Chapter 2: Vital Signs & Physical Assessment Findings of the Pediatric Patient AND Anatomy and Physiology Review of All Systems

Lymph Nodes

should be NONPALPABLE. Lymph nodes that are small, palpable, nontender, and mobile can be an expected finding.

Eyes: Corneas

should be clear

Eyes: Iris

should be round w/ the permanent color manifesting around *6-12 months*

Eyes: Sclera

should be white

Eyes: Pupil

should be: -Round -Equal in size -Reactive to light -Accommodating: refers to the eyes ability to see things that are both close up and far away. If your pupils are nonreactive to accommodation, it means they don't adjust when you try to shift your focus to an object in the distance or near your face. The normal pupil size in adults varies from 2-4mm in diameter in bright light to 4-8mm in the dark. *The movements of the pupils are controlled by the nervous system. As a result, when the pupils dont react accordingly to the light test, it shows that there might be some problems on the pts nervous system, specifically the optic nerve and oculomotor nerve (CN II and III)

Eyes: Eyelids

should close completely and open to allow the lower border and most of the upper portion of the iris tterm-24o be seen

Eyes: Eyelashes

should curve outward and be evenly distributed with no inflammation around any of the hair follicles

Ears: Diagnostics

*Audiometric Testing:* is a hearing evaluation to assess *conductive and sensorineural* hearing loss at different high and low frequencies: -The individual sits in a sound proof room/booth with a set of headphones that are connected to an audiometer, and is instructed to press a button every time they hear a tone at varied frequencies. The audiometer documents the results on a graph for interpretation. *Tympanometry:* assesses the movement of the tympanic membrane and disorders of the middle ear. -During this assessment, a soft ear bud is inserted into the ear canal, which changes the air pressure to move the tympanic membrane. The results of the changes in air pressure are recorded on a graph called a *tympanogram.* This graph identifies whether there is normal air pressure and normal mobility of the tympanic membrane. -This assessment can identify problems leading to hearing loss, the presence of middle ear infections, fluid in the middle ear, and dysfunction of the Eustachian tube.

Abnormal Respiratory Rates and Rhythms

*Bradypnea:* abnormally slow respirations *Tachypnea:* abnormally fast respirations, usually shallow *Kussmaul Respirations:* respirations that are REGULAR but abnormally DEEP and INCREASED in rate *Biot Respirations:* IRREGULAR respirations of VARIABLE DEPTH (usually shallow), alternating with regular or irregular periods of APNEA; also called *ataxic breathing* *Cheyne-Stokes Respirations:* GRADUAL INCREASE in depth of respirations, followed by GRADUAL DECREASE and then a period of APNEA; also called *periodic respirations* *Apnea:* absence of breathing

Thorax & Lungs: Breasts

*Breasts* -Newborns: breasts can be ENLARGED during first few days -Children and Adolescents: nipples and areolas are darker pigmented and symmetric i. *Females:* breasts typically develop between 10 to 14 years of age. The breasts should appear asymmetric, have no masses, and be palpable ii. *Males:* can develop *gynecomastia* which is UNILATERAL or BILATERAL breast enlargement that occurs during puberty

Thorax & Lungs: Chest Shape and Movement

*Chest Shape* -Infants: shape is almost *circular w/ anteroposterior diameter EQUALING the transverse or lateral diameter* -Children and adolescents: the *transverse diameter to anteroposterior diameter changes to 2:1* *Movement* -symmetrical -Infants: *Irregular rhythms are common* -Children younger than 7: more *abdominal movement* is seen during respirations

External Ear

*Collects Sound* 1. The *Auricle (pinna)* is the outer visible portion of the ear made up of flexible cartilage and skin; *Sebaceous glands* are located on the surface; helps direct sound to the eardrum [*tympanic membrane*] Anatomical Structures of the *Auricle:* i. *Helix:* is the prominent outer rim of the auricle ii. *Tragus:* is the protuberance [bump] anterior to the auditory canal iii. *Lobule:* is the soft lobe on the bottle of the auricle 2. *Ear Canal:* is approximately 2.5 cm long and begins at the meatus of the auricle and ends at the tympanic membrane; hairs help to trap debris; has small glands in the skin that produce ear wax (cerumen) -*Cerumen:* cleans and lubricates the ear canal due to its slightly acidic nature and has bactericidal properties to protect the ear canal against foreign bodies

Nails

-pink over nail bed; white at the tips -smooth and firm [slightly flexible in infants]

Nose

-position should be MIDLINE -patency should be present for each nostril w/out excessive flaring -smell can be assessed in older children *Internal Structures:* -*septum:* midline and intact -*mucosa:* is deep pink and moist w/NO discharge

Assessing the Eye: Diagnostics

*Comprehensive Dilated Eye Exam:* is a painless procedure that allows the ophthalmologist or optometrist to examine the eyes and look directly and the retina and internal structures. During this exam, the pt has his/her eyes dilated w/ mydriatic eye drops. These drops are short-acting ciliary muscle paralytics that dilate the pupil. -if administered, mydriatic eye drops cause blurry vision and sensitivity to light. Sunglasses may be helpful when going outside in the sun. Pt should be instructed not to drive 1 to 2 hrs after administration. Pt will need to have someone drive them home. *Tonometry:* is a device to measure intraocular pressure (IOP); the device measures the outflow of the aqueous humor from the eye; screening test for *glaucoma* [: buildup of intraocular pressure that damages the eye's optic nerve causing loss of PERIPHERAL vision] *COMMON EYE DISEASES:* 1. *Cataracts:* are a clouding of the lens that causes blurry, decreased, or loss of vision 2. *Glaucoma:* buildup of intraocular pressure that damages the eye's optic nerve causing loss of PERIPHERAL vision 3. *Macular Degeneration:* is a deterioration of the CENTRAL part of the retina causing loss of CENTRAL vision - caused by the breakdown of cells in the macula of the retina

Corneal Light Reflex

*Corneal Light Reflex:* is a quick and simple way to check ocular alignment. This assessment is particularly useful for testing for *strabismus* [misalignment of the eyes] in newborns, young children, pt w/ poor vision, pt that are not able to fixate or track well - or in any situation where a full motility evaluation is not feasible. 1. Use a light source (penlight) and instruct pt to focus their gaze on your light source 2. From a distance of 2 feet, shine your light source equally into the pts eyes at midline 3. Observe the reflection of light off the cornea, which should appear as a pin-point white light near the center of the pupil in each eye -If there is NORMAL ALIGNMENT, the reflection will appear in the same position in each pupil. If there is misalignment of the eyes, the location of the corneal reflex will appear asymmetric and "off center" of the pupil in the deviated eye. The relative difference in the position of the reflex will be in the opposite direction as the eye deviation. For example, in an *esotropia* [where there is inward deviation of the eye], the light reflex will appear outwardly displaced from the center of the pupil; in a *hypertropia* [where there is an upward deviation of the eye], the light reflex will appear inferiorly displaced from the center of the pupil.

Assessing the Eye: Extraocular Structures

*Eyebrows and Eyelashes:* specialized hair protect the eye *Eyelids:* protect and lubricate the eyes -Small oil-producing glands line the inner edge keeping the eyes moist and clean -*Tarsal Plates:* firm lines of connective tissue within the eyelids that contain meibomian glands, which open on the lid margin and produce tear fluid -*Palpebral Fissure:* distance between the upper and lower lids *Conjunctiva:* thin membrane covering the front of the eye (bulbar conjunctiva) and inner eyelids (palpebral conjunctiva) -produces mucous to lubricate the eye -permits movement of the eyeball *Lacrimal Glands:* the tear ducts that continually release tears and protective fluids to clean, lubricate, and moisten the eyes -Lacrimal sacs are the small pumps that drain the tears or fluid. -Tears and fluid drain into the nasolacrimal duct into the nose keeping the nasal mucosa moist. -*Tear Fluid:* protects the conjunctiva and cornea from drying; produced from the meibomian gland, conjunctival gland, and lacrimal glands.

Mouth & Throat: Hard/Soft Palates, Uvula, Tonsils and Speech

*Hard and Soft Palates* -intact, firm, and CONCAVE *Uvula* -intact and moves w/ vocalization *Tonsils* -Infants: might not be able to visualize -Children: barely visible to prominent, same color as surrounding mucosa *Speech* -Infants: strong cry -Children and adolescents: clear and articulate

Temperature by Age

*INFANT* 3-6 Months: 37.5 [99.5 F] *TODDLER* 1 Year: 37.7 [99.9 F] 3 Years: 37.2 [99 F] *PRESCHOOLER* 5 Years: 37.0 [98.6 F] *SCHOOL-AGED* 7 Years: 36.8 [98.2 F] 9-11 Years: 36.7 [98.1 F] *ADOLESCENT* 13 Years: 36.6 [97.9 F]

Mouth & Throat: Lips, Gums, Mucous Membranes

*Lips* -darker pigmented than facial skin -smooth, soft, moist, and symmetric *Gums* -CORAL pink -tight against the teeth *Mucous Membranes* -w/out lesions -moist, pink, smooth, and glistening

Current Vision History: Visual Acuity, Visual Field, Far/Nearsightedness

*Loss of Visual Acuity:* refers to the inability to see objects clearly. Visual acuity is assessed by having the pt read letters from a chart at a distance of 20 ft. The most common chart is the *Snellen Chart* -*Snellen Chart:* chart consists of 11 rows of the following capital letters: CDEFLOPTZ. The block letters decrease in size w/ the largest letter on top and smallest letters at the bottom. Each eye is assessed separately and then both eyes are assessed uncovered. The result is documented in a *fraction*: the numerator is the distance the pt stands from the chart which should be 20 ft (children stand 10 ft). The denominator identifies the last line the pt read correctly. Normal vision is 20/20 [adults], meaning that the pt has the ability to see from a distance of 20 ft what a person of normal vision should see at this distance. *Loss of Visual Field:* refers to the inability to see from side to side or up and down without moving the eyes or turning the head. Loss of visual field results from damage, injury, disease, or tumor that completely or partially obstructs areas on the visual pathway causing partial loss of vision. The pt may express a blind spot in their field of vision. A *normal visual field* is approximately 160-170 degrees in the horizontal plane; pt who have a visual field of 20 degrees or less are considered legally blind. *Difficulty seeing/reading at a distance:* i. *Farsightedness (HYPEROPIA):* difficulty focusing on NEAR objects; visual image is focused behind the retina instead of on the retina. ii. *Nearsightedness (MYOPIA):* distant objects appear blurred bc the visual image becomes focused in front of the retina instead of on the retina.

Ears: External Ear

-should be free of lesions and nontender -the ear canal should be free of foreign bodies or discharge -cerumen is an expected finding

Head

-symmetric -fontanels should be flat: Posterior fontanel [triangle] usually closes by 6-8 WEEKS of age; Anterior fontanel [diamond] usually closes between 12 and 18 MONTHS of age

Face

-symmetric appearance and movement -proportional features

Inspecting the Thoracic Cage

*Normal Findings:* -*Transverse diameter* is approximately TWICE the *anteroposterior (AP) diameter*; AP to transverse ratio is approximately 1:2, and the costal angle is LESS than 90 degrees -*Conical shape:* smaller at the top and widens at the bottom -Normal adult respiratory rate (*eupnea*) is 12-20 breaths per minute; even and smooth respirations; *normal inspiratory-to-expiratory ratio (I:E) is 1:2*; the expiratory phase is LONGER than the inspiratory phase *Abnormal Findings:* *Barrel Chest:* anterior posterior to transverse ratio is 1:1, and costal angle is GREATER than 90 degrees; increase in the costal angle may be a sign of COPD *Pectus Excavatum (Funnel Chest):* a congenital deformity; sternum is abnormally depressed or sunken into chest *Pectus Carinatum (Pigeon Breast):* is a deformity of the chest; the sternum protrudes out from the chest *Intercostal and Accessory Muscle Retractions:* may indicate problems with air movement; prolonged inspiratory phase may indicate upper airway obstruction; prolonged expiratory phase may indicate lower airway obstruction *Pursed Lip Breathing:* is breathing through the nose and exhaling through pursed lips; commonly seen in pt w/ COPD to reduce the work of breathing *Clubbing of nail plates:* occurs w/ chronic lack of oxygen or hypoxia. The tips of the fingers and nails change in shape and size. -nail beds soften - seem to "float" instead of being firmly attached -nail forms a sharper angle w/ the cuticle greater than 180 degrees [normal angle of nail bed: 160 degrees] -last part of the finger may appear large or bulging, may also be warm and red -nail curves DOWNWARDS so it looks like the round part of an upside-down spoon

Auscultating the Lungs

*Normal Findings:* 1. *Bronchial Breath Sounds:* are heard over the trachea and larger bronchi; expiratory sounds are LOUDER and last LONGER than inspiratory sounds and have a pause between them -high-pitched, hollow, tubular breath sounds 2. *Bronchovesicular Sounds:* are heard over the right and left bronchi; anteriorly over the mid-chest and between the scapula posteriorly -medium pitched sounds 3. *Vesicular Sounds:* are heard throughout the periphery of the lungs; inspiration sound is LONGER and LOUDER than expiration -soft, low-pitched, rustling sounds *Abnormal Findings:* Adventitious Breath Sounds!!!

Inner Ear

*Passes Sound to the Brain* 1. *Inner ear, or Labyrinth,* is responsible for transmitting sound waves through the auditory nerve (CN VIII) to the brain; it contains the following: i. *Cochlea (organ of hearing):* serves as the microphone in the ear, converting sound impulses and vibrations from the outer ear into electric impulses that are sent to the brain via the *acoustic nerve (CN VIII); the organ of *Corti* is located in the cochlea and is the sensory organ of hearing. ii. *Three Semicircular Canals:* are located in the inner ear and assist in the perception of body position and maintenance of balance 2. *Cranial Nerve VIII:* brings sound and information about one's position and movement in space into the brain

Abnormal Physical Findings of the Eye

*Ptosis:* drooping of the eyelid caused by muscle or nerve dysfunction, injury or disease *Blepharitis:* is an inflammation and infection of the eyelid margins. The eyelid margin becomes red, crusty, and greasy due to too much oil being produced by the eye glands. *Blocked Lacrimal Duct:* causes excessive tearing bc tears cannot drain properly. *Cataracts:* is opacity of the lens caused by aging, long-term exposure to UV light, metabolic disorders, trauma or meds *Conjunctivitis:* is a bacterial or viral infection causing erythema of the sclera and yellow-green drainage of the conjunctiva *Corneal Abrasion:* is a painful scratch to the clear surface of the eye, usually r/t trauma to the eye *Ectropion:* is an EVERTED eyelid [turns outwards] *Entropion:* is an INVERTED eyelid [turns inward] *Exophthalmos:* is a protrusion [extend beyond or above a surface] of the anterior portion of the eyeball; common in hyperthyroidism; may cause pt to have dry eyes and difficulty closing the lids *Hordeolum:* a STYE, is an infection of a follicle of an eyelash that causes redness, inflammation, and a lump at the site *Scleral Jaundice (Icterus):* is a sign of elevated bilirubin in the blood; occurs w/ pt who have liver disease *Pterygium:* is a gelatinous, abnormal growth of the conjunctiva; occurs more commonly on the nasal side of the eye *Periorbital Edema:* is swelling in the tissues around the eye

Respiratory Assessment: Diagnostics

*Pulse Oximeter:* measures the oxygen saturation; this is the % of arterial hemoglobin saturated with oxygen; a pulse ox reading should normally be higher than 95% *Arterial Blood Gas (ABGs):* means measuring the levels of oxygen and carbon dioxide in the blood; sites are the radial, brachial, or femoral artery. The radial artery is the most common site. *Thoracentesis:* is insertion of a needle into the thoracic cavity; the test is performed for analysis or removal of fluid from the pleural space for diagnostic or therapeutic purposes *Bronchoscopy:* is a diagnostic or therapeutic procedure that provides direct visualization of the larynx, trachea, and bronchial tree. A fiberoptic bronchoscope w/ a light is inserted through the pts nose or mouth into the trachea or bronchi; this procedure is usually performed while the pt is anesthetized or under conscious sedation *Lung Biopsy:* removes a small piece of lung tissue for analysis; the tissue can be removed during a bronchoscopy, needle biopsy, or surgery *Mantoux Tuberculin Skin Test:* is the standard method of determining whether a person is infection with Mycobacterium tuberculosis. This test is performed by injecting 0.1 mL of tuberculin-purified protein derivative (PPD) under the top layer of skin usually on the forearm. The skin is assessmed for a reaction within 48 to 72 hours after administration.

Thorax & Lungs: Ribs and Sternum, Breath Sounds

*Ribs and Sternum* -more soft and flexible in infants; symmetrical and smooth, w/no protrusions or bulges *Breath Sounds* -*inspiration is LONGER and LOUDER than expirations* -VESICULAR, or soft, swishing sounds are heard over most of the lungs

Skin

-temp should be warm or slightly cool to the touch -skin texture: smooth and slightly dry, NOT OILY -skin turgor exhibits brink elasticity w/ adequate hydration -lesions NOT expected -skin folds SYMMETRICAL

Assessing the Eye: Intraocular Structures

*Sclera:* white AVASCULAR tissue that protects the eye and maintains the shape of the eye *Intraocular Muscles:* SIX small muscles connect to the sclera to control eye movements, secure the eyeball in the sockets, and allow sight in different directions i. *Medial Rectus:* moves the eye towards the nose ii. *Lateral Rectus:* moves the eye away from the nose iii. *Superior Rectus:* raises the eye iv. *Inferior Rectus:* lowers the eye v. *Superior Oblique:* rotates the eye vi. *Inferior Oblique:* rates the eye *Aqueous Humor:* water-like fluid that fills the anterior (space between cornea and iris) and posterior chambers (space between iris and front of the lens); helps to maintain the eyeball shape; a circulatory system assists to control the pressure within the eye *Choroid:* layer of blood vessels between the retina and sclera; supplies blood to the retina *Iris:* composed of connective tissue and smooth muscle; colored part of the eye; color originates from microscopic pigmented cells of melanin; muscles within the iris control pupillary SIZE allowing the pupil to contract and dilate and focus on near and distant objects *Lens:* transparent, biconVEX structure that refracts light to be focused on the retina; changes shape and thickness to be able to focus on objects *Pupil:* black part of the center of the eye; determines the amount of light that enters the eye; average diameter of 2 to 4mm in bright light and 4 to 8mm in the dark *Posterior Chamber:* space between the iris and the front of the lens; filled with aqueous humor that nourishes part of the eye *Cornea:* dome-shaped, AVASCULAR, transparent surface that covers the front part of the eye; covers the iris, pupil, and anterior chamber; allows light to enter and focus; considered to be the window of the eye; contains nerve endings responsible for tears, pain, and the blink reflex *Fundus:* posterior section of the eye that includes the retina, choroid, fovea, macula, optic disc, and retinal vessels *Macula:* yellow spot in the retina that is responsible for CENTRAL VISION; most sensitive area of the retina; *fovea* is the central indentation in the macula responsible for our highest visual acuity *Optic Disc:* bright spot on the retina where the optic nerve leaves the eye; optic nerve connects eye to the brain, has about 1.2 million nerve fibers *Retina:* multilayered, sensory portion that lines the back of the eye; contains millions of *photoreceptors* [rods and cones] that convert light rays into electrical impulses [central and peripheral vision] and transport these impulses to the optic nerve for interpretation in the brain; *vision loss through damage to the retina* *Retinal Blood Vessels - Arteries & Veins:* supply blood to the retina

Mouth & Throat: Tongue & Teeth

*Tongue* -Infants can have *white coating* on their tongues from MILK that can be easily removed. -*Oral Candidiasis* coating is not easily removed -Children and adolescents should have pink, symmetric tongues that they are able to move BEYOND their lips *Teeth* -Infants should have *6-8 teeth by 1 year of age* -Children and adolescents should have teeth that are white and smooth, and begin *replacing the 20 deciduous [temporary, baby teeth] teeth with 32 permanent teeth*

Middle Ear

*Transmits Sound* 1. The middle ear is an *air-filled chamber* behind the eardrum (tympanic membrane), which includes the *three smallest bones (ossicles)* in our body that transmit sound waves from the eardrum to the inner ear and the eustachian tube. The 3 Ossicles include: i. *Malleus:* has the manubrium, a long handle that attaches to the mobile portion of the tympanic membrane ii. *Incus:* acts like a bridge to connect the malleus and stapes iii. *Stapes:* is the smallest bone in the body 2. *Eustachian Tube:* connects the middle ear to the nasopharynx; equalizes ear pressure on each side of the tympanic membrane

Eyes: Internal Exam

-*Red Reflex* should be present in infants -Arteries, veins, optic discs, and maculae can be visualized in older children and adolescents

NOTES NEXT TIME:

-CV system -GI system -Reproductive/Genitalia (Tanners Stages) -Musculoskeletal system -Neuro system -infant reflexes (pg 10) -CN expected findings (pg 11) -Developmental stages -Lab Values

Eyes: Visual Acuity

-Can be difficult to assess in children younger than 3 years of age -Visual Acuity in INFANTS can be assessed by holding an object in front of the eyes are checking to see whether the infant is able to fix on the object and follow it -Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers -Older children (around 6 years old) should be tested using a Snellen Chart or Symbol Chart

Hair and Scalp

-Hair: evenly distributed, smooth, and strong -Manifestations of nutritional deficiencies: hair that is stringy, dull, brittle, and dry -Hair loss or balding spots on infants can indicate the child is spending too much time in same position -Scalp: clean and absent from any scaliness, infestations, and trauma -Assess children approaching adolescence for presence of secondary hair growth

Ears: Internal Ear

-In INFANTS & TODDLERS, pull the pinna DOWN and BACK to visualize the tympanic membrane -In children older than 3 years of age, pull the pinna UP and BACK to visualize -ear canal should be pink w/ fine hairs -tympanic membrane: pearly pink or gray -light reflex should be visible -*Umbo* (tip of the malleolus) and *Manubrium* (long process or handle) are the bony landmarks that should be visible

Eyes: Extraocular Movements - Six Cardinal Fields

-Might not be symmetric in NEWBORNS -*Corneal Light Reflex* should be symmetric -Cover/uncover test should demonstrate EQUAL movement of the eyes -Six Cardinal Fields of gaze should demonstrate NO nystagmus

Ears: Hearing

-Newborns should have intact *acoustic blink reflexes* to sudden sounds -Infants should turn towards sounds -Older children can be screened by *whispering a word* from behind the see whether they can identify the word

Neck

-SHORT in infants -no palpable masses -midline trachea -full ROM present whether assessed actively or passively

Eyes: Color Vision

-Should be assessed using the *Ishihara Color Test* or the *Hardy-Rand-Rittler Test* -The child should be able to correctly identify shapes, symbols, or numbers

General Appearance

-appears undistressed, clean, well-kept, and w/o body odors -*muscle tone*: erect head posture is expected in infants AFTER 4 MONTHS of age -Makes eye contact when addressed (except infants) -follows simple commands (age appropriate) -uses speech, language, and motor skills spontaneously

Expected Physical Assessment Findings

......

Adventitious Breath Sounds

1. *Crackles (rales):* produced by air passing over retained airway secretions or the sudden opening of collapsed airways -usually heard at the END of INSPIRATION but may be heard on inspiration or expiration -may be *cleared by coughing* -*Fine Crackles:* soft, high-pitched sounds; sounds like crunching or a fine rubbing sound -*Coarse Crackles:* are louder, low-pitched lung sounds; sounds like ripping open Velcro 2a. *Wheezes:* caused by narrowed passageways in the trachea-bronchial tree by secretions, inflammation, obstruction, or a foreign body -high-pitched, whistling or MUSICAL sound 2b. *Rhonchi (sonorous wheeze):* are louder, deeper, lower-pitched wheezes occuring in the UPPER BRONCHI; may be r/t obstruction of the larger airways; commonly heard during EXHALATION; sounds like snoring 3. *Pleural Friction Rub:* cause by inflammation of the parietal and visceral pleurae that normally slides w/o friction -deep loud, harsh, leathery sound -PAINFUL; pt may have shallow respirations 4. *Stridor:* heard loudest over the trachea during INSPIRATION; indicates UPPER AIRWAY narrowing or obstruction -Sign of respiratory distress! MEDICAL EMERGENCY!

Review of A&P: Lower Respiratory Tract

1. *Trachea:* (windpipe) is composed of rings of cartilage lined with *pseudostratified ciliated columnar epithelium* -Function of trachea: allowing air to flow into the bronchi of the lungs 2. *Bronchi:* there are 2 bronchi: the right and left main bronchi -*Right* bronchus is SHORTER, WIDER, and more VERTICAL than the left bronchus :Since the right bronchus is WIDER, objects are more easily aspirated into the right bronchus -*Left* bronchus is smaller is size but LONGER in length -Their function: to *warm and moisten air* as it moves in and out of the respiratory tract 3. *Bronchioles:* smaller branches of the bronchial tree -transitional airways that support gas exchange 4. *Alveoli:* smallest air sacs of the lungs made up of squamous cells -secrete *surfactant,* a substance that *reduces the surface tension and keeps the alveoli moist* -*Air is diffused* through small capillaries INTO arterial blood (EXTERNAL RESPIRATION) -*Gases* move across systemic capillaries; exchange of oxygen and carbon dioxide occurs at the cellular level (INTERNAL RESPIRATION) 5. *Lungs:* two cone-shaped, air filled structures -*Right* lung is larger and heavier, has 3 lobes divided by an oblique and horizontal fissure, and is about an inch shorter than the left lung -*Left* lung has 2 lobes divided by an oblique fissure and is longer and narrower than the right lung -They work with the heart to circulate oxygen throughout the body! 6. *Acid-Base Balance:* the lungs control the blood pH through the release of carbon dioxide from the lungs; carbon dioxide is a waste product of oxygen metabolism. -During each respiratory cycle, inhalation and exhalation, oxygen and carbon dioxide are exchanged at the alveoli tissue level; the lungs release carbon dioxide to maintain the acid-base balance -Changes in carbon dioxide influence the respiratory center in the brain by increasing or decreasing the respiratory rate to maintain the acid-base balance. 7. *Pleura:* a serous membrane that forms a two-layer protective lining around the lungs. There are 2 Types of pleurae: i. *Parietal Pleura:* lines and adheres to the thoracic wall; produces a serous fluid known as *pleural fluid* between the two pleurae to keep the area lubricated so the two layers can move easily ii. *Visceral Pleura:* covers the outer surface of the lungs; it secretes a serous fluid that also lubricates the pleural cavity to help keep the lungs expanded *Pleural Cavity:* is the area between the parietal and visceral layers that contains the pleural fluid. 8. *Thoracic Cage:* closed cavity consisting of bones, muscles, and cartilage of the thorax - protects internal organs and supports the upper body. -Consists of 7 pairs of ribs that form the anterior and lateral parts of the thorax and join DIRECTLY to the sternum; the cartilage of ribs 8, 9, and 10 articulates with the cartilage of rib 7, whereas the pairs of 11 and 12 are free floating and do not articulate anteriorly. *Mediastinum:* is the space in the chest between the sternum and the vertebral column that houses the heart, trachea, esophagus, thymus gland, and major blood vessels. It does NOT contain the lungs! -Muscles of the thoracic cage are the internal, external, and accessory costal muscles. -Accessory muscles of neck and chest assist the respiratory system in times of distress and during exercise; they respond from a command from the brain and nervous system 9. *Diaphragm:* a dome-shaped muscle that lies at the bottom of the chest cavity; it is the *principal muscle of respiration* - it separates the thoracic and abdominal cavities! -During INHALATION, the diaphragm CONTRACTS and the thoracic cage EXPANDS as air is drawn into the lungs, *decreasing the air pressure in the thoracic cavity;* during EXHALATION, the diaphragm RELAXES and air flow re-enters the thoracic cavity, thereby *increasing the air pressure in the thoracic cavity* -the *phrenic nerve* controls the diaphragm; it originates from *cranial nerves III-V* 10. *Landmarking the Thoracic Cage:* in performing any assessment, it is important to identify specific landmarks to help you reference your assessment findings. i. *Anterior Thorax* -clavicle -manubrium -sternum -xiphoid process -costal angle ii. *Posterior Thorax* -Vertebral Column :scapula, cervical vertebrae [C1-C7], thoracic vertebrae [T1-T12] iii. *Lobes of the Lungs* -Anterior lobes of the lung: RUL, *RML*, RLL, LUL, LLL -Posterior lobes of the lung: RUL, RLL, LUL, LLL

Internal Eye Exam: Advanced Assessments

Assessing the eyes with an *Ophthalmoscope* - a RN does not routinely assess the internal structures of the eye, but should know about why the assessment is performed. Purpose: to assess the internal structure of the eyes through a beam of light through the pupil that illuminates the internal structures of the eye -Rember to ask if the pt had eye surgery! Do not use the ophthalmoscope in the eye that had surgery bc the eye is sensitive, and this may cause damage to the eye *Red Reflex:* is a red reflection of light illuminating from the retina, the layer of tissue at the back of the inner eye. If you lose the reflection or cannot see this red reflection, try to reposition the ophthalmoscope. -Look through the aperture w/ your right eye and direct the light into the pts right pupil and try to find the red reflex, an *orange/red glow in the pupil*; assess for any opacities interrupting the red reflex *Assessing blood vessels and intraocular structures:* 1. *Optic Disc:* -Color: yellow/orange to creamy pink color -Shape: round or oval -Disc Outline: sharp [defined borders] or cloudy -*Central Physiologic Cup* (if present): slightly depressed, lighter in color [yellowish, whitish color] -*Cup-Disc Ratio:* cup is less than half of the optic disc's diameter 2. *Retinal Arteries, Veins, Background:* -*Arteries:* light red, progressively narrower as they move away from the optic disc -*Veins:* darker red, progressively narrower as they move away from the optic disc -*Background:* consistent uniform red-orange color 3. *Macula:* -Color: darker yellow, highly pigmented -Shape: oval to round *Abnormal Findings: Intraocular Structures* *Gunn's Sign:* an arteriole is crossing a venue and impedes circulation; this may be seen in pts w/ HTN *Cotton Wool Spots:* look like puffy white patches on the retina. They are caused by swelling of the surface of the retina, ischemia, and damaging nerve fibers; commonly seen in diabetic and HTN pts *Diabetic Retinopathy:* damage to the blood vessels of the retina; development of new vessels resulting from ischemia, lack of oxygen and poor circulation. This is common complication of diabetes which eventually may lead to blindness. *Drusen Bodies:* yellow deposits of normal cell metabolic by-products in the eye; seeing some drusen bodies is normal with aging; however, large amounts in the macula may be a sign of aging macular degeneration. *Papilledema:* optic disc swelling caused by increased intracranial pressure along the optic nerve. The optic disc appears swollen and loses its distinctive shape.

Assessing Central Vision

Equipment: *Amsler Grid* -Reading glasses should be worn during this assessment. Instruct pt to hold the Amsler grid at the same distance from the eyes as if he/she was reading. Have pt cover left eye. Instruct pt to focus on the dark dot in the center of the grid w/ the exposed eye. Ask if any of the lines are distorted, broken, or blurred. Ask if there are any missing areas or dark areas in the grid. Have pt cover left eye and repeat the test. Mark areas on the Amsler Grid that the pt is not seeing correctly. Abnormal Findings: -Lines look distorted, broken, or blurred *Macular Degeneration:* which is a breakdown of cells in the macula of the retina, causes loss of CENTRAL vision

Assessing Color Blindness

Equipment: *Ishihara Plates* -There are 24 plates to look at. Plates 1-17 each contain a number, plates 18-24 contain one or two wiggly lines. To pass each test you must identify the correct number or correctly trace the wiggly lines within 3 to 5 seconds. *Color blindness:* is a nerve cell dysfunction causing the eye to misinterpret colors; the most common colors affected are red, green, or blue; may be inherited or found in pts w/ suspected retinal or optic nerve disease

GROWTH

Evaluated using weight, length/height, body mass index (BMI), and head circumference.

Assessing the Ears

Hearing helps us to understand and function in the environment and assists us in communicating effectively. Hearing loss of impairment progresses SLOWLY and is a sensitive topic. Hearing loss may be inherited, caused by maternal rubella or complications at birth, certain infectious diseases such as meningitis, chronic ear infections, use of ototoxic drugs, exposure to excessive noise, and aging.

Temperature Recommended Routes

Less and 2 years: -Axillary -Rectal [if exact measurement necessary] 3 to 6 years: -Axillary -Tympanic -Oral [if child cooperative] -Rectal [if exact measurement necessary] 7 to 13 years: -Oral -Axillary -Tympanic

Developmental AGES

Neonate (0-1 mo [28 days]) Infants (1-12 mo) Toddlers (1-3 yrs) Preschoolers (3-6 yrs) School-age (6-12 yrs) Adolescent (13-18 yrs)

Respirations

Newborn to 1 year: 30-35/min 1 to 2 Years: 25-30/min 2 to 6 Years: 21-25/min 12 years +: 16-19/min

Pulse Rate

Newborns: 80-180/min 1 Week to 3 Months: 120-180/min 3 Months to 2 years: 70-150/min 2 to 10 Years: 60-110/min 10 years +: 50-90/min

Using Confrontation Test for Visual Field Testing (CN III, IV, and VI)

Purpose: to assess PERIPHERAL vision, overall field of vision, and for blind spots -instruct pt to say "now" when he/she can see your fingers and state how many fingers they can see. Cover YOUR right eye; the pt covers their left eye. Instruct pt to look directly w/ his/her right eye into your uncovered eye. Place your left hand w/ extended fingers behind the pt field of vision. Now, move your fingers toward the pts field of vision, stopping when the pt says "now" and states how many of your fingers they see in their peripheral field. Repeat assessing the field of vision from *FOUR different angles:* 1) Superiorly 2) Temporal 3)Nasal 4)Inferiorly - assess whether the pts peripheral vision corresponds w/ your visual fields. Cover opposite eye and repeat. *Normal Findings*: the pt sees your fingers at the same time as you do and correctly states the # of fingers seen. *Peripheral vision should be seen:* -Superiorly (50 degrees) -Temporal (90 degrees) -Nasal (60 degrees) -Inferiorly (70 degrees) *Abnormal Findings:* *Scotoma:* is an area of reduced or absent vision surrounded by an area of normal vision *Hemianopia:* is when half of the visual field is lost

Conducting the Weber Test

Purpose: to assess UNILATERAL hearing loss and functioning of the cochlear nerve (CN VIII). Equipment: 512 Hz tuning fork -Place the pt in sitting position. Hold the base of the 512 Hz tuning fork with one hand w/out touching the tines. Strike the tines on the back of your other hand to initiate the tines to vibrate. Place the base of the tuning fork on the *midline of the top of the pts head.* Ask the pt if she/he *hears the sound equally on both sides or point to the ear in which the sound is heard louder.* -To confirm results, strike the tines again on back of hand. Ask the pt to hold a hand over the right ear, then after a couple seconds have the person hold a hand over the left ear. Ask pt if she/he hears the sound louder in the left or right ear *Normal Findings:* tuning fork sounds vibrate through the bones and the sound quality is heard EQUALLY in BOTH ears. *Abnormal Findings:* -The bad ear seems to be *softer*; the damage is probably *sensorineural hearing loss* -The bad ear seems to be *louder*; the damage is probably *conductive hearing loss* -If the sound seems *equally dull*, the Weber test is *inconclusive* *The Weber test should ALWAYS be accompanied by the Rinne test to screen for hearing loss!*

Inspecting the Ears

Purpose: to assess for ear deformities *Normal Findings:* -Equal size and shape bilaterally; normal size (4 to 10 cm) -Color same as facial skin -Symmetrical -landmarks: *Darwin's Tubercle:* is a congenital deviation that is a small cartilaginous protuberance on the helix of the ear -Angle of attachment less than 10 degrees : assess angle of attachment by 1) drawing an imaginary line from the external canthus of the eye to the top of the helix, 2) drawing an imaginary line perpendicular [straight line at an angle of 90 degrees to a given surface], 3) assess angle of attachment -No deformities, inflammation, nodules, or drainage *Abnormal Findings:* -Asymmetrical -Lesions -Cysts -Drainage :SAFETY ALERT: bloody or clear drainage may be r/t a perforated [pierce and make hole(s)] eardrum or head injury -Color is blue, red, white, or pale *Cauliflower Ear:* occurs from repeated trauma or hitting the ear; a blood clot forms under the skin or there is damage to the cartilage that isn't drained properly causing a change in shape and structure of the ear [cartilage in the outer ear overgrows, resulting in a bulbous deformity on the ear]; commonly seen in westlers or individuals who play contact sports *Microtia:* is a congenital deformity; the pinna is underdeveloped or incompletely formed; may involve one or both ears; less than 4 cm (approx. 1.5 inches) in vertical height in adults *Macrotia:* is abnormally large ears; greater than 10 cm (approx. 4 inches) vertical height in adults *Tophi:* are hard, whitish, or cream-colored, nontender deposits of uric acid crystals indicative of gout

Conducting the Whispered Voice Test

Purpose: to assess for impaired or high-frequency hearing loss -stand behind pt about 2 ft away (so you cannot be seen). ask the pt to cover the right year that you are NOT testing. Whisper six random letter/numbers towards the left ear. Have pt repeat what was heard. If pt responds incorrectly, repeat the test using different number/letters. Repeat test on right side. *Normal Findings:* pt repeats at least three of the six correctly

Assessing Hearing (CN VIII)

Purpose: to assess for impaired or loss of hearing Tests to assess hearing are SUBJECTIVE bc you are relying on the pts response to what he/she says is heard. The tests will only screen for hearing loss. There are *3 types of hearing loss*: 1. *Conductive Hearing Loss:* which is also considered *middle ear hearing loss,* is when sound is not conducted through the outer ear canal to the eardrum and the ossicles of the middle ear; involves a reduction in sound level or the ability to hear faint sounds -*Wax impaction* is the most common cause of conductive hearing loss 2. *Sensorineural Hearing Loss:* which is considered *inner ear hearing loss,* occurs when there is damage to the inner ear [cochlea], or to the nerve pathways from the inner ear to the brain; speech may sound unclear or muffles; most common type of permanent hearing loss 3. *Mixed Hearing Loss:* includes both conductive and sensorineural hearing loss

Conducting the Rinne Test

Purpose: to assess hearing by bone conduction versus air conduction and middle ear disease -TIP: the Rinne test is more accurate if conductive hearing loss is suspected Equipment: 512 Hertz tuning fork, watch w/ second hand -Place pt in sitting position. Strike the tines on the back of your other hand to initiate the tines to vibrate. Gently place the tuning fork on the *mastoid bone,* about 1 inch from the left ear; tell the pt to say "now" when he/she NO LONGER hears the vibration sound. Time how many seconds the vibrations are heard by the pt. Move the tuning fork *perpendicular to the pts left ear canal*; tell the pt to say "now" when he/she NO LONGER hears the vibrations. Time how many seconds the vibrations are heard by pt. Repeat on the right side. -*Instruct pt to tell you if she hears better w/ the tuning fork on the mastoid bone or next to the ear!* *Normal Findings:* *Positive Rinne:* air conduction (AC) is heard TWICE as long as bone conduction (BC) - (AC > BC) *Abnormal Findings:* *Negative Rinne:* bone conduction is heard longer than air conduction (BC > AC) and is indicative of *conductive hearing loss*

Testing for Convergence and Accommodation (CN II and CN III)

Purpose: to assess the accommodation reflex of the eye Equipment: penlight (optional) -hold a penlight or your finger in front of the pts eyes about 14 inches in front of his/her nose. Instruct pt to focus on your finger/object for 30 seconds. Instruct the pt to follow your finger/object as you move it towards their nose. Assess for convergence [the simultaneous inward movement of both eyes toward each other, usually in an effort to maintain single binocular vision when viewing and object: cross-eyed] and pupil size [pupils should CONSTRICT] *Normal Findings:* both eyes converge and both pupils constrict (accommodation) simultaneously to focus on a near object *Abnormal Findings:* pupils do not converge or constrict

Assessing the Ears w/ Otoscope: Advanced Assessments

Purpose: to assess the external auditory canal, middle ear, and eardrum Equipment: Otoscope 1. Turn the light on for the otoscope and choose the largest and shortest speculum that fits comfortably in the pts ear canal. 2. Ask pt to sit up straight w/ head tilted to the left side 3. Hold otoscope in dominant hand w the handle either up or down 4. With other hand, use your fingers to grasp the right auricle and gently lift the auricle UP and BACK to clearly visualize the external auditory canal [adults] -For CHILDREN, pull auricle DOWN and BACK 5. Gently insert the speculum into the outer third (about 1/2 inch) of the ear canal 6. Look through the magnifying lens to assess the: i. external ear canal ii. tympanic membrane iii. portions of the malleus (dense, whitish streak) assessed through the translucent tympanic membrane iv. *umbo* (the central depressed portion of the concavity on the lateral surface of the tympanic membrane) v. *cone of light* (a triangular reflection when the light is focused on the malleus) *Normal Findings:* -external ear canal patent -no inflammation/drainage -small amounts of yellow, moist wax -tympanic membrane intact, *pearly gray color; translucent; contour slightly conical* -bony landmarks visible -*cone of light present* : you will see the cone of light in the anterior, inferior quadrant at the 7 o'clock location in the left ear and 5 o'clock location in the right ear *Abnormal Findings:* *Earwax (Cerumen):* is a moist or dry, waxy substance that acts to protect the skin of the external ear canal from water damage, infection, trauma, and foreign bodies; usually asymptomatic but LARGE amounts of IMPACTED wax can cause *conductive hearing loss* and ear discomfort *Otitis Externa:* inflammation of the outer ear causing redness, inflammation, discharge, and pain; may be r/t infection or swimmer's ear *Otitis Media:* inflammation of the inner ear causing pain, inflammation, pressure, and a build-up of fluid; bright, red bulging eardrum w/ diminished or no cone of light visible *Serous Otitis Media:* is an accumulation of fluid in the middle ear caused by an obstruction of the eustachian tube; tympanic membrane will appear to be yellowish color, with air bubbles, and bulging *Otomycosis:* is a fungal infection of the external auditory canal; black and white dots will be present on the eardrum or external canal *Scarred Tympanic Membrane:* has less blood supply and appears to have white, dense, streaks and spotting; the individual may have had many ear infections during childhood *Perforated Tympanic Membrane:* is a ruptured tympanic membrane; a dark oval, hole will be present in the membrane TIP: *Otalgia* (ear pain) and *Otorrhea* (ear drainage) are the most common individual complaints in which individuals seek medical care for the ears.

Testing for Ocular Motility: Six Cardinal Positions of Gaze (CN III, IV, VI)

Purpose: to assess the function of the ocular muscles Equipment: penlight (optional) -Use your finger or use penlight about 12 to 14 inches from pt face. Instruct pt not to move head but to follow your finger/penlight with just the eyes. If the pt is unable to follow w/out moving head, gently hold the pt head in place. Move the object in six different positions using a wide "H" or "star" pattern to assess the six cardinal positions. Pausing in between changing positions allows you to watch for any involuntary movements of the eye. *Normal Findings:* the eyes have a normal pattern of movement in each of the six cardinal directions. Mild nystagmus in the lateral angles is normal. *Abnormal Findings:* pt is not able to follow the pattern of movement in each of the six cardinal directions may indicate ocular muscle weakness; pt may experience double vision [diplopia] or uncontrolled eye movements. *Diplopia:* is a subjective complaint that may be r/t a muscular dysfunction of the eye or neurological problem *Nystagmus:* is an involuntary, cyclical movement of the eyes; occurs when the pt gazes or follows an object; may also occur if the pt has a fixed gaze in the peripheral field; may indicate a neurological disorder

Inspecting Pupil Size and Consensual Pupil Response (CN II and CN III) - PERRLA

Purpose: to assess the pupillary light reflex that controls the diameter of the pupil, and to assess the integrity of the optic pathways [consensual pupil response] Equipment: penlight and pupil-size measurement chart -stand in front of pt. Use penlight to inspect pupils. Assess color, shape of each pupil, symmetry. Assess direct reaction - shine light into the right eye pupil. Assess consensual reaction - put your nondominant hand between the pts two eyes. Shine light into the left eye pupil and assess the right eye; right eye should constrict and have *consensual response* [this response is a REFLEX - Normally light that is directed in one eye produces pupil constriction in both eyes. The consensual response is the change in pupil size in the eye opposite to the eye to which the light is directed] . Repeat test in left eye. *Measure the size of each pupil in millimeters (mm)!* *Normal Findings:* -Pupils constrict in response to light -Both eyes have a consensual response on constricting to direct light -Pupil is round and black -Both pupils are equal size -Pupil diameter is 2 to 8 mm *Abnormal Findings:* -Pupils are unequal in size or both dilated or constricted and fixed *Anisocoria:* is unequal size of the pupils; may be genetics, medications, or r/t a neurological disorder *Mydriasis:* is bilateral dilated and fixed pupils; may be caused by eye drops, stimulation of sympathetic nerves, anesthesia, or CNS injury *Miosis:* is an abnormal constriction of the pupils; may be caused by stroke, medications, or brain damage *Horner Syndrome:* is a sign of a medical condition that affects one side of the face; drooping eyelid, constricted pupil (miosis)

Blood Pressure

Refer to ATI book

Eyes: Peripheral Visual Fields

Should be... -Upward (superiorly): 50 degrees -Downward (inferiorly): 70 degrees -Nasally: 60 degrees -Temporally: 90 degrees

Assessing for Visual Acuity (CN II): Abnormal Findings

Snellen Chart: a higher denominator means POORER distant visual acuity *Nearsightedness (MYOPIA):* is poor visual acuity; distant objects appear blurred bc the images are focused in front of the retina rather that on it. The denominator is greater than 20. *Farsightedness (HYPEROPIA):* is the ability to see distant objects clearly, but objects nearby may be blurry *Presbyopia:* is the inability to focus clearly on near objects; the pt holds the print farther away to focus; magnifying glasses are used to read *Legal Blindness:* is visual acuity of 20/200 or more; this means that the pt standing at 20 ft can see what a pt with normal vision can see at 200 ft or a visual field diameter of less than 20 degrees; these pt can only see straight in front of them

Ears: Sound

Sound is described in terms of: i. *Frequency:* the pitch of sound, measured in Hertz (Hz) ii. *Intensity:* the loudness of sound, measured in decibels (dB)

Special Considerations: PEDIATRIC Ear Assessment

TIP: it may be helpful to demonstrate examining the parent's ear first Examining the INTERNAL structure of the ear of a young child can be challenging bc the child cannot observe the procedure. Position the child in one of two ways: 1. Place the child in the supine position and, if needed, have the parent restrain the arms 2. Have the child sit in the parents lap facing front or sideways so the nurse can assess the inner ear Older children are likely to cooperate and should not need restraint. In children LESS than 3 years old, the external auditory canal is directed upward. Therefore, *pull the pinna DOWN and BACK* to straighten the canal for best view. In children OLDER than 3 years old, *pull the pinna UPWARD and BACKWARD* to straighten the canal for best view. If examining a painful ear, examine the unaffected ear FIRST!

Special Considerations: PEDIATRIC EYE ASSESSMENT

Testing *1) Visual Acuity* [Snellen, Tumbling E, HOTV] and *2) Color Blindness* [Ishihara Plates] Test visual acuity beginning between ages 3 to 4 years old. For children unable to read letters (Snellen Chart), the tumbling E or HOTV test is useful. -The *tumbling E* uses the capital letter E pointing in four different directions. The child, 3 to 5 years old, is standing 10 ft from the chart and is asked to point in the direction the E is facing. -The *HOTV test* consists of a wall chart with the letters H, O, T, V. The child, 3 to 5 years old, stands 10 ft from the chart and is given a board to hold containing the same letters. The examiner points to a letter on the wall chart and the child matches the letter on the board they are holding. -The *Snellen Chart* is used for children 6 years and older. -If the child wears glasses, the glasses should be worn during the vision assessment. Reading glasses should NOT be worn. Document if child has worn glasses during the assessment. In all tests for visual acuity it is important that BOTH eyes show the same results; otherwise, refer to an ophthalmologist for further testing.

Review of A&P: Upper Respiratory Tract

The Upper Respiratory Tract includes the *nose and oropharynx* 1. *Nose:* the respiratory cycle begins are air enters through the nostrils. -air moves through the nasal cavity where it *warms, humidifies, and is filtered* 2. *Oropharynx:* this is the passageway between nose, sinuses, larynx, and trachea. -the *larynx* contains the VOICE BOX and VOCAL CORDS; cartilage in the front of the larynx is called the Adam's apple -Major roles are *speech, breathing, and the ability to talk*; its closing mechanism PREVENTS ASPIRATION of liquids and solids during swallowing -No air exchange occurs in the oropharynx

Assessing the Respiratory System

The average adult takes 12 to 20 breaths per minute. Lungs mature by age 25 and after age 35 lung function begins to decline. The major function of the lungs is GAS EXCHANGE and the delivery of oxygen to all parts of the body. Total lung capacity is about *6 liters*

Eyes: Conjunctiva

The conjunctiva is the clear, thin membrane that covers part of the front surface of the eye and the inner surface of the eyelids. It has two segments: Bulbar conjunctiva. This portion of the conjunctiva covers the anterior part of the sclera (the "white" of the eye). The bulbar conjunctiva stops at the junction between the sclera and cornea; it does not cover the cornea. Palpebral conjunctiva. This portion covers the inner surface of both the upper and lower eyelids. (Another term for the palpebral conjunctiva is tarsal conjunctiva.) The bulbar and palpebral conjunctiva are continuous (see illustration). This feature makes it impossible for a contact lens (or anything else) to get lost behind your eye. -Palpebral is PINK -Bulbar is TRANSPARENT

Review of A&P of the Ears

The ear is the sensory organ that identifies and interprets sounds. It also has a role in *maintaining equilibrium and body position.* There are 3 parts to the ear: 1. *External Ear* [collects sound] 2. *Middle Ear* [transmits sound] 3. *Inner Ear* [passes sound to the brain]

Review of A&P of the Eye

Three cranial nerves control motor nerve activity of the eye: i. Cranial Nerve III: Oculomotor ii. Cranial Nerve IV: Trochlear iii. Cranial Nerve VI: Abducens Visual perception occurs as light waves travel through the conear, anterior chamber, pupil, lens, and posterior chamber to the central fovea of the macula and are transformed into nerve impulses. -These impulses continue to travel through the optic nerve to the brain for interpretation of images -The entire visual field is now interpreted and seen by the eye. -Eyes and brain are influenced by the parasympathetic and sympathetic NS -Eyes INVERT images; the left side of what we see ends up in the right side of our brain, and vice versa. Optic pathways carry impulses from the retina to the occipital cortex; any damage on this pathway will cause a visual defect.

Eyes: Eyebrows

symmetric and evenly distributed from the inner to outer canthus

Ears: Alignment

the TOP of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye

Eyes: Lacrimal Apparatus

w/o excessive tearing, redness, or discharge