Assessing the Eyes and Ears 眼、耳评估
Ask if client has a history of eye disease, trauma, or vision
Ask if client has a history of ear disease, trauma, or hearing
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。
Use Standard Protocol. 采用标准护理程序
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.
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
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.
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，检查时头部保持不动。
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.
D. Keep finger within normal field of vision. 手指保持在正常视野范围内。
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。
Test pupillary reflexes 瞳孔反射测试
A. Dim room lights to test reaction to light. 关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.
C. Observe pupillary response of both eyes. 观察双眼瞳孔反应。
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. 青光眼手术矫正可以引起虹膜内缘缺陷。
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。
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。注意结膜是否理垂。
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.
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.
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，或拇指靠在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。检查虹膜否对称。
Examine external ear. 检查外耳
A. Inspect auricle for placement, size, symmetry, and color.
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，轻拉耳廓和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. 观察耳道口有无损伤、漏液、肿大、异物升炎症。
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。
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 逐眼检查。
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
If hearing loss is suspected, perform a tuning fork test.
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
Ask client if sound is heard equally in both ears or better in one
B. Rinne test
Place stem of vibrating tuning fork against client's mastoid process.
Ask client to tell you when sound is no longer heard. Observe the
length of time in seconds.
Quickly place the still-vibrating tines 1 to 2 cm （1/2 to 1 inch） from
Ask client to tell you when sound is no longer heard. Again, time with
Compare the number of seconds for bone conduction versus air
Use Completion Protocol. 采用护理完成程序
Compare findings with client's baseline and normal expected findings.
Identify Unexpected Outcomes and Nursing Intervention Record and
Assessment findings. 评估所见
Description of abnormalities. 异常说明
Abnormal findings （report to physician）. 异常结果（报告医生）