| Assessing the Eyes and Ears | 眼、耳評(píng)估 |
| Assessment | 評(píng)估 |
| 1. Ask if client has a history of eye disease, trauma, or vision problems. | 詢問受檢者是否有眼疾、外傷或視力問題史?！?/td> |
| 2. Ask if client has a history of ear disease, trauma, or hearing problems. | 詢問受檢者是否有耳疾、外傷或聽力問題史。 |
| 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 |
| 1. Use Standard Protocol. | 采用標(biāo)準(zhǔn)護(hù)理程序 |
| 2. Test visual acuity: | 視敏度測(cè)試 |
| 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?！?/td> |
| 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(cè)試兩眼視力。 |
| 3. Test visual fields. | 視野測(cè)試 |
| 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(duì)檢查者坐或站于60 cm處。檢查者兩眼與受檢者兩眼同高?！?/td> |
| 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(duì)面直視檢查者眼睛。檢查者閉上或遮住異側(cè)眼睛（即左眼）?！?/td> |
| 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(dòng)手臂并不斷擺動(dòng)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. | 在檢查者與受檢者等距離處移動(dòng)手指或物體至自身視野外。緩緩移進(jìn)視野，告訴病人在第一眼看到手指或物體時(shí)就告訴檢查者。各個(gè)方位重復(fù)操作，檢查雙眼?！?/td> |
| 4. Test extraocular movements | 眼外運(yùn)動(dòng)測(cè)試 |
| A. Instruct client to look straight ahead toward you, keeping head motionless throughout examination. | 囑病人直視檢查者，檢查時(shí)頭部保持不動(dòng)?！?/td> |
| 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?！?/td> |
| C. Ask client to follow movement of finger with eyes, keeping head still. Move finger slowly through each of eight cardinal gazes. | 囑受檢者雙眼隨手指移動(dòng)，頭部不動(dòng)。按八個(gè)方位移動(dòng)手指?！?/td> |
| D. Keep finger within normal field of vision. | 手指保持在正常視野范圍內(nèi)?！?/td> |
| 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(dòng)、上眼瞼與虹膜對(duì)比位置和眼震。 |
| 5. Test pupillary reflexes | 瞳孔反射測(cè)試 |
| A. Dim room lights to test reaction to light. | 關(guān)暗燈光測(cè)試對(duì)光反應(yīng)?！?/td> |
| 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，將燈光直接照射于受檢者瞳孔?！?/td> |
| C. Observe pupillary response of both eyes. | 觀察雙眼瞳孔反應(yīng)?！?/td> |
| D. Note corneal light reflex. | 注意角膜對(duì)光反射?！?/td> |
| E. Defects along inner margins of the iris may be from surgical correction for glaucoma. | 青光眼手術(shù)矯正可以引起虹膜內(nèi)緣缺陷?！?/td> |
| 6. Test accommodation. | 調(diào)節(jié)能力測(cè)試 |
| 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?！?/td> |
| B. Move finger smoothly toward nasal bridge; watch for pupil constriction and convergence. | 手指平穩(wěn)地向鼻柱移動(dòng)，觀察瞳孔收縮會(huì)聚?！?/td> |
| 7. Assess external eye. | 外眼評(píng)估 |
| 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)膜是否理垂?！?/td> |
| 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. | 受檢者閉上雙眼，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?！?/td> |
| 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. | 檢查淚器，注意水腫或炎癥。觸碰檢查有無觸痛。（注意：如有滲液就帶手套）檢查有無淚水過多或內(nèi)眥水腫?！?/td> |
| 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，或拇指靠在眼眶輕輕按壓下眼瞼檢查有無損傷。囑受檢者抬眼。?！?/td> |
| 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(duì)等。檢查虹膜否對(duì)稱?！?/td> |
| 8. Examine external ear. | 檢查外耳 |
| A. Inspect auricle for placement, size, symmetry, and color. | 檢查耳廓布局、大小、對(duì)稱性和顏色?！?/td> |
| 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，輕拉耳廓和按耳屏及耳后顳骨乳突部?！?/td> |
| C. Observe opening of ear canal for lesions, discharge, swelling, foreign bodies, or inflammation. | 觀察耳道口有無損傷、漏液、腫大、異物升炎癥?！?/td> |
| 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。 |
| 9. Assess hearing acuity. | 評(píng)估聽敏度 |
| A. Ask client to remove hearing aid and close eyes. | 囑受檢者取下助聽器，閉眼。 |
| B. Test one ear at a time | 逐眼檢查?！?/td> |
| 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?！?/td> |
| 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)?！?/td> |
| 10. If hearing loss is suspected, perform a tuning fork test. | 如疑有聽力喪失，可進(jìn)行音叉測(cè)試。 |
A. Weber's test
1. 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.
2. Ask client if sound is heard equally in both ears or better in one ear. | 韋伯試驗(yàn)
握住音叉，輕輕擊掌根，將震動(dòng)音叉面放在受檢者頭頂正中線或額頭中間。
詢問受檢者兩耳聲音是否一樣或有差異?！?/td> |
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. | 林納試驗(yàn)
將震動(dòng)音叉桿靠在受檢者乳突。囑受檢者在聽不到聲音時(shí)通知你。觀察持續(xù)時(shí)間（秒）。
迅速將仍在震動(dòng)的音叉尖端放于離耳道1-2 cm處。
囑受檢者病人在聽不到聲音時(shí)通知你。記錄時(shí)間。
對(duì)比骨導(dǎo)和氣導(dǎo)時(shí)間?！?/td> |
| 11. Use Completion Protocol. | 采用護(hù)理完成程序 |
| Evaluation | 評(píng)價(jià) |
| 1. Compare findings with client's baseline and normal expected findings. | 對(duì)比受檢者基線值和正常預(yù)期值?！?/td> |
| 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 |
| 1. Assessment findings. | 評(píng)估所見 |
| 2. Description of abnormalities. | 異常說明 |
| 3. Abnormal findings （report to physician）. | 異常結(jié)果（報(bào)告醫(yī)生） |
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