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54 C h a p t e r 4 Physical Assessment

PROCEDURE 4.1
Assessing the Eyes
OVERVIEW
● The eyes are the sensory organ of vision. They allow humans to be
an integral part of the world.
● Careful assessment of the eyes and vision is essential for promoting

health and well-being.

P R E PA R AT I O N
● Review related history including
• Vision difficulty, photophobia.
• Eye pain; external eye problems, such as excessive tearing;
discharge; entropion; and ectropion.
• Glaucoma.
• Use of glasses or contact lenses.
Special Considerations
Pediatric Patient
• Special accommodations must be made for the evaluation of visual
acuity in children, adults who cannot read, and those patients who
do not speak English. Often, the Snellen E chart can be used, and the
patient can point a finger in the direction that the legs are facing.
Picture cards can also be used. A translator or family member can
translate directions.
• In examining the eyes of infants and children, it is important to
remember that a child does not achieve 20/20 vision until the age of
6 or 7. Color vision should be tested once between the ages of 4 and
8. Testing for strabismus is an important screening to perform in
early childhood, to receive the best prognosis. A funduscopic exami-
nation is difficult to perform on infants, but the red reflex and pupil-
lary response to light should be checked. School-age children’s
funduscopic examinations can be performed using the same proce-
dure as that for adults.
Elderly Patient
• The loss of elasticity in the skin may make the lids appear heavier
and the eyes appear sunken.
• Decreased tear production causes the eye to look and feel dry.
• Central acuity and peripheral vision may decrease as well.
• Cataract formation, glaucoma, and macular degeneration are more
prevalent in the aging population.
• Careful assessment is imperative to maintain adequate vision in
these populations.
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P r o c e d u r e 4 . 1 Assessing the Eyes 55

EXPECTED OUTCOMES
● Completion of the eye examination while maintaining the patient’s
comfort
● Examination adjusted for age, and developmental and educational

levels

R E L E VA N T N U R S I N G D I A G N O S E S
● Possible disturbed sensory perception: visual

EQUIPMENT/SUPPLIES
Snellen eye chart
Near-vision card (Jaeger card)
or newsprint
Opaque cover card
Penlight
Ophthalmoscope

FIGURE 4.1 Ophthalmoscope.

I M P L E M E N TAT I O N
➧ Wash hands.
Reduces transmission of microorganisms.
➧ Explain procedure to patient.
Careful explanation reduces the patient’s anxiety.
➧ To test visual acuity.
● Check distance vision using the Snellen eye chart.
This is the most common and accurate measure of visual acuity.
● Position the patient exactly 20 feet from the chart.
Ensures accurate measurement of visual acuity.
● If patient wears corrective lenses, conduct the test with them on.
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56 C h a p t e r 4 Physical Assessment

Only remove reading glasses because they will blur the patient’s far vision.
Record results and make sure to state the results were with corrective lenses
in place.
● Direct patient to cover one eye with the opaque card and read the
smallest line possible.
Record the result as 20 (distance from the chart) over the number beside the
smallest line of print the patient can read with at least half the numbers cor-
rect.
● Repeat for opposite eye.
Evaluates each eye separately.
● Check near vision in patients who are older than 40 years or in
those complaining of reading difficulty.
Near vision is most commonly impaired in people who are older than 40
years. Use near vision card or newsprint to evaluate near-vision acuity.
● Place the Jaeger card 14 inches in front of the patient’s face.
Ensures accurate measurement of visual acuity.
● If patient wears corrective lenses, conduct the test with them on.
Allows evaluation of corrected vision.
● Direct patient to cover one eye with the opaque card and read the
smallest line possible.
Record the results as J1 through J12 as indicated on the chart.
● Repeat for opposite eye.
Evaluates each eye separately.
● Have patient hold and read from newsprint at a comfortable
distance.
Record the type of reading material and the distance held from the face.
➧ Test visual fields by performing the confrontation test.
This test is a gross measure of peripheral vision. It compares the patient’s
peripheral with the examiner’s.
● Position yourself at eye level and about 2 feet away from the patient.
Allows the patient and examiner to have the same field of vision.
● Direct the patient to cover one eye with the opaque card and to
look straight at you with his or her left eye. Cover your eye opposite
to the patient’s covered one.
Allows the patient and examiner to have the same field of vision.
● Hold a raised finger or pen midline between you and the patient
and slowly advance it from the periphery in several directions
(temporal, nasal, superior, and inferior).
Provides a focus target; tests all peripheral vision fields except the temporal in
which the object should come from slightly behind the patient’s head.
● Have the patient say “now” as the target is first seen; this should be
just about the time that you see the object also.
Compares the patient’s peripheral vision to your own.
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● Repeat the entire procedure for the opposite eye.

Tests peripheral vision of both eyes.
➧ Test extraocular muscle function.
➧ Check corneal light reflex.
Assesses the parallel alignment of the eyes.
● Instruct the patient to stare straight ahead while you shine a light
into his or her eyes from 30 cm (12 inches) away.
● Note the location of the light reflection on the corneas; it should be

in exactly the same spot in each eye.

Allows detection of any deviation in alignment due to eye muscle weakness
or paralysis.
➧ Check for coordinated movement of the eyes.
Elicits any eye muscle weakness during movement.
● Direct patient to hold head still and follow your finger only with his
or her eyes as it moves.
Encourages eye movement only.
● Hold your finger about 30 cm (12 inches) in front of the patient.
Allows the patient to focus comfortably on the object.
● Slowly move your finger from the center out to each of the six car-
dinal fields of gaze, hold it momentarily, and then move it back to
center.
Allows detection of any eye movement that is not parallel. Also detects nys-
tagmus and lid lag.
● Observe for a normal response, which is parallel tracking of the fin-
ger with both eyes.
An abnormal response indicates weakness of an extraocular muscle or dys-
function of the cranial nerve innervating it.
➧ Check for convergence.
Elicits any eye muscle weakness during movement.
● Have the patient watch your finger as it is moved from in front of
the eyes to the bridge of the nose.
Encourages a focal point of vision.
● Observe for medial movement of both eyes.
Elicits an asymmetric response if abnormal.
➧ Inspect the external eye structures.
● Note eyelids and lashes.
Note any visible sclera above the iris, closure, or lesions. Note distribution and
direction of lashes.
● Note the position of the globe.
Protrusion may be indicative of thyroid disorder; sunken eyes may be indica-
tive of dehydration or wasting illness.
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● Note the conjunctiva and sclera.

Indicative of local infection, hemorrhage, or jaundice.
● Note the lacrimal gland.
Redness, swelling or excessive tearing may indicate blockage of the naso-
lacrimal duct.
➧ Inspect the anterior eye structures.
Provides an evaluation of the anatomic structures involved in sight.
● Check the clarity of the cornea by shining a light from the side
onto each eye.
This oblique view allows detection of any irregularities in the corneal surface
such as opacities or irregular ridges in the reflected light.These findings may be
indicative of fluid accumulation or a corneal abrasion, respectively.
● Note the shape and coloration of the irises. Compare the irises
bilaterally.
May indicate infection, glaucoma, or abnormalities in the pupils.
➧ Inspect the pupils for color, size, and equality.
Abnormalities may indicate cataracts or neurologic problems.
➧ Test the pupillary response to light.
Abnormalities may indicate neurologic problems.
● Have the patient look into the distance, then shine a light on each
pupil in turn. Make sure to advance the light from the side to
directly in front of the pupil.
Bringing the light in from the side will elicit a true light reflex. If the light is
advanced from the front, the eyes will constrict to accommodate for near
vision.
● Observe for constriction of the pupil into which the light was
shown (direct response) and for the simultaneous constriction
of the other pupil (consensual response).
These responses provide information on the central nervous system and the
effect of certain drugs, including narcotics and anticholinergics.
➧ Test for accommodation.
Elicits vision problems or eye muscle weakness.
● Direct the patient to focus on an object in the distance, then have
the person focus on your finger held 8 to 10 cm (3–4 inches) from
the nose.
Focusing on distant objects dilates the pupils, whereas focusing on near
objects constricts the pupils.
● Observe the patient for pupillary constriction and convergence.
Absence of constriction or convergence indicates a problem with vision
and/or eye muscle weakness.
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➧ Examine the ocular fundus (retina, optic disk, macula, and retinal
vessels) in a darkened room using an ophthalmoscope.
Perform this examination to view the inner structures of the eye. This is the
only place in the body where you can directly view the blood vessels that are
affected in systemic diseases, namely hypertension.
● Remove eyeglasses worn by either the patient or you.
Eyeglasses obstruct close movement, and you can adjust the diopter setting
to correct your vision.
● Select a large, round aperture with white light for routine
examination.
The light used should have maximum brightness to facilitate an
adequate examination.
● Hold the ophthalmoscope in your right hand up to your right eye
to examine the patient’s right eye while placing your free hand on
the patient’s forehead.
This position allows you to gain close proximity to your patient while your
free hand helps to orient you and secure the patient’s upper lid to help pre-
vent blinking.
● Have the patient focus on a distant fixed object.
Staring at a distant object helps to dilate the pupils and hold the retinal
structures still.
● Begin the examination about 10 inches from the patient slightly
lateral to the patient’s field of vision; note the red reflex and
steadily move closer to the eye.
The red reflex is caused by the reflection of the light of the ophthalmoscope
off the retina; any variations such as dark or black spots may indicate
cataracts.
● Continue moving in along a 15-degree lateral line to locate the
optic disk, which is to the nasal side of the retina; it can also be
found by following a blood vessel as it enlarges.
The larger retinal vessels converge at the optic disk.
● Focus on the optic disk, and note its color, shape, margins, and cup-
disk ratio.
The disk should be creamy yellow-orange to pink, round or oval, with distinct
margins. The cup-disk ratio may vary, but is normally not greater than one
half the disk diameter. Variations in color and margins may indicate pallor or
differences in pigmentation.
● Note the retinal arterioles and veins (darker and larger than arteri-
oles). Observe their branching pattern, contour, and integrity.
Many systemic diseases that affect the vascular system show signs in the reti-
nal vessels. Narrowed, discolored, and/or nicked vessels are some of the most
significant evidence of hypertension and arteriosclerosis.
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60 C h a p t e r 4 Physical Assessment

● Examine the general background of the fundus.

Color should be consistent with the patient’s skin color; look for lesions, exu-
dates, or microaneurysms.
● Last, locate the macula, which should be 2 disc diameters (DD)
temporal to the disc.
Examine this structure last, because it may cause watering and discomfort.
Clumped pigment in the macula may indicate trauma or retinal detachment.

E VA L U AT I O N A N D F O L L O W - U P A C T I V I T I E S
● Compare assessment findings to normal
● Refer patient to optometrist or ophthalmologist as needed for evalu-
ation of abnormal findings

KEY POINTS FOR REPORTING AND RECORDING

● Visual acuity results for the left eye (O.S.) and right eye (O.D.)
separately. For Snellen chart, record the result as 20 over the
number beside the smallest line of print the patient can read
with at least half the numbers correct. For the Jaeger chart,
record the results as J1 through J12 as indicated.
● Results of visual confrontation test, extraocular movements,
normal or abnormal findings.
● Symmetry of corneal light reflex, eyelids.
● Color of conjunctiva and sclera, and any abnormal findings
during the external eye examination.
● Pupillary findings: if normal, may chart PERRLA (pupils equal,
round, reactive to light, and accommodation); if abnormal,
chart findings.
● Fundi findings—shape, margins, vessels, ability to see macula.
Document any abnormal findings in the fundus by noting the
clock position and relation to the optic disk in terms of size
and distance. Example: Noted at 2 o’clock 3 DD from the disk.
● Visual acuity results.
● Patient’s use of corrective lenses or glasses and vision with
“corrected” noted.