St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

COLLEGE DEPARMENT

DEPARTMENT OF NURSING

NURSING PROCEDURE

ASSESSING EYES

Name: __________________________________________________________Date: _______________

Course/Year_________________Clinical Instructor: _______________________Score: _____________

Direction: Rate the procedure base on the rating scale below by putting a check mark on the
column provided beside the steps as follows:

5 The skill was performed very comprehensively.

4 The skill was performed comprehensively.
3 The skill was performed with some minor errors.
2 The skill was performed with major errors.
1 The skill was performed with none of the required features at all.

ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL 5 4 3 2 1

FINDINGS
EVALUATING VISION
Test distant visual acuity. Normal distant visual Myopia (impaired far
Position the client 20 ft from acuity is 20/20 with or vision) is present when
Snellen or E Chart and ask her without corrective the second number in
to read each to line until she lenses. This means the test result is larger
cannot decipher the letters or that the client can than the first 20/40. The
their direction. distinguish what the higher the second
person with normal number, the poorer the
vision can distinguish vision. A client is
During the vision test, note from 20 ft away. considered legally blind
any client behaviors (i.e., when the vision in the
leaning forward, heat tilting, or better eye with
squinting) that could be corrective lenses is
unconscious attempts to see 20/200 or less. Refer
better any client with vision
worse than 20/30 for
further evaluation.
Test near visual acuity. Use Normal near visual Presbyopia (impaired
this test for middle-aged clients acuity is 14/14 (with or near vision) is indicated
and others who have difficulty without corrective when the client moves
with near vision or with lenses). This means the chart away from the
reading. that the client can eyes to focus on the
read what the normal print. It is caused by
Give the client a hand-held eye can read from a decreased
vision chart (e.g., Jaeger distance of 14 in. accommodation.
reading card, Snellen card, or
comparable chart) to hold 14 Presbyopia is a
in from the eyes. Have the common condition in
client cover on eye with an clients over 45 years of
opaque card before reading age.

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from top (largest print) to
bottom (smallest print). Repeat
the test for other eye.
Test visual fields for gross With normal peripheral A delayed or absent
peripheral vision. To perform vision, the client perception of the
the confrontation test, position should see the examiner’s finger
yourself approximately 2 ft examiner’s finger at indicates reduced
away from the client at eye the same time the peripheral vision. Refer
level. Have the client cover the examiner sees. the client for further
left eye while you cover your Normal visual field evaluation
right eye. Look directly at each degrees are
other with your uncovered approximately as
eyes. Next, fully extend your follows:
arm at midline and slowly  Inferior: 70
move one finger (or a pencil) degrees
upward from below until the  Superior: 50
client sees your finger (or degrees
pencil). Test the remaining  Temporal: 90
three visual fields of client’s degrees
right eye (i.e., superior,  Nasal: 60
temporal and nasal) repeat the degrees
test for the opposite eye.
TESTING EXTRAOCULAR NORMAL FINDINGS ABNORMAL 5 4 3 2 1
MUSCLE FUNCTION FINDINGS
Perform corneal light reflex The reflection on the Asymmetric position on
test. This test assesses light on the corneas the light reflex indicates
parallel alignment of the eyes. should be in the exact deviated alignment of
Hold a penlight approximately same spot on each the eyes. This may due
12 in from the client’s face. eye, which indicates to muscle weakness or
Shine the light toward the parallel alignment. paralysis.
bridge of the nose while the
client stares straight ahead.
Note the light reflected on the
corneas.
Perform cover test. The The uncovered eye The uncovered eye will
cover test detects the deviation should remain fixed move to establish focus
in alignment or strength and straight ahead. The when the opposite eye
slight deviations in eye covered eye should is covered. When the
movement by interrupting the remain fixed straight covered eye is
fusion reflex that normally ahead after being uncovered, movement
keeps the eyes parallel. uncovered. to re-establish focus
occurs. Either of these
Ask the client to stare straight findings indicate a
ahead and focus on a distant deviation in alignment of
object. Cover one of the the eyes and muscle
client’s eyes with an opaque weakness.
card. As you cover the eye,
observe the uncovered eye for Phoria is a term used to
movement. Now remove the describe misalignment
opaque card and observe the that occurs only when
previously covered eye for any fusion reflex is blocked.
movement. Repeat test on the Strabismus is constant
opposite eye. malalignment of the
eyes.
Tropia is a specific pf
misalignment:
Esotropia is an inward

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 turn of the eye, and
Exotropia is an
outward turn of the eye.

Perform the cardinal Eye movement Failure to eyes to follow movement

fields of gaze test, which should be smooth symmetrically in any or all
assesses eye muscle and symmetric directions indicates a weakness in
strength and cranial nerve throughout all six one or more extraocular muscles
function. directions. or dysfunction of the cranial nerve
that innervates the particular
Instruct the client to focus muscle.
on an object you are
holding (approximately 12 Nystagmus—an oscillating
in from the client’s face). (shaking) movement of the eye—
Move the object through the may be associated with an inner
six cardinal positions of ear disorder, multiple sclerosis,
gaze in a clockwise brain lesions, or narcotics use.
direction, and observe the
client’s eye movements.
EXTERNAL EYE
STRUCTURS
INSPECTION AND NORMAL ABNORMAL FINDINGS 5 4 3 2 1
PALPATION FINDINGS
Inspect the eyelids and The upper lid Drooping of the upper lid, called
eye lashes. margin should be ptosis (formal term
between the upper blepharoptosis), may be attributed
Note width and position of margin of the iris to oculomotor nerve damage,
palpebral fissures. and the upper myasthenia gravis, weakened
margin of the pupil. muscle or tissue, or a congenital
The lower lid disorder. Retracted lid margins,
margin rests on the which allow for viewing of the
lower border of the sclera when the eyes are open,
iris. No white sclera suggest hyperthyroidism.
is seen above or
below the iris.
Palpebral fissures
may be horizontal.

Assess ability of eyelids to The upper and Failure lids to close completely
close. lower lids close puts client at risk for corneal
easily and meet damage.
completely when
closed.

Note the position of the The lower eyelid is An inverted lower lid is a condition
eyelids in comparison with upright with no called an entropion, which may
the eyeballs. Also note any inward or outward cause pain and injure the cornea
unusual turning. Eyelashes as the eyelash brushes against the
 Turnings are evenly conjunctiva and cornea.
 Color distributed and cure
 Swelling outward along the Ectropion, an inverted lower
 Lesions lid margins. eyelid, results in exposure and
 Discharge Xanthelasma, drying the conjunctiva. Both
raised yellow conditions interfere with normal
plaques located tear drainage.
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 most often near the
inner canthus, are a
normal variation
associated with
increasing age and
high lipid levels.

Skin on both Redness and crusting along the lid

Observe for redness, eyelids is without margins suggest seborrhea or
swelling, discharge or redness, swelling, blepharitis, an infection caused by
lesions. or lesions. Staphylococcus aureus.
Hordeolum (style), a hair follicle
infection, causes local redness,
swelling and pain. A chalazion, an
infection of the meibomian gland
(located in the eyelid), may
produce extreme swelling of the
lid, moderate redness, but minimal
pain.
Observe the position and Eyeballs are Protrusion of the eyeballs
alignment of the eyeball symmetrically accompanied by retracted eyelid
in the eye socket. aligned in sockets margins is termed exophthalmos
without protruding and is characteristic of Graves
or sinking. disease (a type of
hyperthyroidism). A sunken
appearance of the eyes may be
seen with severe dehydration or
chronic wasting illnesses.
Inspect the bulbar Bulbar conjunctiva Generalized redness of the
conjunctiva and sclera. is clear, moist, and conjunctiva suggests
Have the client keep the smooth. Underlying Conjunctivitis (pink eye).
head straight while looking structures are Areas of dryness are associated
from side to side then up clearly visible. with allergies or trauma.
toward the ceiling. Observe Sclera is white. Episcleritis is a local,
clarity, color, and texture. noninfectious inflammation of the
sclera. The condition is usually
characterized by either a nodular
appearance or by redness with
dilated vessels.
Yellow sclera occurs when the
client has jaundice or icterus.
Bright red areas on the sclera
indicate a subconjunctival
hemorrhage. These are often
caused by sneezing, coughing or
vomiting, which may break a blood
vessel. This may lead to
accumulation pf trapped blood,
which is not quickly absorbed. It is
harmless and disappears in 1-2
wks.
Inspect the palpebral
conjunctiva.

Put on gloves for this The lower and Cyanosis of the lower lid suggests
assessment procedure. upper palpebral a heart or lung disorder.
First inspect the palpebral conjunctiva are

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conjunctiva of the lower clear and free of
eyelid by placing your swelling or lesions.
thumbs bilaterally at the
level of the lower bony
orbital rim and gently
pulling down to expose the
palpebral conjunctiva.
Avoid putting pressure on
the eye. Ask the client to
look up as you observe the
exposed areas.
Evert the upper eyelid. Ask Palpebral A foreign body or lesion may cause
the client to look down with conjunctiva is free irritation, burning, pain, and/or
of his/her eyes slightly of swelling, foreign swelling of the upper eyelid.
open. Gently grasp the bodies, or trauma.
client’s upper eyelashes
and pull the lid downward.
Place a cotton-tipped
applicator approximately 1
cm above the eyelid margin
and push down with the
applicator while still holding
the eyelashes.
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 up and blink.
The eyelid should return to
normal.
Inspect the lacrimal No swelling or Swelling of the lacrimal gland may
apparatus. Assess the redness should be visible in the lateral aspect of
areas over the lacrimal appear over seas of the upper eyelid. This may be
glands (lateral aspect of the lacrimal gland. caused by blockage, infection, or
upper eyelid) and the The puncta is an inflammatory condition.
puncta (medial aspect of visible without Redness or swelling around the
the lower eyelid). swelling or redness puncta may indicate an infectious
and is turned or inflammatory condition.
slightly toward the Excessive tearing may indicate a
eye. nasolacrimal sac obstruction.

Palpate the lacrimal No drainage should Expressed drainage form the

apparatus. Put on be noted from the puncta on palpation occurs with
disposable gloves to puncta when duct blockage.
palpate the nasolacrimal palpating the
duct to assess for blockage. nasolacrimal duct.
Use one finger and palpate

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just inside the lower orbital
rim.
Inspect the cornea and The cornea is Areas of roughness or dryness on
lens. Shine a light from the transparent, with no the cornea are often associated
side of the eye for an opacities. The with injury or allergic responses.
oblique view. Look through oblique view shows Opacities of the lens are seen with
the pupil to inspect the lens. a smooth and cataracts.
overall moist Abnoral findings: Corneal scar and
surface; the lens is nuclear cataracts.
free of opacities.
Inspect the iris and pupil. The iris is typically Typical abnormal findings include
Inspect shape and color of round, flat, and irregularly shaped irises, miosis,
iris and size and shape of evenly colored. The mydriasis, and anisocoria.
the pupil. Measure pupils pupil, round with a
against a gauge if they regular border, is If the difference in pupil size
appear larger or smaller centered in the iris. changes throughout pupillary
than normal or if they Pupils are normally response tests, the inequality of
appear to be two different equal in size (3-5 size is abnormal.
sizes. mm). An inequality
in pupil size of less
than 0.5 mm occurs
in 20% of clients.
This condition,
called anisocoria, is
normal.
Test pupillary reaction to The normal Monocular blindness can be
light. consensual detected when light directed to the
Test for direct response by pupillary response blind eye results in no response in
darkening the room and is constriction. either pupil. When the light is
asking the client to focus on directed into the unaffected eye,
a distant object. To test both pupils constrict.
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.
Assess consensual The normal Pupils do not react at all to direct
response at the same time consensual and consensual pupillary testing.
as direct response by pupillary response
shining a light obliquely into is constriction.
one eye and observing the
pupillary reaction in the
opposite eye.

Test accommodation of The normal pupillary Pupils do not constrict; eyes do

pupils. Accommodation responses constriction not converge.
occurs when the client of the pupils and
moves his or her focus of convergence of the
vision from a distant point eyes when focusing on
to a near object, causing a near object.
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the pupils to constrict. (Accommodation and
Hold your finger or a convergence).
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 in toward
the eyes.
INTERNAL EYE NORMAL FINDINGS ABNORMAL FINDINGS 5 4 3 2 1
STRUCTURES
Using an The red reflex should Abnormalities of the red reflex
ophthalmoscope, inspect be easily visible most often result from cataract.
the internal eye. To through the These usually appears as black
observe the red reflex, set ophthalmoscope. The spots against the background of
the diopter at 0 and red area should appear ted red light reflex. Two types of
strand 10-15 in from the round, with regular age-related cataracts are
client’s head, which helps borders. nuclear cataracts and
limit head movement. peripheral cataracts.
Shine the light beam
toward the client’s pupil.

Inspect the optic disc. The optic disc should Papilledema or swelling of the
Keep the light beam be round to oval with optic disc appears as a swollen
focused on the pupil sharp, well defined disc with blurred margins, a
move closer to the client border. hypereremic ( blood filled)
from a 15 degree angle. appearance, more visible and
The nasal edge of the more numerous disc vessels
optic disc may be and lack of visible phyisiologic
blurred. The disc is cup. The condition may result
normally creamy, from hypertension or increased
You should be very close yellow-orange to pink, intracranial pressure.
to the client’s eye ( about and approximately 1.5
3-5 cm) almost touching mm wide.
the eye lashes. Rotate
the diopter setting to bring
the retinal structures into The physiologic cup, The intraocular pressure
sharp focus. The diopter the point at which the associated with glaucoma
should be 0 if neither the optic nerve enters the interferes with blood supply to
examiner nor the client eyeball, appears on the optic structures and results in
has refractive errors. Note optic disc as slightly the following characteristics: an
shape, color size, and depressed and a lighter enlarged physiologic cup that
physiologic cup. color than the disc. The occupies more than half of the
cup occupies less than disc’s diameter, pale base of
half of the disc’s enlarged physiologic cup, and
diameter. The disc’s obscured or displaced retinal
border may be vessels.
surrounded by rings
and crescents, Optic atrophy is evidenced by
consisting of white the disc being white in color
sclera or black retinal and a lack of disc vessels. This
pigment. These normal condition is caused by the
variations are not death of optic nerve fibers.
considered in the optic
disc diameter.
Inspect the retinal Four sets of arterioles Changes in the blood supply to
vessels. Remain in the and venules should the retina may be observed in

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same position as pass through the optic constricted arterioles, dilated
described previously. disc. veins, or absence of major
Inspect the sets of retinal vessels.
vessels by following them
out to the periphery of
each section of the eye.
Note the number of sets
of arterioles and venules.
Also note color and Arterioles are bright red Initially hypertension may cause
diameter of the arterioles. and progressively a widening of the arterioles’
narrow as they move light reflex and the arterioles
away from the optic take on a copper color. With
disc. Arterioles have a long-standing hypertension,
light reflex that appears arteriole walls thicken and
as a thine, white line in appear opaque or silver.
the center of the
arteriole. Venules are
darker red and larger
than arterioles. They
also progressively
narrow as they move
away from the optic
disc.
Observe the The ratio of the
arteriovenous (AV) ratio. arteriole diameter to
vein diameter (AV ratio)
is 2:3 or 4:5.
Look at AV crossings. In a normal AV Arteriole nicking, tapering, and
crossing, the vein banking are abnormal AV
passing underneath the crossings caused by
arteriole is seen right hypertension or arteriosclerosis.
up to the column of
blood on either side of
the arteriole (the
arteriole wall itself is
normally transparent).

Inspect retinal General background Cotton wall patches (soft

background. appears consistent in exudates) and hard exudates
Remain in the same texture. The red-orange from diabetes and hypertension
position described color of the background appear as light-colored spots
previously and search the is lighter near the optic on the retinal background.
retinal background from disc. Hemorrhages and
the disc to the macula, microaneurysms appear as red
noting the color and the spots and streaks on the retinal
presence of any lesions background.
Inspect fovea (sharpest The macula is the Excessive clumped pigment
area of vision) and darker area, one-disc appears with detached retinas
macula. Remain in the diameter in size, or retinal injuries. Macular
same position described located to the temporal degeneration may be due to
previously. Shine the light side of the optic disc. hemorrhages, exudates, or
beam toward the side of Within this area is a cysts.
the eye or ask the client star-like light reflex
to look directly into the called the fovea.
light. Observe the fovea
and the macula that
surrounds it.

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Inspect anterior The anterior chamber is Hyphemia occurs when injury
chamber. Remain in the transparent. causes red blood cells to collect
same position and rotate in the lower half of the anterior
the lens wheel slowly to chamber.
+10, +12, or higher to Hypopyon usually results from
inspect the anterior an inflammatory response in
chamber of the eye. which white blood cells
accumulate in the anterior
chamber and produce
cloudiness in front of the iris.
ASSESING EYE NORMAL FINDINGS ABNORMAL FINDINGS 5 4 3 2 1
TRAUMA
In the event of an eye No foreign body is Refer the client to an eye doctor
trauma in which the client observed. The eye immediately if a foreign body
is experiencing eye pain, globe is intact with no cannot be removed with gentle
discomfort, or feel indication of blood in washing, there is perforation of
something is in the eye, eye. globe, blood in eye, and/or
observe for: client has impaired vision.
 Foreign body that
remains after gentle
washing
 Perforated globe
 Blood in eye
In case of blunt eye There is no swelling of Refer client to eye doctor
trauma, observe for: eye, no blood in immediately if eye is swollen,
 Lid swollen shut anterior chamber, blood is observed in anterior
 Blood in anterior cornea is clear, pupils chamber, cornea is hazy, or
chamber equal and reactive to pupils are irregularly shaped,
 White/hazy cornea light. fixed, dilated, or constricted.
 Irregularly See a list of common eye
shaped, fixed, injuries and need for referral,
dilated, or especially if injury needs
constricted pupil. immediate emergency referral.

Total: ______________

STUDENT LEARNING

Student’s Significant Learning

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Problems Encountered
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Students Signature

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