Assessing the Eyes and Ears 眼、耳評估
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. 檢查職業史及眼鏡、隱形眼鏡、助聽器和藥物使用情況。
Use Standard Protocol. 采用標準護理程序
Test visual acuity: 視敏度測試
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紙，注意受檢者看報時眼睛與報紙的距離。
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. 視野測試
A. Have client sit or stand 60 cm （2 feet） away and face you. Your
eyes should be at eye level of client. 病人面對檢查者坐或站于60 cm處。檢查者兩眼與受檢者兩眼同高。
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. 檢查者手臂前伸至與受檢者距離中間處，移動手臂并不斷擺動手指。
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 眼外運動測試
A. Instruct client to look straight ahead toward you, keeping head
motionless throughout examination. 囑病人直視檢查者，檢查時頭部保持不動。
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。
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. 手指保持在正常視野范圍內。
E. Observe parallel eye movement, position of upper lid in relation to
iris, and presence of nystagmus. 觀察眼睛平行運動、上眼瞼與虹膜對比位置和眼震。
Test pupillary reflexes 瞳孔反射測試
A. Dim room lights to test reaction to light. 關暗燈光測試對光反應。
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. 觀察雙眼瞳孔反應。
D. Note corneal light reflex. 注意角膜對光反射。
E. Defects along inner margins of the iris may be from surgical
correction for glaucoma. 青光眼手術矯正可以引起虹膜內緣缺陷。
Test accommodation. 調節能力測試
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. 囑受檢者看遠處墻壁?？燜俳種敢浦潦薌煺弒喬?0-15 cm處，要求受檢者看手指。
B. Move finger smoothly toward nasal bridge; watch for pupil
constriction and convergence. 手指平穩地向鼻柱移動，觀察瞳孔收縮會聚。
Assess external eye. 外眼評估
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. 檢查結膜顏色、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。。
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、形狀和對等。檢查虹膜否對稱。
Examine external ear. 檢查外耳
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. 觸碰耳廓檢查質地、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。
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。
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間。
Assess hearing acuity. 評估聽敏度
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。
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，輕柔地說出一串數字，音節間重音相等。
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. 采用護理完成程序
Compare findings with client's baseline and normal expected findings.
Identify Unexpected Outcomes and Nursing Intervention Record and
Assessment findings. 評估所見
Description of abnormalities. 異常說明
Abnormal findings （report to physician）. 異常結果（報告醫生）