CANOSSA COLLEGE

College of Nursing
San Pablo City

SKILLS CHECKLIST FOR NURSING CARE MANAGEMENT 101

Physical Assessment
2nd semester, 2020-2021

Student Name: Score:

Clinical Instructor: Date:

Checklist: Eye Assessment

Rubrics:
3 – the student was able to perform the procedures correctly based on standards
2 – the student was able to perform the procedures but needs improvement in some areas
1 –the student was not able to perform the procedure correctly because of unpreparedness showing nervousness

Note:
 Place the client in an appropriate room for assessing the eyes and vision.
 The nurse must be able to control natural and overhead lighting during some portion of examination.
Equipment: Millimeter ruler, Penlight, Snellen or E chart, Opaque card

Implementation 1 2 3 Remarks
1. Prepare equipment
2. Greet the patient, introduce self, verify the client’s
identity and state the purpose of the procedure
3. Perform hand washing
4. Provide privacy
5. Assist the client in a comfortable position
6. Inquire if the client has any family history of eye
problems, previous diagnosis of the eye and other
treatments provided.
External eye structure 1 2 3 Remarks
7. Inspect the eyebrows for hair distribution and
alignment and skin quality and movement
8. Inspect the eyelashes for evenness of distribution and
direction of curl.
9. Inspect the eyelids for surface characteristics
10. Inspect the bulbar conjunctiva
11. Inspect cornea for clarity and texture
12. Inspect the pupil for color, shape and symmetry of size
13. Assess each pupil’s direct and consensual reaction to
light to determine the function of third and fourth
cranial nerve
14. Assess each pupil reaction to accommodation
Visual field 1 2 3
15. Assess peripheral visual fields to determine function of
the retina and neuronal visual pathways to the brain
and second cranial nerve

1
Extra ocular muscle tests 1 2 3
16. Assess six ocular movements to determine eye
alignment and coordination
17. Assess for location of light reflex by shining penlight on
the corneal surface (Hirschberg test)
18. Have client fixate on a near or far object (cover test)
Visual Acuity 1 2 3
19. Ask the client to read from a magazine or newspaper
held at distance of 36 cm (14 in.)
20. Assess the client distance vision
21. Document findings and record.

Remarks
Preparation – able to
gather the instruments and
able to consider safety of
the patient, able to discuss
to the patient information
prior to the performance of
the procedure) 15%
Knowledge (able to answer
questions that may be
asked by the Clinical
Instructor 15%
Performance based on the
checklist guideline (50%)
Professionalism -the
conduct of performing the
procedure (20%)

Total Grade

Evaluator:
______________________________________________
Clinical Instructor