eye assessment

Eye Eye AssessmeAssessmentnt

Edwin B. Malic RN

External eye structureExternal eye structureEyelidsEyelashesConjunctivaLacrimal apparatusExtraocular muscleeyeball

Internal structureInternal structureIrisLensRetinaOptic discRetinal vessel

visionvision

Visual fields and visual pathwayUpper temporalLower temporalUpper nasalLower nasal

Visual reflexesVisual reflexesPupillary light reflex- Direct- Indirect or consensual

accommodation

Anatomy of the eyeAnatomy of the eye

Collecting subjective dataCollecting subjective dataDo you see spots or floaters in

front of your eyes?Do you experience blind spots?

Are they constant or intermittent?Do you see halos or rings around

lights?Do you have trouble seeing at

night?Do you experience double vision?

Collecting subjective dataCollecting subjective dataDo you have any eye pain or

itching? DescribeDo you have any redness or

swelling in your eyes?Do you experience excessive

watering or tearing of the eye? One eye or both eyes?

Have you had any eye discharge? describe

Collecting subjective dataCollecting subjective dataHave you ever had problems with

your eyes or vision?Have you ever had eye surgery?Describe any past treatments

you have received for eye problems (medication, surgery, laser treatments, corrective lenses). Were these successful? Were you satisfied?

Family historyFamily historyIs there a history

of eye problems or vision loss in your family?

Lifestyle and health Lifestyle and health practicespracticesAre you exposed to conditions or

substance In work place or home that may harm your eyes or vision? Do you wear safety glasses during exposure to harmful substances?

Do you wear sunglasses during exposure to the sun?

What types of medications do you take?

Lifestyle and health Lifestyle and health practicespracticesWhen was your last eye

examination?Do you have a prescription for

corrective lenses? Do you wear them regularly? If you wear contacts, how long do you wear them? How do you clean them?

Collecting objective dataCollecting objective data

Preparing the clientExplain each vision test

EquipmentSnellen or E chartHand-held snellen card or near

vision screenerpenlight


EquipmentOpaque cardsOphthalmoscopeDisposable gloves

Physical assessmentPhysical assessment

While performing examination, remember these key points

Administer vision test competently and record the results

Use the ophthalmoscope correctly and confidently

Recognize and distinguish normal variation from abnormal findings

Evaluating visionEvaluating vision

Test distant visual acuity

o Position the client 20 feet from the snellen or e chart

o Ask her to read each line until she cannot decipler the letters or their direction

o Document results


Test distant visual acuity

Normal visual acuity is 20/20

Deviation from normal

Myopia20/200 is considered

legally blindAny client with vision

worse than 20/30 should be referred for further evaluation


Test near visual acuityo Use for middle aged clients and

others who complain difficulty in reading

o Give the client a hand-held vision chart

o Have the client cover one eye with an opaque card before reading from top to bottom


Test near visual acuity

Normal near visual acuity is 14/14


Presbyopia (impaired near vision)


Test visual fields for gross peripheral vision

The client should see the examiner’s finger at the same time the examiner sees it


A delayed or absent perception of the examiner’s finger indicates reduced peripheral vision

Testing extraocular muscle Testing extraocular muscle functionfunctionPerform corneal light reflexHold the penlight approximately

12 inches from the client’s faceShine the light toward the bridge

of the nose while the client stares ahead.

Testing extraocular muscle Testing extraocular muscle functionfunctionPerform corneal

light reflex

The reflection of light on the corneas should be in the exact same spot on each eye, which indicate parallel alignment


Asymmetric position of the light reflex indicates deviated alignment of the eyes due to muscle weakness or paralysis

Testing extraocular muscle Testing extraocular muscle functionfunctionPerform cover testAsk the client to stare straight

ahead and focus on a distant object. Cover one eye with an opaque card.

As you cover the eye, observe the uncovered eye for movement.

Now remove the card and observe the previously covered eye for any movement

Testing extraocular muscle Testing extraocular muscle functionfunction

Perform cover test

The uncovered eye should remain fixed straight ahead. The uncovered eye should remain fixed straight ahead after being uncovered


The uncovered eye will move to establish focus when the opposite eye is covered. When covered eye is uncovered, movement to reestablish focus occurs

Phoria, strabismus, tropia

Testing extraocular muscle Testing extraocular muscle functionfunctionPerform the positions testo Instruct the client to focus on an

object you are holding (approximately 12 inches from the client’s face)

o Move the object through the six cardinal positions of gaze in clockwise direction, and observe the client’s eye movement

Cardinal Positions of Gaze

The six positions in which the eyes can be turned where each eye is controlled primarily by one muscle: up/right, right, down/right, down/left, left, and up/left.

Testing extraocular muscle Testing extraocular muscle functionfunctionPerform the

positions test assesses eye muscle strength and cranial nerve function

o Eye movement should be smooth and symmetric throughout all six direction


Failure of eyes to follow movement symmetrically indicates weakness

Nystagmus, an oscillating (shaking movement)

External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashes

Note width and position of palpebral fissures

Upper lid margin should be between the upper margin of the pupil

The lower lid rest on the lower border of the iris. No white sclera is seen above or below the iris

Palpebral fissures may be horizontal


o Drooping of the eyelid(ptosis) oculomotor damage

o Retracted lid margins

External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashesAssess the ability

of eyelids to close

o The upper and lower lids close easily and meet completely when closed


Failure of lids to close completely puts client at risk for corneal damage

External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashes

Note the position of eyelids in comparison with the eyeballs. Note any unusual turnings, color, swelling, lesion, discharge


External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashesLower eyelid is upright with no inward or outward turning

Eyelashes are evenly distributed and curve along the lid margins

Xanthelasma, raised yellow plaques located most often near the inner canthus, are normal with increasing age and high lipid levels

Inverted lower lid(entropion) may cause pain and injure the cornea

Ectropion an evertted lower eyelid, results in exposure and drying of the conjunctiva

External eye structureExternal eye structureinspect the eyelids and inspect the eyelids and eyelasheseyelashesObserve for

redness, swelling, discharge, or lesion

o Skin on both eyelids is without redness, swelling, or lesion


Redness and crusting along the lid margins suggest seborrhea or blepharitis

External eye structureExternal eye structure

Observe the position and alignment of the eyeball in the eye socket

o Eyeballs are symmetrically aligned in sockets without protruding or sinking


Protrusion of the eyeballs accompanied by retracted eyelid margins is termed exophthalmus

Sunken eyes may be seen with severe dehydration


Inspect the bulbar conjunctivao Have the client keep her head

straight while looking from side to side then up toward the ceiling

o Observe clarity, color, and textureo This procedure is stressful and

uncomfortable for the client. It is usually only done if the client complain of pain “something in the eye”


Inspect the bulbar conjunctivaAssess the areas over the

lacrimal glands (lateral aspect of upper eyelid) and the puncta (medial aspect of lower eyelid)


Inspect the bulbar conjunctiva

o Bulbar conjunctiva is clear, moist, and smooth.

o Sclera is white


o Generalized redness of conjunctiva (conjuctivitis)

o Areas of dryness are associated with allergies/ trauma

o Episcleritis is a local, noninfectious inflammation of sclera


inspect the palpebral conjunctivao Put on gloves, first inspect the

palpebral conjunctiva of the lower eyelid by placing your thumbs bilaterally at the level of the lower bony orbital rim and gently pulling down to expose palpebral conjunctiva

o Ask the client to look up as you observe the exposed area

Inspect the palpebral conjunctivaEvert the upper eyelidAsk the client to look down with

his eyes slightly openPlace a cotton applicator

approximately 1 cm above the eyelid margin and push down while still holding the eyelashes


Inspect the palpebral conjunctiva

Clear and free of swelling or lesion

Free of foreign bodies, or trauma


Cyanosis of the lower lid (lung heart disorder)

Foreign body or lesion may cause irritation, burning, pain


Inspect the lacrimal apparatus

o No swelling/redness


Swelling of the lacrimal gland may be visible in the lateral aspect of the upper eyelid. May be cause by blockage, infection, or an inflammation


palpate the lacrimal apparatuso Put on disposable gloves to

palpate the nasolacrimal duct to assess for blockage

o Use one finger and palpate just inside the orbital rim


Palpate the lacrimal apparatus

No drainage should be noted from the puncta when palpating the nasolacrimal gland


Expressed drainage from the puncta on palpation occurs with duct blockage


Inspect the cornea and lenso Shine a light from the side of the

eye for n oblique viewo Look through the pupil to inspect

the lens


Inspect the cornea and lens

The cornea is transparent with no opacities. The oblique view shows a smooth and overall moist surface; the lens is free of opacities


Areas of roughness, dryness on the cornea are often associated with injury or allergic responses.

Opacities of the lens are seen with cataracts


Inspect the iris and pupil

o Iris is typically round, flat, and evenly colored. The pupil, round with a regular border, is centered in the iris. Pupils are normally equal in size (3-5mm)

o anisocoria


o Irregularly shape irises, miosis, mydriasis, and anisocoria


Test pupillary reaction to light

o Normal reaction is constriction


o Monocular blindness can be detected when light directed results no response

o When light is directed into the unaffected eye, both pupils constrict


Test accommodation of pupils

o The normal pupillary response is constriction and convergence of the eyes when focusing on a near object


o Pupils do not constrict; eyes do not converge

Abnormal findingsAbnormal findings

Pseudostrabismus Ptosis

Abnormal findingsAbnormal findingsentropion ectropion

Abnormal findingsAbnormal findingsConjunctivitis

Ear Ear AssessmentAssessment

Structure and functionStructure and functionExternal

earMiddle earInner ear

HEARING

Collecting subjective dataCollecting subjective dataHistory of present health concern

o Changes in hearing- describe any recent changes in

your hearing- Are all sounds affected with this

change or just some sounds

Collecting subjective dataCollecting subjective dataHistory of present health concern

o Other symptoms- Do you have any ear drainage?

Describe the amount and any odor

- do you have any ear pain? If so, do you have an accompanying sore throat. Sinus infection, or problem with your teeth or gums?

- Do you experience any ringing or crackling in your ears?

- Do you ever feel like you are spinning or that the room is spinning? Do you ever feel dizzy or unbalanced?

Past health historyPast health historyHave you ever had any problems

with your ears such as infection, trauma or earaches?

Describe any past treatments you have received for ear problems (medication, surgery, hearing aids). Were these successful? Were you satisfied?

Family HistoryFamily HistoryIs there a

history of hearing loss in your family?

Lifestyle and health Lifestyle and health practicespracticesDo you work or live in an area with

frequent or continuous loud noise? How do you protect your ears from the noise?

Do you spend a lot of time swimming or in water? How do you protect your ears?

Has your hearing loss affect your ability to care for yourself? To work?

Has your hearing loss affect socializing with others?

Lifestyle and Health Lifestyle and Health PracticesPracticesWhen was your last hearing

examination?How do you care for your ears?


Preparing the cliento Make sure client is seated

comfortablyo Test should explained thoroughly

to guarantee accurate results.


EquipmentWatch with a second-hand for

romberg testTuning forkOtoscope


Physical assessmentRecognize the role of hearing in

communication and adaptationKnow how to use the otoscope

effectivelyUnderstand the usefulness and

significance of basic hearing tests

External ear structuresExternal ear structures

Inspect the auricle, tragus, and lobule

Ears are equal in size bilaterally (4-10cm)

Skin is smooth with no lesion, lumps, or nodules

No discharge should be present

Darwin’s tubercle


Ears are smaller than 4cm

Malaligned or low set ears may be seen with genitourinary disorder

Enlarged preauricular and posturicular lymph nodes-infection

External ear structuresExternal ear structures

Palpate the auricle and mastoid process

o Auricle, tragus, and mastoid process are not tender.


Painful auricle/tragus associated with postauricular cyst

Tenderness over the mastoid process (mastoiditis)

Tenderness behind the ear may occur with otitis media

Internal ear: otoscopic Internal ear: otoscopic examinationexamination

Inspect the external auditory

Small amount of odorless cerumen (earwax) is the only discharge normally present


o Foul smelling, sticky, yellow discharge

o Bloody purulent discharge

o Blood or watery drainage

o Impacted cerumen bloking the view of ear canal

Internal ear: otoscopic Internal ear: otoscopic examinationexaminationObserve the color

and consistency of the ear canal walls

o The canal walls should be pink and smooth without nodules


o Reddened, swollen canals

o Exostoses (nonmalignat nodular swellings)

o Polyps

Inspect the tympanic membrane

o Should be pearly, gray, shiny, and translucent with no bulging or retraction

o slightly concave, smooth and


o Red, bulging eardrum and distorted, diminished or absent light reflex

o Yellowish, bulging membrane with bubbles behind

o Bluish or dark red color

o White spotso perforations

Perform the weber’s testo Helps to evaluate the conduction of

sound waveso Strike a tuning fork softly with the

back of your hand and place it in the center of the client’s head or forehead.

o Ask whether the client hears the sound better in one ear or the same in both ears

A tuning fork is an acoustic resonator in the form of a two-pronged fork with the prongs (tines) formed from a U-shaped bar of elastic metal (usually steel). It resonates at a specific constant pitch when set vibrating by striking it against a surface or with an object, and emits a pure musical tone after waiting a moment to allow some high overtones to die out

Perform the weber’s test if the client reports diminished or lost hearing in one ear

o Vibrations are heard equally well in both ears

o No lateralization of sound to either ear


o With conductive hearing loss, client reports lateralization of sound to the poor ear

o With sensorineural hearing loss, client reports lateralization in good ear

Perform the rinne testPerform the rinne testStrike a tuning fork and place the

base of the fork on client’s mastoid process

Ask the client to tell you when the sound is no longer heard. Move the prongs of the tuning fork to the front of the external auditory canal

Ask the client to tell you if the sound is audible after the fork is moved

Perform the rinne test

o Air conduction sound is normally heard longer than bone conduction sound


o With conductive hearing loss, bone conduction sound is heard longer than or equally s long as air conduction side.

o With sensorineural hearing loss, air conduction sound is heard longer than bone conduction sound

Perform romberg test

o Client maintains position for 20 sec without swaying or with minimal swaying


o Clients moves feet apart to prevent falls or starts to fall from loss of balance. This may indicate vestibular disorder

Mouth, throat, nose, and Mouth, throat, nose, and sinussinus

Structure and functionStructure and functionMouthThroatNoseSinuses

Collecting subjective dataCollecting subjective dataTongue and mouth- do you experience tongue or mouth

sores or lesions? Are they painful? How long have you had them? Do they recur? Is it single or do you have many?

- do you experience redness, swelling, bleeding, or pain of the gums or mouth? How long has this been happening? Have you lost any permanent teeth?

Collecting subjective dataCollecting subjective data nose and sinuses- Do you have pain over your sinuses?- do you experience nosebleeds? How

much bleeding? What color?- Do you experience frequent clear or

mucous drainage from your nose?- Can you breath through both of your

nostrils? Do you have a stuffy nose at times during the day or night?

Collecting subjective dataCollecting subjective data nose and sinuses- Do you have seasonal allergies,

had fever? Describe the timing of the allergies and symptoms

- have you experienced a change in your ability to smell or taste?

Collecting subjective dataCollecting subjective data throat- Do you have difficulty chewing or

swallowing food? How long have you had this? Do you have any pain?

- Do you have a sore throat? How long have you had it? Describe. How often do you get sore throats?

- Do you experience hoarseness? How long?

Past health historyPast health historyHave you ever had any oral,

nasal, or sinus surgery? Do you have a history of sinus infections? Describe your symptoms. Do you use nasal sprays?

Family historyFamily historyIs there a

history of mouth, throat, nose, or sinus cancer in your family

Lifestyle and health Lifestyle and health practicespracticesDo you smoke or use smokeless

tobacco? If so, how much? Are you interested in quitting this habit?

Do you drink alcohol? How much and how often?

Do you grind your teeth?

Lifestyle and health Lifestyle and health practicespractices

o Describe how you care for your teeth or dentures., how often do you brush and use dental floss? When was your last dental examination?

o If the client wear braces: how do you care for your braces? Do you avoid any specific types of foods? Describe your usual dietary intake for a day

o Do you brush your tongue?o How often are you in the sun? do you

use lip sunscreen products?

Preparing the clientPreparing the clientPlace on sitting positionExplain the procedureA gentle, yet confident and

matter of fact approach may help the client to feel more at ease

EquipmentEquipmentGloves4x4 gauze padPenlightShort, wide- tipped speculum

attached to the head of an otoscope

Tongue depressorNasal speculum

Physical assessmentPhysical assessment

When preparing to examine the nose and mouth

o Be able to identify and understand the relationship among the structures of the mouth and throat, nose, and sinuses

o Know age related changes of the oral cavity and nasal and sinus

o Refine examination techniques

mouthmouth

Inspect the lips (observe for lip consistency and color)

o Lips are smooth and smooth without lesions or swelling


o Pallor around the lips

o Reddish lipso swelling

mouthmouth

Inspect the teeth and gumso Ask the client to open the moutho Note the number, color,

condition, and alignment of the teeth

o Put on gloves and retract the client’s lips and cheeks to check gums for color and consistency

Inspect the teeth and gums

o Thirty two pearly whitish teeth with smooth surface and edges

o Some clients normally have only 28 teeth if the four wisdom teeth do not erupt


o Yellow or brownish teeth

o Missing teeth can affect chewing as well as self image

o White spot on teeth may result from antibiotic therapy

Gums are pink, moist, and firm with tight margins to the tooth.

No lesion or masses


Red, swollen gums that bleed easily, scurvy (vitamin c deficiency), and leukemia.

Enlarged reddened gums (hyperplasia)

Inspect the buccal mucosao Use a penlight and tongue

depressor to retract the lips and cheeks to check the color and consistency

o Also note the stenson’s ducts (parotid ducts) located on the buccal mucosa across from the second upper molars

Inspect the buccal mucosa

o It should be appear pink, tissue is smooth and moist without lesions

o Stenson’s duct are visible with flow of saliva and with no redness, swelling, pain, or moistness


o Leukoplakia may be seen in chronic irritation and smoking

o Leukoplakia is a percancerous lesion and client should be referred for evaluation

Inspect and palpate the tongueo Ask the client to stick out the

tongueo Inspect the color, moisture, size,

and textureo Observe for fasciculation's (fine

tremors), and check for midline protrusion

o Palpate any lesions present for induration (hardness)

Inspect and palpate the tongue

o Tongue should be pink, moist a moderate size with papillae (little protuberances) present

o No lesion are present


o Deep longitudinal fissures seen in dehydration

o Black tongue (bismuth toxicity)

o Black, hairy tongue; smooth reddish, shiny tongue w/o papillae indicative of niacin or vit. B12 deficiencies

Assess the ventral surface of the tongue

o Ask the client to touch the tongue to the roof of the mouth, and use a penlight to inspect ventral surface of tongue, frenulum

o Palpate the area if you see lesion

o It should be smooth, shiny, pink or slightly pale with no lesion

o Older client may have varicose veins on the ventral surface


o Leokoplakia, persistent lesions, ulcers or nodules may indicate cancer

Inspect for the wharton’s duct

o The frenulum is mdline; wharton’s ducts are visible with salivary glands

Dviation from normal

o Lesions, ulcers, nodules, or hypertrophied duct

Observe the sides of the tongueo use a square gauze pad to hold

the client’s tongue to each sideo Palpate any lesion, ulcers, or

nodules

No lesion, ulcers or nodules are apparent


Canker sore may be seen on the sides of the tongue in clients receiving certain kinds of chemotherapy

Leukoplakia, persistent lesion nodules may indicate cancer

Check the strength of the tonguePlace your fingers on the external

surface of the cheekAsk the client to press the

tongue’s tip against the inside of the cheek to resist pressure

Repeat from other side

The tongue offers strong resistance


o Decreased tongue strength may occur with 12 cranial nerve defect

Check the anterior tongue’s ability to taste

o By placing the drops of sugar and salty water on the tip and sides of tongue depressor

The client can distinguish between sweet and salty


o Loss of taste discrimination occurs with zinc deficiency, seven cranial nerve defect and certain medication use

Inspect the hard (anterior) and soft palate (posterior) and uvula

Ask the client to open the mouth wide while you use penlight to look at roof. Observe color and integrity

The hard palate is pale or whitish with firm, transverse rugae (wrinkle like folds)


Yellow tint to the hard palate may indicate jaundice

An opening in the hard palate are called cleft palate

Note the odor

o No unusual or foul odor is noted


o Fruity or acetone breath is associated with diabetic ketoacidosis

o Foul odors may indicate oral or respiratory infection

Assess the uvula

o Apply tongue depressor to the tongue and shine a penlight into client’s wide-open mouth

o Ask the client to say “ahhhhhhh”

No redness of or exudate from uvula or soft palate

Midline elevation of the uvula and symmetric elevation of the soft palate


o Bifid uvula looks like a split in two/ (submucous cleft palate)

o Asymmetric movement or loss of movement (CVA)

Inspect the tonsilso Using the tongue depressor to

keep the mouth open wide, inspect the tonsils for color, size, and presence of exudate or lesions

They are normally pink and symmetric and may be enlarged to 1+ in healthy clients

No exudate, swelling or lesions should be present


Tonsil are red, enlarge and covered with exudate

Maybe indurated with pathches of white or yellow exudates

Inspect the posterior pharyngeal wall

o Keeping the tongue depressor in place, shine the penlight on the back of the throat

o Observe the color of the throat, and note any exudate or lesions

Throat is normally pink without exudate or lesion


o A bright red throat with white or yellow exudate indicates pharyngitis

o Yellowish mucus on throat may be seen with postnasal sinus drainage

nosenose

inspect and palpate the external nose

Color is the same as the rest of the face; nasal structure is smooth and symmetric; clients report no tenderness


o Nasal tenderness on palpation may accompanies a local infection

Check the patency of air flow through the nostril

By occluding one nostril at a time and asking the client to sniff

Client is able to sniff through each nostril while other is occluded


o Client cannot sniff through a nostril

o This maybe a sign of swelling, rhinitis, or a foreign object obstruction

Inspect the internal nose

Dark pink, moist and free of exudate

Nasal septum is intact and free of ulcers and perforation


Nasal mucosa is swollen and pale or bluish gray in clients with allergies

sinusessinuses

Palpate the sinusPalpate the frontal sinuses using

thumb to press up on the brow on each side of the nose

Palpate the maxillary sinuses by pressing with thumbs up

Sinuses are not tender


The frontal and maxillary sinuses are tender in clients with allergies or sinus infection

Transilluminate the sinus (frontal and maxillary)

a red glow


Absence of red glow usually indicates a sinus filled with fluid, pus thick mucus

eye assessment

Documents

uncovered eye

eye anatomy

eye examination

eye surgery

eye pain

opposite eye

eye discharge

eye muscle strength