Republic the Philippines

Laguna State Polytechnic University

Province of Laguna
College of Nursing and Allied Health

NURSING CARE MANAGEMENT 101

HEALTH ASSESSMENT

ASSESSMENT OF VISION 2

NAME OF STUDENT: ____________________ SECTION & GROUP NUMBER: _______________________

DATE OF RETURN DEMONSTRATION: ________________ CLINICAL INSTRUCTOR: ___________________

Definition or
Purpose

Preparing the 1. Explain the procedure such as how to prepare oneself, purpose, physical
Client and environment, how he/she can participate, client positions, preferences, pain,
Physical vital signs will be taken.
Assessment 2. Ask client to wear gown or as necessary.
3. Provide Privacy
4. Collect subjective data such as current symptoms, past history, family history,
lifestyles and health practices.

Equipment Gather Equipment:

1. Snellen or E chart
2. Hand-held Snellen card or near-vision screener
3. Penlight
4. Opaque cards
5. Ophthalmoscope
6. Disposable gloves (wear as needed to prevent spreading infection or coming in
contact with exudate)

ASSESSMENT PROCEDURE
(this can be typewrite based on the sequence of parts to be SCORES
examined and techniques)

0 1 2 REMARKS
STEPS NOT DONE MASTER
DONE
Evaluating Vision
1 Test distant visual acuity. Position the client 20 ft from
the Snellen or E chart (See Assessment Guide 16-1) and
ask them to read each line until they cannot decipher
the letters or their direction. Document the results by
recording the smallest line of numbers the client can
read on the bottom. For example, 20/20 is normal
vision.
 During the vision test, note any client behaviors (i.e.,
leaning forward, head tilting, or squinting) that could be
unconscious attempts to see better.
2 Test near visual acuity. Use this test for middle-aged
clients and others who have difficulty with near vision
or with reading. Give the client a hand-held vision chart
(e.g. Jaeger reading card, Snellen card, or comparable
chart) to hold 14 in. from the eyes. Have the client
cover one eye with an opaque card before reading from
top (largest print) to bottom (smallest print). Repeat
test for other eye.
3 The client who wears glasses should keep them on for
this test. Test visual fields for gross peripheral vision. To
perform the confrontation test, position yourself -2 ft
away from the client at eye level. Have the client cover
the left eye while you cover your right eye. Look directly
at each other with your uncovered eyes. Next, fully
extend your left arm at midline and slowly move one
finger (or a pencil) upward from below until the client
sees your finger (or pencil). Test the remaining three
visual fields of the client's right eye (i.e., superior,
temporal, and nasal). Repeat the test for the opposite
eye.
TESTING EXTRAOCULAR MUSCLE FUNCTION
1 Perform corneal light reflex test. This test assesses
parallel alignment of the eyes. Hold a penlight 12 in.
from the client's face. Shine the light toward the bridge
of the nose while the client stares straight ahead. Note
the light reflected on the corneas.
2 Perform cover test. The cover test detects deviation in
alignment or strength and slight deviations in eye
movement by interrupting the fusion reflex that
normally keeps the eyes parallel.

Ask the client to stare straight ahead and focus on a

distant object. Cover one of the client's eyes with an
opaque card. As you cover the eye, observe the
uncovered eye for movement. Now remove the opaque
card and observe the previously covered eye for any
movement. Repeat test on the opposite eye.
3 Perform the cardinal fields of gaze test, which assesses
eye muscle strength and cranial nerve function.

Instruct the client to focus on an object you are holding

(~ 12 in. from the client's face). Move the object
through the six cardinal positions of gaze in a clockwise
direction and observe the client's eye movements.
External Eye Structure
INSPECTION AND PALPATION
1 Inspect the eyelids and eyelashes. Note width and
position of palpebral fissures.
2 Assess ability of eyelids to close.
 Note the position of the eyelids in comparison with the
eyeballs. Also note any unusual
● Turnings
● Color
● Swelling
● Lesions
● Discharge
3 Observe for redness, swelling, discharge, or lesions.
4 Observe the position and alignment of the eyeball in
the eye socket.
5 Inspect the bulbar conjunctiva and sclera. Have the
client keep the head straight while looking from side to
side then up toward the ceiling. Observe clarity, color,
and texture.
External Eye Structures
Inspect the palpebral conjunctiva.
1 Put on gloves for this assessment procedure. 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 the
palpebral conjunctiva (Fig. 16-14). Avoid putting
pressure on the eye. Ask the client to look up as you
observe the exposed areas.
2 Evert the upper eyelid. Ask the client to look down with
their eyes slightly open. Gently grasp the client's upper
eyelashes and pull the lid downward
3 Place a cotton-tipped applicator ~ 1 cm above the eyelid
margin and push down with the applicator while still
holding the eyelashes
4 Hold the eyelashes against the upper ridge of the bony
orbit just below the eyebrow, to maintain the everted
position of the eyelid. Examine the palpebral
conjunctiva for swelling, foreign bodies, or trauma.

Return the eyelid to normal by moving the lashes

forward and asking the client to look u and blink. The
eyelid should return to normal.
5 Inspect the lacrimal apparatus. Assess the areas over
the lacrimal glands (lateral aspect of upper eyelid) and
the puncta (medial aspect of lower eyelid).
6 Palpate the lacrimal apparatus. Put on disposable
gloves to palpate the nasolacrimal duct to assess for
blockage. Use one finger and palpate just inside the
lower orbital rim.
7 Inspect the cornea and lens. Shine a light from the side
of the eye for an oblique view. Look through the pupil
to inspect the lens.
8 Inspect the iris and pupil. Inspect shape and color of iris
and size and shape of pupil. Measure pupils against a
gauge if they appear larger or smaller than normal or if
they appear to be two different sizes.
9 Test pupillary reaction to light. Test for direct response
by darkening the room and asking the client to focus on
a distant object. To test direct pupil reaction, shine a
 light obliquely into one eye and observe the pupillary
reaction. Shining the light obliquely into the pupil and
asking the client to focus on an object in the distance
ensures that pupillary constriction is a reaction to light
and not a near reaction.
10 Assess consensual response at the same time as direct
response by shining a light obliquely into one eye and
observing the pupillary reaction in the opposite eye.
11 Test accommodation of pupils. Accommodation occurs
when the client moves their focus of vision from a
distant point to a near object, causing the pupils to
constrict. Hold your finger or a pencil about 12-15 in.
from the client. Ask the client to focus on your finger or
pencil and to remain focused on it as you move it closer
toward the eyes.
Internal Eye Structure
12 Using an ophthalmoscope, inspect the internal eye. To
observe the red reflex, set the diopter at 0 and stand
10-15 in. from the client's right side at a 15-degree
angle. Place your free hand on the client's head, which
helps limit head movement (Fig. 16-20). Shine the light
beam toward the client's pupil.
13 Inspect the optic disc. Keep the light beam focused on
the pupil and move closer to the client from a
15-degree angle. You should be very close to the client's
eye (about 3-5 cm), almost touching the eyelashes.
Rotate the diopter setting to bring the retinal structures
into sharp focus. The diopter should be 0 if neither the
examiner nor the client has refractive errors. Note
shape, color, size, and physiologic cup.
14 Inspect the retinal vessels. Remain in the same position
as described previously. Inspect the sets of retinal
vessels by following them out to the periphery of each
section of the eye. Note the number of sets of arterioles
and venules.
15 Also note color and diameter of the arterioles.
16 Observe the arteriovenous (AV) ratio.
17 Look at AV crossings.
18 Inspect retinal background. Remain in the same
position described previously and search the retinal
background from the disc to the macula, noting the
color and the presence of any lesions.
19 Inspect fovea (sharpest area of vision) and macula.
Remain in the same position described previously. Shine
the light beam toward the side of the eye or ask the
client to look directly into the light. Observe the fovea
and the macula that surrounds it.
20 Inspect anterior chamber. Remain in the same position
and rotate the lens wheel slowly to +10, +12, or higher
to inspect the anterior chamber of the eye.
ASSESSING EYE TRAUMA
21 In the event of an eye trauma in which the client is
experiencing eye pain, discomfort, or feels something is
in the eye, observe for:
 ● Foreign body that remains after gentle washing
● Perforated globe
● Blood in eye
22 In the case of blunt eye trauma, observe for:
● Lid swollen shut
● Blood in anterior chamber
● White/hazy cornea
● Irregularly shaped, fixed, dilated, or constricted
pupil.

GIVEN SCORES / TOTAL NUMBER OF SCORES * 50+50 =

_______________________________
Signature of Clinical Instructor/Date