. Fully extend arm midway between client and yourself, then move it centrally with fingers moving.

检查者手臂前伸至与受检者距离中间处，移动手臂并不断摆动手指。

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.

在检查者与受检者等距离处移动手指或物体至自身视野外。缓缓移进视野，要求病人在第一眼看到手或物体时就告诉检查者。重复各个方位，检查两眼。

4. Test extraocular movements

眼外运动测试

A. Instruct client to look straight ahead toward you, keeping head motionless throughout examination.

嘱病人直视检查者，检查期间头部保持不动。

B. Hold finger 15 to 30 cm (6 to 12 inches) in front of client's eyes.

手指放于受检者前方10-30 cm处。

C. Ask client to follow movement of finger with eyes, keeping head still. Move finger slowly through each of eight cardinal gazes.

嘱受检者两眼随手指移动，头部不动。按八个方位移动手指。

D. Keep finger within normal field of vision.

手指停留在正常视野范围内。

E. Observe parallel eye movement, position of upper lid in relation to iris, and presence of nystagmus.

观察眼睛平行运动、上眼睑与虹膜对比位置和眼震。

5. Test pupillary reflexes

瞳孔反射测试

A. Dim room lights to test reaction to light.

调暗灯光，测试对光反应。

B. As client looks straight ahead, move light source from side of client's face and direct light onto pupil.

受检者直视前方，将灯源从受检者脸部外侧内移，灯光直接照射受检者瞳孔。

C. Observe pupillary response of both eyes.

观察两眼瞳孔反应。

D. Note corneal light reflex.

注意角膜对光反射。

E. Defects along inner margins of the iris may be from surgical correction for glaucoma.

青光眼手术矫正会引起虹膜内缘缺陷。

6. Test accommodation.

调节能力测试

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.

嘱受检者看远处墙壁。快速将手指移至受检者鼻前10-15 cm处，要求受检者看手指。

B. Move finger smoothly toward nasal bridge; watch for pupil constriction and convergence.

手指平稳地向鼻柱移动，观察瞳孔收缩会聚情况。

7. Assess external eye.

外眼评估

A. Inspect eye position with eyes open. Note if any portion of lower conjunctiva is visible.

受检者睁蛝，检查眼睛位置。注意结膜是否下垂。

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.

受检者闭上两眼，检查眼睑位置。揭开眉毛，检查上眼睑颜色、浮肿及有无损伤。嘱受检者睁眼，注意瞬目反射。

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.

检查泪器，注意水肿或炎症。触碰检查有无触痛。(注意：如有渗液就带手套)检查有无泪水过多或内眦水肿。

D. Inspect conjunctiva for color, edema, or lesions by gently depressing lower lid with thumb pressed against bony orbit. Ask client to look up.

检查结膜颜色、水肿，或拇指靠住眼眶轻轻按压下眼睑检查有无损伤。嘱受检者抬眼。

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.

用手电光斜照角膜，检查角膜浊斑。检查瞳孔大小、形状和对等。检查虹膜是否对称。

8. Examine external ear.

检查外耳

A. Inspect auricle for placement, size, symmetry, and color.

检查耳廓布局、大小、对称性和颜色。

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.

触碰耳廓检查质地、触痛，有无损伤。如受检者叫痛，轻拉耳廓、按耳屏及耳后颞骨乳突部。

C. Observe opening of ear canal for lesions, discharge, swelling, foreign bodies, or inflammation. 医学全在线网站www.med126.com

观察耳道口有无损伤、漏液、肿大、异物或炎症。

D. Inspect canal for buildup of cerumen. If canal is clear, ask how often client usually cleans ears.

检查耳道有无耳垢。如耳道干净，询问受检者通常清理时间。

9. Assess hearing acuity.

评估听敏度

A. Ask client to remove hearing aid and close eyes.

嘱受检者取下助听器，闭眼。

B. Test one ear at a time

逐耳检查。

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开外，呼气，轻柔地说出一串数字，音节间重音相等。

D. Ask client to repeat. Repeat in conversational or loud tones if needed.

嘱受检者重复。必要时可用谈话语调或大声重复。

10. If hearing loss is suspected, perform a tuning fork test.

如疑有听力丧失，可行音叉测试。

A. Weber's test

• Hold fork at its base and tap lightly against heel of palm. Place base of vibrating fork on midline vertex of client's head or middle of forehead.
• Ask client if sound is heard equally in both ears or better in one ear.

韦伯试验

• 握住音叉，轻击掌根，将震动音叉面放在受检者头顶正中线或额头中间。
• 询问受检者两耳声音是否一样或有差异。

B. Rinne test

• 1. Place stem of vibrating tuning fork against client's mastoid process.
• 2. Ask client to tell you when sound is no longer heard. Observe the length of time in seconds.
• 3. Quickly place the still-vibrating tines 1 to 2 cm (1/2 to 1 inch) from ear canal.
• 4. Ask client to tell you when sound is no longer heard. Again, time with a watch.
• 5. Compare the number of seconds for bone conduction versus air conduction.

林纳试验

• 将震动音叉杆靠在受检者乳突。嘱受检者在听不到声音时通知你。观察持续时间(秒)。
• 迅速将仍在震动的音叉尖端放于离耳道1-2 cm处。
• 嘱受检者病人在听不到声音时通知你。记录时间。
• 对比骨导和气导时间。

11. Use Completion Protocol.

按标准程序完成操作

Evaluation

评价

1. Compare findings with client's baseline and normal expected findings.

对比受检者基线值和正常预期值。

2. Identify Unexpected Outcomes and Nursing Intervention

Record and Report

确认意外结果和护理措施

记录和报告

1. Assessment findings.

评估所见

2. Description of abnormalities.

异常说明

3. Abnormal findings (report to physician).

异常结果(报告医生)