Assisting in Ophthalmology
and Otolaryngology
Chapter 37
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
1
Learning Objectives
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Define, spell, and pronounce the terms listed
in the vocabulary.
Apply critical thinking skills in performing
patient assessment and care.
Explain the differences among an
ophthalmologist, optometrist, and optician.
Identify the anatomic structures of the eye.
Describe how vision occurs.
Differentiate among the major types of
refractive errors.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
2
Learning Objectives
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Summarize typical disorders of the eye.
Define the various diagnostic procedures for
the eye.
Conduct a vision acuity test using the Snellen
chart.
Assess color acuity.
Illustrate the purpose of eye irrigations and the
instillation of medication.
Properly irrigate a patient’s eyes.
Accurately instill eye medication.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
3
Learning Objectives
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Identify the structures and explain the functions
of the external, middle, and internal ear.
Describe the conditions that can lead to hearing
loss, including conductive, neurogenic, and
congenital hearing losses.
Define the major disorders of the ear, including
otitis, impacted cerumen, and Ménière’s
disease.
Explain the various otic diagnostic procedures.
Accurately measure the hearing acuity of a
patient by using an audiometer.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
4
Learning Objectives
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Identify the purpose of ear irrigations and
instillation of ear medication.
Demonstrate ear irrigations.
Accurately instill otic drops.
Summarize the nose and throat examination.
Perform a throat culture.
Describe the effect of sensory loss on patient
education.
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5
Examination of the Eye
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The ophthalmologist is a medical physician
specializing in the diagnosis and treatment of
the eye.
The optometrist examines and treats visual
defects.
An optician fills prescriptions for corrective
lenses.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
6
Anatomy and Physiology of the Eye
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The anatomy of the eye begins with the outer
covering, the conjunctiva, and the three layers of
tissue: sclera, choroid, and retina.
The retina in the inner layer of the eye is where
light rays are converted into nervous energy for
interpretation by the brain.
The lens is a transparent body that helps focus
light after it passes through the cornea.
The posterior cavity contains vitreous humor and
the anterior cavity contains aqueous humor.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
7
Anatomy and Physiology of the Eye
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
8
Vision
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Vision begins with the passage of light through the
cornea, where it is refracted and then passes
through the aqueous humor and pupil into the lens.
The ciliary muscle adjusts the curvature of the lens
to refract the light rays so they pass into the retina,
triggering the photoreceptor cells of the rods and
cones.
Light energy is then converted into an electrical
impulse, which is sent through the optic nerve to
the brain, where interpretation occurs.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
9
Disorders of the Eye
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Refractive errors:
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Hyperopia
Myopia
Presbyopia
Astigmatism
All are caused by a problem with bending light
so it can be accurately focused on the retina.
They are usually caused by defects in the
shape of the eyeball and can be corrected with
glasses, contact lenses, or surgery.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
10
Refractive Errors
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11
Signs and Symptoms of Refractive
Errors
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Squinting
Frequent rubbing of the eyes
Headaches
Blurring of vision and/or fading of words at
reading level
Some refractive errors are familial in nature
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12
Treatment of Refractive Errors
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Eyeglasses and contact lenses
Photorefractive Keratectomy (PRK)
Laser-Assisted In-Situ Keratomileusis (LASIK)
Laser-Assisted Epithelial Keratomileusis
(LASEK)
Conductive Keratoplasty (CK)
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13
Surgical Corrections of Refractive
Errors
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Photorefractive Keratectomy – laser reshapes
the central cornea; procedure replaced by LASIK.
Laser-Assisted In-Situ Keratomileusis –
excimer laser reshapes the central cornea
Laser-Assisted Epithelium Keratomileusis –
softens the eye’s surface with an alcohol
solution, allowing the epithelial layer to be rolled
back and cornea to be seen; laser is used to
reshape the cornea
Conductive Keratoplasty (CK) – laser heat is
applied to the cornea’s outer edge so it tightens
and makes the cornea steeper
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14
Disorders
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Strabismus—eyes do not track together
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Amblyopia
Nystagmus
Infections of the eye:
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Hordeolum
Chalazions
Keratitis
Conjunctivitis
Blepharitis
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15
Corneal Abrasions
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Symptoms include pain, inflammation, tearing,
photophobia
Caused by trauma or foreign body in eye
Diagnosed – physician applies fluorescein stain to
eye, uses a cobalt-blue filtered light to visualize the
abrasions, which will appear green
Treatment – antibiotic ophthalmic ointment to
prevent infection, topical nonsteroidal
antiinflammatory (NSAID) ophthalmic ointments
such as diclofenac (Voltaren) and ketorolac
(Acular) as well as oral analgesics
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16
Cataracts
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Cataracts – opaque changes in the lens;
cause blurred, less acute vision. Diagnosis
made with a slit lamp
Treatment – outpatient surgical removal of
lens and placement of artificial lens
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Extracapsular extraction removes cataract in one
piece
 Phacoemulsification – ultrasonic probe breaks up
cataract and then pieces are aspirated
 Artificial intraocular lens (IOL) is implanted
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17
Glaucoma
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Aqueous humor builds up, increasing
intraocular pressure and decreasing blood
supply to retina and optic nerve
Signs and symptoms – frequent need to
change eyeglass prescriptions, loss of
peripheral vision, mild headaches, and
impaired adaptation to the dark
Diagnosis – tonometer and eye examination
Treatment – miotic drops, beta-blockers, or
laser surgery
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18
Macular Degeneration
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Macula lutea is part of the retina and defines
the center of the field of vision
Progressive deterioration of macula lutea
causes progressive loss of central vision
Age-related; no cure
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antioxidants including carotene, selenium, zinc,
and vitamins C and E may prevent the condition or
slow its progress
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19
Diagnostic Procedures
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Diagnostic procedures for the eye begin with
examination of the eye with an ophthalmoscope.
Next the eyelids are examined for abnormalities.
Pupils are assessed for PERRLA:
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Pupils equal round and reactive to light and
accommodation
More advanced techniques include the use of a
slit lamp to view the fine details of the eye and the
exophthalmometer to measure the pressure in the
central renal artery.
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20
Diagnostic Procedures: Slit Lamp
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21
Distance Visual Acuity
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Distance visual acuity is typically assessed
using a Snellen chart.
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May use E chart, pediatric picture chart, or alphabet
chart
 Patient stands 20 feet from chart at eye level
 Eyes tested with corrective lenses worn
 Record results as fraction with 20 feet on top
 Both eyes remain open during the examination; no
squinting or straining
 Abbreviations: OD (right), OS (left), OU (both)
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22
Types of Snellen Charts
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23
Critical Thinking Application
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Susie Anthony, a 19-year-old patient, is seen
today for a general eye examination. The
physician orders a routine Snellen test, and
Kim administers it. Susie wears contacts and
with the right eye reads without errors to the
20/25 line but squints and makes three errors
at the 20/20 line. With the left eye Susie
makes two mistakes at the 20/30 line. How
should Kim document this procedure?
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24
Vision Screening
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Near visual acuity is tested with a near-vision
acuity chart; size of type varies.
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Helps with diagnosis of presbyopia
 Give in well-lit room, with patient holding card
14 to 16 inches away
 Given in each eye; monitor patient for squinting or
straining
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The Ishihara test assesses color vision defects.
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Usually inherited by son from mother
 Test detects total colorblindness as well as
red-green blindness that occurs with genetic type
 Patient shown colored dots in numeric patterns;
requires sunlight
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25
Treatment Procedures: Irrigations
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Eye irrigations relieve inflammation, remove
drainage, dilute chemicals, or wash away
foreign bodies.
Sterile technique and equipment must be used
to avoid contamination.
Pour solution from inner canthus out, with head
tilted toward the affected eye.
Procedure 37-3
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26
Eye Irrigation
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27
Ophthalmic Medication Procedures
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Medication may be instilled into the eye for
treatment of an infection, to soothe an eye
irritation, to anesthetize the eye, or to dilate the
pupils before examination or treatment.
Eye drops—do not touch anything with applicator;
insert into lower conjunctival sac while patient
looks up.
Eye ung—sterile procedure; apply thin ribbon of
medication in lower conjunctival sac.
Patient should gently close eye after application
and rotate eyeball to disperse medication.
Refer to Table 37-2
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28
Asepsis and Ophthalmic Medications
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A major concern in ophthalmologic procedures is
the contamination of eye medication applicators
Use of stock ophthalmic medications is
discouraged
Sterility of eye medications is critical
Newly opened sterile solutions should be used
for each patient and either disposed of after
instillation or given to the patient for home use
All instruments used for the removal of a foreign
body in the eye should be sterile
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29
Examination of the Ear
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Otorhinolaryngology
Usually the specialty otorhinolaryngology
is referred to simply as ear, nose, and
throat (ENT).
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30
Anatomy and Physiology of the Ear
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The external ear consists of the auricle or pinna and
the external auditory canal, which transmits sound
waves to the tympanic membrane.
The middle ear is an air-filled cavity that contains the
ossicles (malleus, incus, stapes). The sound vibration
passes through the tympanic membrane, causing the
ossicles to vibrate. This bone-conducted vibration
passes through the oval window into the inner ear.
The organ of Corti in the cochlea of the inner ear
converts the sound waves into nervous energy that is
sent to the brain for interpretation. The semicircular
canals in the inner ear maintain equilibrium.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
31
Anatomy of the Ear
Modified from Jarvis C: Physical examination and health assessment, ed 4, Philadelphia, 2004, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
32
Disorders of the Ear
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Conductive hearing loss originates in the external or
middle ear; prevents sound vibrations from passing
through the external auditory canal, limits vibration of
the tympanic membrane, or interferes with passage of
bone-conducted sound in the middle ear.
Patient can benefit from a hearing aid.
Caused by
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impacted cerumen
 trauma to tympanic membrane
 otosclerosis
 chronic otitis media
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33
Disorders of the Ear
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Sensorineural hearing loss – results from damage
to the organ of Corti or the auditory nerve;
prevents sound vibration from becoming nervous
stimuli that can be interpreted by the brain as
sound.
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Caused by rubella in utero, influenza, head trauma,
ototoxic medications, prolonged exposure to loud noise
Presbycusis – hearing loss that affects aging
people, is caused by a reduced number of receptor
cells in the organ of Corti
Tinnitus – ringing in the ears
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34
Causes of Deafness
From Damijanov I: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
35
Disorders of the Ear
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Otitis externa
 Affects the external ear canal and is called
otitis externa, or swimmer's ear
 Caused by bacterial or fungal infection,
psoriasis, trauma to the canal
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36
Disorders of the Ear
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Otitis media—inflammation of the normally
air-filled middle ear, resulting in a collection of
fluid behind the tympanic membrane (TM).
Otitis media:
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Serous—buildup of clear fluid with full feeling and
hearing loss
Suppurative—purulent fluid with fever, pain, hearing
loss; caused by URI or allergic reaction
Diagnosed with otoscopy—pearly gray TM is inflamed
and bulging
Tympanogram—determines air pressure of middle ear
and mobility of TM
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37
Diagnosis and Treatment of Otitis
Media
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Otoscopic examination – TM inflamed and
bulging; fluid or pus may be visible through the
membrane
Tympanogram – determine the air pressure of
the middle ear and mobility of the tympanic
membrane
Antibiotics, analgesics, and decongestant
prescribed
Myringotomy – done to treat chronic otitis media
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surgical incision in the tympanic membrane to drain the
fluid
 insert tympanostomy tube to continually drain the
middle ear of fluid.
 may help prevent permanent hearing loss because of
damage to the ossicles
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38
Recommendations for Treatment of
Otitis Media
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Delay treatment with antibiotics for 24–72 hours; if
no improvement prescribe an appropriate antibiotic
Complete medication as ordered to prevent
infection from recurring
May treat otitis media with a short course of
antibiotics—5 days—but with a higher dose
Antibiotics will not help if otitis is caused by a virus
Parental education important – why antibiotic
therapy may not be recommended; importance of
administering antibiotic as ordered
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39
Ear Inflammations
From Damijanov I: Pathology for the health-related professions, ed 3, Philadelphia, 2006, Saunders.
Copyright © 2011, 2007, 2003, 1999 by Saunders, an imprint of Elsevier Inc. All rights reserved.
40
Disorders of the Ear
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Impacted cerumen
An excessive secretion of cerumen can gradually
cause hearing loss, tinnitus, a feeling of fullness,
and otalgia (ear pain).
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Cerumen pushed tightly up against the eardrum;
frequent cause of conductive hearing loss
Individuals with psoriasis, abnormally narrow ear
canals, or an excessive amount of hair growing
within the ear canals are more prone to this
condition.
Treated with ear irrigation.
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41
Disorders of the Ear
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Ménière’s disease is a chronic, progressive
condition that affects the labyrinth and causes
recurring attacks of vertigo, tinnitus, a
sensation of pressure in the affected ear, and
advancing hearing loss.
Treatment—salt-restricted diet, medications for
nausea and vomiting, diuretics, antihistamines
Can result in permanent deafness
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42
Interview Questions for Ear Problems
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Are you experiencing nausea, vomiting, vertigo, otalgia,
fever, headache, upper respiratory infection, tinnitus,
drainage, loss of balance, or hearing loss?
What are the onset, duration, and frequency of
symptoms?
Have you taken any medication for the symptoms?
What? Has it been helpful?
Is the problem bilateral?
Are you experiencing pain? What number on the 1–10
pain scale? Is it localized or radiating, one ear or both?
Have you discovered anything that brings relief of
symptoms?
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43
Diagnostic Ear Procedures
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The ear examination begins with an otoscopic
examination
Tuning fork tests
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Rinne test
Weber test
Audiometric testing
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44
Diagnostic Ear Procedures
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45
Treatment Procedures
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Ear irrigation—to remove excess cerumen
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Direct solution toward roof of canal
 Abbreviations—AU (both), AD (right), AS (left)
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Straightening ear canal
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Adult—pull pinna up and back
Child under 3 years—pull ear lobe down and back
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46
Critical Thinking Application
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Kim is ordered to perform a bilateral ear irrigation
on a 68-year-old patient with impacted cerumen.
She checks the auditory canals before the
procedure with an otoscope and sees a large
amount of dark brown cerumen in the right ear
completely covering the tympanic membrane.
The left ear has a moderate amount of golden
brown cerumen covering the bottom half of the
tympanic membrane. After the procedure both
membranes are visible, and the patient tolerated
the procedure without complaints. How should
Kim document the procedure?
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47
Irrigation and Medication
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Ear irrigation is used to remove excessive or
impacted cerumen; to remove a foreign body;
or to treat the inflamed ear with an antiseptic
solution.
Medication instilled into the ear generally
softens impacted cerumen, relieves pain, or
fights an infectious pathogen.
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48
Examination of Nose and Throat
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Examination of the nose and throat begins with
the nasal cavity, then the throat and the
nasopharynx
Throat cultures may be done to determine the
presence of a streptococcal infection
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collected by gently swabbing the back of the throat
and the surfaces of the tonsils with a sterile swab
mouth and tongue should be avoided to prevent
contamination of the swab
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49
Patient Education
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Patients with vision or hearing impairments
face serious challenges and require
individualized attention to meet their health
education needs.
Teaching adaptations may be required for
these patients.
Those with vision losses may need large-print
forms and handouts, increased levels of
lighting, or oral instructions rather than written
ones.
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50
Patient Education: Hearing Deficits
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Individuals with hearing deficits may benefit
from printed instructions, demonstrations of
how to manage treatments, or even sign
language interpretation.
Family members should be included in the
patient’s treatment plan, and referrals to
appropriate community or professional
resources may be very beneficial.
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51
HIPAA Applications
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Notice of Privacy Practices (NPP) – form
developed by the facility that outlines the
patient’s rights and the facility’s legal
responsibilities to safeguard the patient’s
protected health information
Each new patient must be given an NPP at the
first office visit
Document must be in a language that the
patient easily understands
Patients with vision and hearing deficits might
need help understanding the form
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52