Eye Assessment

An eye assessment should be carried out as part of the client initial physical examination. Unlike most organs of the body, the eye is available for external examination, and its anatomy is more easily assessed than many other body parts. The nurse, through careful questioning, elicits the necessary information that can assist in diagnosis of an ophthalmic condition. Following the health history, the patient’s visual acuity is assessed. This is an essential part of the eye examination and is measure against which all therapeutic outcomes are based. The Snellen chart, which is composed of a series of progressively smaller rows of letters, is used to test distance vision. The fraction 20/20 is considered the standard of normal vision. Most people
The lid margins and lashes should have no edema, erythema, or lesions. The examiner looks for scaling or crusting, and the sclera is inspected. A normal sclera is opaque and white. Lesions on the conjunctiva, discharge, and tearing or blinking are noted. The room should be darkened so that the pupils can be examined. The pupillary response is checked with a penlight to determine if the pupils are equally reactive and regular. A normal pupil is black. An irregular pupil may result from trauma, previous surgery, or a disease process. The patient’s eyes are observed in primary or direct gaze, and any head tilt is noted. A tilt may indicate cranial nerve palsy. The patient is asked to stare at a target; each eye is covered and uncovered quickly while the examiner looks for any shift in gaze. The examiner observes for nystagmus (ie, oscillating movement of the eyeball). The extraocular movements of the eyes are tested by having the patient follow the examiner’s finger, pencil, or a hand light through the six cardinal directions of gaze (ie, up, down, right, left, and both diagonals). This is especially important when screening patients for ocular trauma or for neurologic disorders. (Suddarth's,
Normal findings uncovered eye does not move. Deviation if misalignment is present, when dominant eye is covered, the uncovered eye will move to focus on object.
Assess near vision by providing adequate lighting and asking the client to read from a magazine or newspaper held at a distance of 36cm (14 in). If the client normally wears corrective lenses, the glasses or lenses should be worn during the test. Normal finding is Client being able to read newsprint. Deviations from normal is difficulty reading newsprint unless due to aging process.
Assess distance vision by asking the client to wear corrective lenses, unless they are used for reading only.i.e., for distances of only 36 cm (12 to 14 in). Normal findings are 20/20 vision on Snellen-type chart. Deviations from normal is denominator of 40 or more on Snellen-type chart with corrective lenses.
If client is unable to see even the top line (20/200) of the Snellen-type chart, perform function vision test. Deviation from normal functional vision only (e.g., light perception, hand movement, counting fingers at 1 ft). At the end of the assessment document findings in the clients records using forms of checklists supplemented by narrative notes when