ASSESSING THE EYES:
Usually occur on
 If a person is 40 yrs old and below, it is
recommended to have a regular eye
examination every 3 to 5 years or more
frequently.
 If you have family history (ex. Diabetes,
hypertension, and blood dyscrasia), it is
recommended to have more frequent
eye examination and assessment
 diabetic retinopathy
- Diabetes can cause blurry of
vision. The blood vessels which
supplies to the eye which carries
oxygen and nutrients are
minute, small, slim, fragile and
slender. A patient with diabetes,
the blood become viscous and
because of that, the blood
cannot past through to the
blood vessels anymore and
there will be no efficient supply
of blood and there will be
deprivation of oxygen to the eye
resulting to the damage of the
parts of the eye.
 After 40 years old, it is recommended to
have eye examination every 2 years
because glaucoma might be present.
 Glaucoma
- Most common cause of
blindness amongst people who
are 40 years old and above.
Assessment of the eye would include:
1. Assessment of Visual Acuity
Visual Acuity – the degree of detail the eye can
discern image.
2. Assessment of Ocular Movements
- Assessing the cranial nerve
function (specifically, number 3
oculomotor)
3. Check the Visual Fields
Visual Fields – area that an individual can see
when looking straight ahead.
4. Check the External Structures of the
Eye
Common Defects and Eye Problem:
 Myopia (near-sightedness)
- Can only see objects that are
near
 Hyperopia (far-sightedness)
- can only see objects which are
far
 Presbyopia
- Loss of elasticity of the lens. The
patient will loss an ability to see
close objects.
people 45 years old and above.
 Diplopia (di- means double)
- Double vision. Usually occur to
people with increase
intracranial pressure or there is
an increase pressure inside of
the skull.
 Halos
- Halos around lights, these are
rainbow circles around lights.
Common amongst people who
have narrow angled glaucoma.
 Scotoma (Blind Spots)
- It is surrounded by either
normal or slightly diminished
peripheral vision. Seen with
people with glaucoma.
 Astigmatism
- Brought about by uneven
curvature of the cornea that
prevents horizontal and vertical
rays from focusing on the
retina.
 Epiphora
- Excessive tearing
 Unilateral Epiphora – only one
eye is excessively tearing. May
be indicated of foreign body.
 Bilateral Epiphora – two eyes
are excessively tearing.
Indicative of irritation and
commonly seen with patients
who are experiencing allergic
reactions.
 Conjunctivitis
- Inflammation of the bulbar and
palpebral conjunctiva. The color
of the bulbar conjunctiva is
TRANSPARENT OR CLEAR. The
palpebral conjunctiva is the one
that is pinkish. Brought about
by chemical, foreign bodies, and
allergenic agents.
- Will experience redness,
itchiness and mucopurulent
drainage.
 Dacryocystitis
- Inflammation of the lacrimal
sac.
- Tearing, discharge from the
nasolacrimal sac
 Hordeolum (also called stye)
- Swelling and tenderness of the
hair follicle and glands that
empty at the edge of the
eyelids.
 Iritis
- Inflammation of the iris.
 -
Result in pain, tearing and
photophobia – sensitivity to the
light
 Contusion Hematoma (black)
- Hematoma around the eyes or
it may also be seen in pupil.
 Raccoon’s Eye
- Commonly seen in people who
sustained head injury.
 Cataract
- 65 years old and above
- Opacity of the lens and its
capsule which blocks the light
rays
- Congenital cataract – cataract
of the infants. Babies whose
mother experienced german
measles or rubella
 Glaucoma
- Problem in circulation of the
vitreous humor or blockage that
resulted in increased
intraocular pressure.
- One of the characteristic is
tunnel vision
- Normal Intraocular pressure:
10-21 mmHg (measure through
tonometer)
- Hypotonia – if the intraocular
pressure is less than 5 mmHg.
 Ptosis
- Drooping of the eyelids.
- Touches the border of the
cornea
- It may be associated with aging,
with edema, or systemic
disease
- Periorbital edema – edema
around the eyes
 Ectropion
- Eversion or the turning out of
the eyelid.
 Entropion
- Inversion or the turning inward
of the eyelid.
NOTE: The normal diameter of the pupil is 3-7
mm
In the Pupil:
P – pupils
E – equally
R - round
R – reactive to
L – Light and
A – Accommodation
 If pupil is exposed to light, the pupil
should constrict
 In dark room, the pupil should dilate in
order to accommodate
 If looking at the close subject, it should
constrict
 If looking at the far object, it should
dilate
 Mydriasis
- Enlarged or dilated pupil.
 Miosis or Myosis
- Abnormal constriction of the
pupil
 Anisocoria
- unequal; one is dilated and one
is constricted
 Xerophthalmia
- Caused by severe vitamin A
deficiency in the children
 Exophthalmos
- Bulging of the eyes
 Strabismus – cross-eyed
Types:
- Exotropia - the eyes are
deviated outward
- Esotropia - both eyes turns
inward
Types:
Snellen’s Chart – checking for the vision
Snellen’s E Chart – if the patient is illiterate and
could not read alphabet
Snellen’s Children Chart – for children
ASSESSING: STEP BY STEP:
1. Introduce yourself and explain to the
client
2. Provide Privacy
3. Wash Hands and Wear Gloves
4. Asked Client about the History:
- Diabetes Mellitus
- Hypertension
- blood dyscrasia
- eye diseases in the family
- ask for the presence of injury
- surgery
- Last visit to the
ophthalmologists
- Are there eye medications
which you are taking
- Do you use contact lens
- Do you use glasses
- Do you use reading glasses
 - Do you have blind spots
- Do you see halos around light
- Do you have difficulty in terms
of night vision
5. Inspect the eyebrows for its distribution
and alignment
- Asked the client to raise the
eyebrows
- It should be symmetrical
6. Inspect the eyelashes for evenness
distribution
- Should be slightly curve
outward
- Ectropiol – severely curved
outward
- Entropiol – severely curved
inward
7. Inspect the eyelids for surface
characteristics
- Check for skin quality, texture,
the position
8. Check the ability of the patient to blink
- Blink reflex and the frequency
- Normal: 15-20 blinks per
minute
- Nystagmus – involuntary
blinking or twitching. Maybe
indicative of neurological
impairment. Also in ear
disorder or inner ear disorder
- Xanthelasma – also called as
planar xanthoma. Yellowish
plaques that occur most
commonly near the inner
canthus of the eyelid, more
often on the upper lid than the
lower lid
9. Inspect the bulbar conjunctiva
- Asked the client to look up,
down and side to side
- Pinguecula – yellowish nodules
on bulbar conjunctiva
 Assess the sclera
- The normal color is bluish white
or blue white
- Anemia – if the sclera is too
white
- Jaundice – If the sclera is
yellow. Commonly seen in
people with hepatobiliary
disorder
- Anicteric Sclera – if the sclera is
normal
- Icteric Sclera – If the sclera is
yellow because of jaundice
- Ipiscleritis – local non-
infectious inflammation of the
sclera
10. Inspect and Palpate the Lacrimal Gland
- Palpate and there should no
tearing
- Used the tip of the index finger
11. Inspect and Palpate the nasolacrimal
duct
- No tearing
12. Inspect the cornea for its clarity and
texture
- Hold the penlight in an oblique
angle
- 12 inches from the patient
- In older people: you can see
grayish ring around the cornea
of the elderly: normal (Arcus
Senilis or senile arc)
- Start at the side, look straight in
the eyes and the lights should
be dim
 Corneal Sensitivity Test – test for the
function of trigeminal nerve or the fifth
cranial nerve
Note: The client should blink
- Ipiscleritis – local non-
infectious inflammation of the
sclera
13. Check the pupillary reaction
- The room should be dim
 Inspect the anterior chamber of the eye
for the transparency and depth.
- Still used oblique lighting
- The chamber should be
transparent
- There should be no shadows of
light
- The depth should be 3 mm
- Glaucoma – too shallow
14. Check for the eye
- Check for direct response:
If the illuminated pupil is
reactant to light or will constrict
- Consensual response:
The non-illuminated pupil
should constrict with the
illuminated pupil
- Check for accommodation:
Hold the penlight in front of the
patient around 10 cm or 4
inches. Asked the patient to
look at the peak of the penlight
and observe the pupil. After,
asked the client to look at the
object from far away.
- If the it is normal, we can say
that the patient has PERRLA
15. Check for Peripheral Fields
- To determine the function of
the retina
- Peripheral fields are decreased
in the Glaucoma
- Check for one eye and the
another eye and both eyes
 - The distance of the nurse to the
patient should be 60 – 90 cm or
2 – 3 feet. Temporal is 90
degrees. Upper is 50 degrees
because of the supraorbital
lobe. Downward is 70 degrees
because of cheekbone. Pass the
nasal field is 50-60 degrees
because of nasal septum.
- Cover the eye indirectly
opposite: if the patient covered
right eye, the nurse should have
covered left eye
16. Extraocular muscle test
- It can perform on clients with
more than 6 months of age
- Brain Lesions – if there is
squinting or abnormal
strabismus
- The penlight should be one foot
away from the client
17. Cover’s Test
- stares straight ahead and focus
at the distant object and cover
one eye.
- Phoria – mis-alignment that
occurs only when fusion reflex
is blocked
- With the use of cardboard
18. Visual Acuity Test
- First, test for near vision and
adequate lighting with the
distance of 30 cm or 14 inches
(magazine or newspaper)
- Then, test for distance vision
with the use of Snellen’s Chart.
The distance should be 20 feet
or 6 meters.
- Three readings: Left eye, right
eye and both eyes
- 20/200 legally blind
 Functional vision test:
1. Light perception
2. Counting Fingers: 1 foot
3. Hand movement
Infants: 4 months could follow objects
6 months they could focus on both eyes
6 years old 20/20 vision
Elders:
- not able to perceive the purple
color and not appreciate the
pastel colors
- The gray ring in the cornea is
the Lipid Accumulation
Lacrimal glands will not mature until 3 months
of age
Infants will not be able to differentiate colors
not until 5 years of age.
Recording of the Snellen:
For the Right eye: Oculus Dexter
Example:
OD 20/20 s c
For the Left eye: Oculus Sinister
Example:
OS 20/20 s c
For both eyes: Oculus Universalis
ASSESSING THE EARS:
Otitis Media – People who have commonly
have upper respiratory infection because of the
connection between Eustachian tube to the
nasal pharynx. The bacteria easily ascend or
transfer.
Ear – responsible for the balance and the
equilibrium in the body
8th cranial nerve (auditory nerve) – is the
responsible for hearing.
COMMON DEFICITS IN THE EAR:
 Presbycusis – the elderly cannot
appreciate the sound such as F, S, SH,
and PH
Types of Hearing Loss:
1. Conduction Hearing Loss – is an
interrupted transmission of sounds or
sound waves through the outer middle
ear structures.
Causes:
Tear in the Tympanic Membrane,
swelling of the ear
2. Sensory Neural Hearing Loss – result in
the damage of the inner ear, the
auditory nerve, or hearing center in the
brain.
3. Mixed Hearing Loss – mixture of both
conduction and sensory neural
 Exostosis – this is benign growth from a
bony surface cut with a cartilage
ASSESSMENT PROCESS:

The usual process
1. Inspect the auricle for its symmetry, size
and position
- Normally, the auricle is about 9-
10 cm
- The auricle aligns with a corner
of each eye
- The angle from the outer potion
of the eye to the ear should
only be 10 degrees.
- Chromosomal Aberration – if
the ear is more than 10 degrees
and a low-set ears. Also seen in
people with trisomy 21 or Down
Syndrome.
- Darwin’s Tubercle - small
bump on the inside of their
upper ear. There is no problem
with that and clinically
insignificant.
2. Palpate the auricle for its texture,
elasticity and areas of tenderness
- Pull the ear upward, sideward,
and downward
- Press the tragus; there should
be no tenderness
- Otitis Externa and Post
auricular cyst – if there is
tenderness in the auricle and
the tragus
- Apply pressure to the mastoid
process and there should be no
tenderness
- Mastoiditis – inflammation of
the mastoid
3. Use otoscope
- Otoscope – used to examine
the external ear or cerumen.
Check for skin lesions.
4. Inspect the Tympanic Membrane for its
color and loss
- The normal color for tympanic
membrane is pearly gray. It is
semi-transparent. Can also be
translucent and it should not be
bulging. The tympanic
membrane should be slightly
concave (medyo nalubong)
- Otitis Media - Red or absence
of light reflex
- Otitis Externa – if you cannot
see the light or glossy
- Serous otitis Media - If it is
yellowish, bulging with some
bubbles
- Blood coming from the skull
trauma - If it is bluish or dark
red in color
- Redness or bluish Discoloration
of the Tympanic membrane –
resulted from the head injury or
trauma
- Scarred Tympanic Membrane –
If there are white spots or scars
from previous infection such as
otitis media
- Increased pressure in the ear –
if it is bulging and there is an
increased risk of rupture of the
tympanic membrane
5. Assess the normal voice tone or normal
response of the client to normal voice
tones
- Talk to the client in your normal
voice tone
- Watch Tick Test – 2 to 3 cm or
1-2 inches and ask the client if
he can hear the ticking of the
clock
- You should be behind of the
client
 2 test performed in hearing:
1. Weber Test – the normal is weber
negative. The abnormal is weber
positive. You can say that that it is
normal when the sound is heard on
both ears or the vibration of the sound
is centrally located at the head.
- Bone Conduction Hearing Loss
– if the impaired ear is the one
who heard the sound
- Sensory Neural Hearing Loss –
if the vibration is heard on the
normal ear
2. Rinne Test – The normal is rinne
positive and abnormal is rinne negative.
You check here the air conduction vs.
bone conduction. The air conduction
should always be greater than the bone
conduction.
ASSESSMENT OF THE
MOUTH:
 Parotitis – inflammation of the parotid
2 problems which affect the teeth:
1. Dental caries or cavities
2. Periodontal Disease or Pyorrhea
 Plaque – invisible soft film that adheres
the enamel surface of teeth; consists of
bacteria, molecules of saliva, and
remnants of epithelial cells and
leukocytes.
 Tartar – visible, hard deposit of plaque
and dead bacteria that forms at the  Herples Simplex – eruptions in the
gum lines. It can alter the fibers that mouth.
attach the teeth to the gum and
eventually disrupt bone tissue. Assessment:
The usual
 Gingivitis – inflammation of the gums. It History:
is characterized in Periodontal Disease. Routine dental care
Red swollen gingiva, bleeding, receding How often do you go or visit to the
gum lines, and formation of pockets dentist?
between the teeth and gums. Do you experience any periodontal
diseases?
 Glossitis – inflammation of the tongue If there are ulcers in the mouth, how
long has this been present
 Stomatitis – inflammation of the oral Do you have dentures
mucosa Is there any discomfort in the dentures?

 Parotitis – inflammation of the parotid  Defect of the seventh cranial nerve or

salivary glands
 Sordes – the accumulation of foul
matter on the teeth and gums
 Beefy red tongue – found in people
with vitamin B deficiency, iron
deficiency, niacin deficiency, and iron
deficiency anemia.
 Strawberry Tongue – seen in people
with Kawasaki Disease, is an
autoimmune disease or self-destruction
disease.
 Leukoplakia – caused by candida. Hairy
Leukoplakia commonly seen in people
who are immunocompromised or
people who have problems in the
immune system.
facial nerve – if the client failed to do
purse lips
 Circumoval cyanosis – cyanosis in the
mouth
 Angioedema – edema in the lips or
swollen of the lips
 Caviar spots – varicose veins in the
tongue
 The hard palate is lighter pink in color
than the soft palate and is more
irregular
 Exostosis – bony growth in the palate
 Kaposi Sarcoma - Deep purple lesions in
the palate. Seen in people with HIV
 Candida Albicans – white bumps in the
mouth

 Oral Thrush – cause by candida albi

cancer. Also known as Oral candidiasis.

 Halitosis – bad breath

 Canker Sores – seen in

immunocompromised patient. May be
caused by stress, virus, viral infection or
patient who has fever and etc. Small,
shallow lesions that develop on the soft
tissues in your mouth or at the base of
your gums.

 Angular Cheilitis – also seen in people

with immunocompromised.
Inflammation of one or both corners of
the mouth.

 Kylosis – cracking and drying of the lips.

Commonly seen in people who are
dehydrated.