EYE ASSESSMENT SCRIPT

Prior to performing the procedure, check the doctor’s To verify the order
order for the need to perform the assessment.
Prepare pieces of equipment needed for the To ensure organization and increase efficiency
assessment. during the procedure
 Snellen – E chart
 Penlight
 Ballpen for documentation
 Comprehensive assessment form
Perform hand washing or hand hygiene, apply gloves, and observe To reduce the risk of contamination
other appropriate infection prevention procedure.
Greeted the client politely (and client's companion if around). To ensure that we will be doing the right
Introduced self and verified the client's identity. Asked how the assessment to the right client, and establish
client would like to be called during the assessment. rapport with them.
Explain the procedure to the client and Explaining the procedure to the client can reduce
how he/she can participate during the assessment. client’s anxiety and promotes cooperation.
Provide for client’s privacy. Ensures adequate lighting Providing for client’s privacy protects client’s
is available. integrity and enhances comfort.
Adequate lighting enhances visualization of the
assessed parts.
Position the client to be seated comfortably. Proper positioning facilitates client’s comfort and
efficiency in performing the assessment.
DISTANT VISUAL ACUITY
To checks how well a person can see the details of a letter or symbol from a specific distance
Position the client 20ft (6m) from the Snellen or E
Chart. Cover the eye being tested, and ask him/her to
read each line until he/she cannot decipher the letters
or their direction.
Take three readings: right eye, left eye, both eyes. If the client has
prescription glasses, let them wear it during the test.
Record the readings of each eye and both eyes (the smallest line
from which the person is able to read one half or more of the
letters).
Document (and interpret) findings.
If the client is unable to see even the top line (20/200) of the
Snellen type chart, perform tests for light perception, hand
movements, then counting fingers (if necessary)
TESTING VISUAL FIELDS FOR GROSS PHERIPHERAL VISION
To determine the function of the retina and neuronal visual pathways to the brain and second (optic) cranial nerve.
Have the client sit directly facing the examiner at a distance of 60 to
90cm (2 to 3 ft)
Ask the client to cover the right eye with a card and look directly at
your nose.
Cover or close the examiner’s eye directly opposite the client’s
covered eye (your left eye) and look directly at the client’s nose.
Hold an object (penlight or pencil) in your
fingers, extend your arm, and move the object
into the visual field from various points in the
periphery. Ask the client to tell you when the
moving object is first spotted.
a. To test the temporal field of the left eye,
extend and move your right arm in from the
client’s right periphery
b. To test the upward field of the left eye,
extend and move your right arm down from the
upward periphery
c. To test the downward field of the left eye,
extend and move your right arm up from the
lower periphery.
d. To test the nasal field of the left eye, extend
and move your left arm in from the periphery
19. Repeat the above steps for the right eye, reversing the process.
ASSESSING THE EXTERNAL EYE STRUCTURES: EYEBROW DISTRIBUTION – EYELIDS
Visually inspected the eyes for alignment and symmetry.
Inspect the eyebrows for equal distribution and alignment and skin
quality and movement. (ask the client to raise and lower eyebrows)
Inspect the eyelashes for evenness of distribution and direction of
curl
Inspect the eyelids for surface characteristics (skin quality and
texture), position in relation to the cornea, ability to blink, and
frequency of blinking. Inspect the lower eyelids while the client’s
eyes are closed.
Inspect the area over the lacrimal gland and lacrimal sac for
swelling.
Ask the patient to look up; depress the lower lid of the patient with
one's thumbs afterwards to assess sclera and bulbar conjunctivae.
Evert the eyelid to assess the palpebral conjunctiva.
Inspected carefully each iris and pupil.
Inspected each cornea and lens for opacities / clarity and texture:
Shone a penlight from the side toward the eye or shone a penlight
at an oblique angle to the eye, and moved the light slowly across
the corneal surface. Asked the client to look straight ahead while
doing so.
Assess each Assess each pupil’s direct and consensual to light to determine the function of the third
pupil’s reaction reaction (oculomotor) and fourth (trochlear) cranial
to nerves.
accommodation: a. Partially darken the room. Ask the client to
look straight ahead.
b. Using a penlight and approaching from the
side, shine a light on the pupil. Observe the
response of the illuminated pupil. It should
constrict (direct response)
c. Shine the light on the pupil again, and
observes the response of the other pupil. It
should also constrict (consensual response)
Assessed ocular Assess each pupil’s reaction to accommodation to light to determine the function of the third
alignment (oculomotor) and fourth (trochlear) cranial
arising from the nerves.
extraocular a. Hold an object (penlight or pencil) about 10cm
muscles: (4inch) from the bridge of the client’s nose.
b. Ask the client to look at the top of the object
and then at a distant object (far wall) behind the
penlight. Alternate the gaze from the near to the
far object, Observe the pupil response
c. Next, ask the client to look at the near object
and then move the penlight or pencil toward the
client’s nose
Assessed (a) Stood two to three feet in front of the patient to light to determine the function of the third
extraocular (oculomotor) and fourth (trochlear) cranial
movements, nerves.
looking for (b) Asked the patient to follow the examiner's
normal (you) finger or a pencil while making a wide H in
conjugate the air.
movement of (c) Looked for jerky movements of nystagmus on
the eyes in each lateral gaze and on upward gaze.
direction or any
deviation from
normal,
nystagmus, lid
lag, and
convergence.
Watch for a rim of sclera between the upper lid and iris as the eyes
move up and down.
Asked the patient to look at examiner's (you) finger as the examiner
moves it towards the bridge of the nose. Check eye convergence
Summarize the information obtained during the working phase and
discussed findings to the client. Discussed to the client possible
plans to resolve health concern, if present.
Assess for client's understanding of the plan and the need for
further teaching. Provided the client the opportunity to clarify, ask or
raise any concern.
 THORAX AND LUNGS ASSESSMENT
Review the client’s previous medical record To be informed about the client’s current health status
Verify the doctor’s order and determine the To verify if there is a need to do the assessment
scope of the assessment
Prepare of the necessary equipment needed To ensure organization and increase efficiency during the procedure
for the assessment:
 Working gloves
 Stethoscope
 Ballpen
 Notebook or the comprehensive
assessment form

Perform hand washing or hand hygiene, To reduce the risk of contamination

apply gloves, and observe other appropriate
infection prevention procedure.
Greeted the client politely (and client's
companion if around). Introduced self and
verified the client's identity. Asked how the
client would like to be called during the
assessment.
Explain the procedure to the client and
how he/she can participate during the
assessment.
Provide for client’s privacy. Ensures
adequate lighting is available and the sound
of the surroundings is muted
Position the client to be seated comfortably.
REVIEW THE CHEST AND RESPIRATION
INSPECT: Signs for respiratory distress or
problems with oxygenation
Check for CRT
PALPATE: Suprasternal notch and note the
position of the trachea
POSTERIOR THORAX AND LUNGS
INSPECT: configuration
INSPECT: Spinal alignment
PALPATE: Assess the temperature and skin
integrity
PALPATE: The thorax areas
PALPATE: for respiratory excursion or
expansion
 Place the palms of both your hands
over the lower thorax (T9-T10) with
your thumbs adjacent to the spine
and your fingers stretched laterally.
 Ask the client to take a deep breath
while you observe the movement of
your hands and any lag in movement
PALPATE: Vocal (tactile) fremitus
Place the palmar surfaces of your fingertips
or the ulnar aspect of your hand or closed
fist on the posterior thorax, starting near the
apex of the lungs
Ask the client to repeat such words as “blue
moon” or “one, two, three.”
To ensure that we will be doing the right assessment to the right client,
and establish rapport with them.
Explaining the procedure to the client can reduce
client’s anxiety and promotes cooperation.
Providing for client’s privacy protects client’s integrity and enhances
comfort.
Adequate lighting enhances visualization of the assessed parts and
reduced environment sound can help for better hearing of the
percussed and auscultated parts.
Proper positioning facilitates client’s comfort and
efficiency in performing the assessment.
Normal Breathing;12-20 cpm
Quiet, effortless respirations
To know if the notch has any
signs of swelling or tenderness,
and the trachea is misaligned
To observe the position of the  Scapulae are symmetric and
scapula and configuration of non-protruding.
chest wall  Shoulders and Scapulae are of
equal horizontal positions.
 The ratio of anteroposterior to
transverse diameter is 1:2.
To determine any abnormal  Spine vertically aligned
curvature of the spine.  Spinal column is straight, right
and left shoulders and hips are
at same height
Skin intact; uniform temperature
To assess for bulges, tenders, or Chest wall intact, no tenderness or
abnormal movements masses
To assess the movement of the Full and Symmetric Thorax
thoracic diaphragm during Expansion during deep inspiration.
breathing
To assess for increase or  Bilateral symmetry of vocal
decrease fremitus
of lung density  Fremitus is felt most clearly at
the apex of the lungs
Repeat the two steps sequentially down to
the base of the lungs and compare as
suggested
PERCUSS: Ask the client to bend the This separates the scapula and  Percussion notes resonate,
Thorax head and fold the arms exposes more lung tissue to except over scapula
forward across the chest. percussion.  Lowest point of resonance is
Percuss in the intercostal at the diaphragm
spaces at about 5-cm (2-
in.) intervals in a
systematic sequence.
Compare one side of the
lung with the other.
Percuss the lateral thorax
every few inches, starting
at the axilla and working
down to the eighth rib.
MEASURE: Used percussion to Diaphragmatic excursion is Normal diaphragmatic excursion
Diaphragmatic identify the level of the positively correlated with lung should be 3–5 cm
excursion diaphragm and measured inspiratory volumes and
diaphragmatic excursion. can accurately reflect the muscle
Percussed downwards strength and function
from above the expected
level of diaphragmatic
dullness until dullness is
definitely heard.
Marked the level of full
expiration (after gaining
the patient's permission
for the marking).
Had the patient inhale
deeply and hold it in.
Then, percussed
downward to the level of
dullness and full
inspiration and marked it.
Repeated this process on
the other side. Measured
the distance between the
expiratory and inspiratory
levels of dullness.
ASSUCLTATE: Place the diaphragm of To assess airflow through the  Vesicular breath sound
Breath sounds the stethoscope firmly and airways  Bronchial breath sound
directly on the posterior  Bronchovesicular breath
chest wall at the apex of sounds
the lung at C7.
Ask the client to breath
deeply through the mouth
for each area of
auscultation.
Using the systematic
zigzag procedure used in
percussion, listen at each
point to the breath sounds
during ventilation.
Compare findings at each
point with the
corresponding point on the
opposite side of the
thorax.
AUSCULATE:
Bronchophony (Asked the client to repeat
the phrase "ninety-nine" while auscultating
the chest wall)
Egophony (Asked the client to repeat the
letter "E" while listening over the chest wall)
Whispered pectoriloquy (Asked the client to
whisper the phrase "one- two-three" while
auscultating the chest wall.)
ANTERIOR THORAX AND LUNGS
INSPECT: Breathing patterns through the Various respiratory patterns have  Normal Breathing;12-20 cpm
rise and fall of the chest
 localizing significance in the  Quiet, effortless respirations
patient with altered
consciousness.
INSPECT: Coastal angle To evaluate expansion of thoracic Costal angle is less than 90° and
cage the ribs insert into the spine at
approximately a 45° angle
PALPATE: Anterior thorax To assess for tenderness, No tenderness or pain is palpated
 Using your fingers, palpate for sensation, surface masses, over the lung area with
tenderness and sensation crepitus, and fremitus respirations
 Palpate with your hand positioned
over the left clavicle (over the apex
of the lung) and move your hand left
to right, comparing findings
bilaterally.
 Move systematically and accordingly
as suggested then repeat for
crepitus and fremitus.
PALPATE: Respiratory excursion To assess the movement of the Full and symmetric excursion
 Place the palms of both your hands thoracic diaphragm during
along the lower rib cage with your breathing.
thumbs along the costal margins
 Ask the client to take a deep breath
while you observe the movement of
your hands
PALPATE: Vocal (tactile) fremitus To assess for increase and  Bilateral symmetry of vocal
 Place the palmar surfaces of your decrease of lung density. fremitus
fingertips or the ulnar aspect of your  Fremitus is felt most clearly at
hand or closed fist on the anterior the apex of the lungs
thorax, starting near the apex of the  Low-pitched voices of males
lungs are more readily palpated than
 Ask the client to repeat such words higher pitched voices of
as “blue moon” or “one, two, three.” females
 Repeat the two steps sequentially
down to the base of the lungs and
compare as suggested
PERCUSS: Anterior thorax To assess for lungs’ resonance. Percussion notes resonate down
 Begin above the clavicles in the to
supraclavicular space and proceed the sixth rib at the level of the
downward to the diaphragm. diaphragm but are flat over areas
 Compare the lung on one side to the of heavy muscle and bone, dull on
lung on the other side. areas over the heart and the liver,
 Displace female breasts to facilitate
and tympanic over the underlying
percussion of the lungs.
stomach
ASCULTATE: breath sounds specifically the To assess airflow through the
trachea and the anterior thorax. airway.
 Place the diaphragm of the
stethoscope firmly and directly on
the anterior chest wall.
 Ask the client to breathe deeply
through his mouth for each
auscultation.
 Use the systematic zigzag
procedure, listen at each point to the
breath sounds during auscultation.