MODULE 5 9/18/12. A Guide to Geriatric Nursing Assessment In A Skilled Nursing Care Center. Eyes Ears Nose Throat

Transcription

1 A Guide to Geriatric Nursing Assessment In A Skilled Nursing Care Center Instructor: Christine O Rourke BSN, RN, MSN, FNP-C This module has been prepared for the ongoing education of registered nurses. Nursing autonomy of practice and nursing career development places a priority on a lifelong commitment to the principles of education and professional development. The knowledge base of nursing theory and practice is expanding and while care has been taken to ensure the accuracy and timeliness of the information presented in this module and series, clinicians are advised to always verify the most current national guidelines and recommendations and to practice in accordance with professional standards of care used with regard to the unique circumstances that apply in each practice situation. Therefore, the authors, presenters, producers and consultants of this educational module cannot accept responsibility for error or omissions, or for any consequence or liability, injury and/or damages to persons or property from application of the information in this module/series and make no warranty, expressed or implied, with respect to the contents. MODULE 5 Eyes Ears Nose Throat 1

2 Purpose & Function Transmits visual stimuli to brain INTERNAL STRUCTURES Sclera Cornea Uvea Lens Retina EXTERNAL STRUCTURES Eyelid Conjunctiva Lacrimal gland Eye muscles Geriatric Changes Rigid & Denser lens Weaker ciliary muscles Excessive tearing or dry eyes Vision changes Scleral brown spots Nocturnal eye pain ** Inspection n Eyebrows Orbital area Puffiness Edema Sagging Tissue Xanthelasma Eyelids Pitosis Ectropion Entropion 2

3 Inspection Conjunctiva Cornea Iris / Pupil Miosis Mydriasis Lens Cataracts Sclera Palpation Eyelids Eye Extraocular Muscles (oculomotor), IV (trochlear), VI (abducens) Superior rectus Lateral rectus CN VI Inferior rectus Inferior oblique Medial rectus Inferior oblique Superior oblique CN IV Superior rectus I Lateral rectus CN VI Inferior rectus EARS Purpose & Function Transmits sound Maintenance of equilibrium Structures External ear Middle ear Inner ear 3

4 EARS Geriatric Changes Conductive hearing loss Dry cerumen sebaceous gland less active Sclerotic tympanic membrane Sensorineural hearing loss Poor hair cell function Presbycusis Loss of high-frequency sounds then progresses to lower frequency sounds Inspection EARS External Ear Auricles (pinna) Auditory canals Color, size, shape, symmetry, position on head Deformities, lesions, nodules, discharge, odor Palpation EARS Auricles / Mastoid Tenderness, swelling 4

5 NOSE Purpose & Function Passageway for inspired & expired air Dampens, filters and warms inspired air Identifies odors Resonance of laryngeal sound Structures Nares Vestibules Nasal bridge Turbinates NOSE Geriatric Changes Cartilage continues to grow Dry/Dull nasal mucosa Increased terminal hair in vestibules Loss of olfactory sensory neurons Inspection NOSE Skin Texture, lesions, edema, color Nasal bridge Alignment Nares Position, flaring/narrowing, discharge 5

6 Palpation NOSE Nasal bridge Tenderness, masses, displacement Nares Patency Sinuses Frontal Maxillary THROAT Purpose & Function Passageway for: Inspired & expired air Food, liquid & saliva Exhalation of air for vocalization Identifies taste Mastication for digestion THROAT Geriatric Changes Soft tissue changes Tongue Fissured Altered motor function Decreased saliva production Xerostomia Decreased sensitivity to odors and tastes 6

7 Inspection THROAT Lips Symmetry, color, edema, ulcerations Oral Cavity Symmetry, color, edema, ulcerations Palpation THROAT Lips Swelling, tenderness, consistency Gums Tenderness, thickening, masses Tongue / Floor of mouth Lumps, nodules, ulceration See post test # 5 document 7

8 REFERENCES Seidel, H., Ball, J., Dains, J., & Benedict, W. (2006). Eyes. Mosby s Guide to Physical Examination Seidel, H., Ball, J., Dains, J., & Benedict, W. (2006). Ears, Nose and Throat. Mosby s Guide to Physical Examination