Definition
Assessment of eye is a vital component of both general physical and neurological examinations. It helps detect visual impairments, ocular diseases, systemic conditions, and even neurological deficits.
Itis the systematic assessment or examination of the eves to identify any deviation from the normal. It consists of the external examination, examination using ophthalmoscope and assessment of the functional aspect of the eyes.
Articles Required
- Torch with battery.
- Ophthalmoscope.
- Snellen’s chart.
- Colour plates (red, green, blue).
Procedure
| Nursing Actions | Rationale | |
| 1. | Explain the procedure to the patient and make the patient feel comfortable. | It ensures cooperation from the patient. |
| 2. | Assemble the articles near the patient. | It enables a systematic stepwise assessment without any delay. |
| 3. | Take note of the history of presenting complaints along with other relevant information. General observation – How patient walks, gait, stature, position, skin colour, speech and odour. Chief complaints – Blurred vision, loss of vision, redness in eyes, etc. Visual and ocular history – Duration of complain, history of recurrence, progress of disease, duration of treatment, previous injuries or surgeries, last eye examination. Medical history – Presence of any systemic disease, any medications that cause systemic changes in vision and ocular manifestations, etc. Family ocular history – History of similar disease of the eye or vision loss, etc. On the basis the data collected, and the general observation made proceed for further assessment. | It prepares the patient for individualized assessment. |
| 4. | Perform the assessment in a stepwise orderly manner as described below: A. External examination: In this The anterior segment of the eyes and their appendages are examined. Technique used: Inspection, palpation. Assess for: General appearance of the eyelids, eyelashes, and lacrimal apparatus. Observe for: a. Redness around the eye. b. Discharge or crusting. C. Growths on eyes or eyelids. d. Excessive tearing. Position and mobility can be observed by having the patient rotate the eyes, looking up, down, and to each side. | |
| B. Pupillary response: Reaction to light – Seat the patient in an area with even lighting and instruct him to fix his gaze on a distant object. Cover one eye and shine a flashlight in front of the exposed eye. Near point reaction – When the gaze is changed from a distant object to an object close at hand, the pupils should contract. The assessment of pupils is performed and remembered by using the acronym PERRLA. | The pupil should contract (constrict) because of the light. This response is called a direct reaction. The covered pupil should also contract. This response is called a consensual reaction. | |
| C. Ophthalmoscope examination By looking through the various lenses of an ophthalmoscope, the trained examiner views and the internal structures of the eye are assessed. This examination is routinely performed by the physician. | ||
| D. Functional examinations: Focusing power (power of accommodation) Method – A line of print is placed close to the eye, then slowly moving it back to the point at which the patient is able to read it. Visual field: Method – Have the patient and the examiner face each other at a distance of about 2-3 feet, each focusing his gaze at the other’s nose. The examiner should then extend his arm to the side, point his finger, and slowly move his arm back in, along a plane half-way between himself and the patient. The examiner’s finger should appear in the patient’s visual field at the same time the examiner sees it (assuming the examiner’s visual field is grossly normal). Colour sense is tested by using specially designed colour plates (Ishihara test) to distinguish red, green and blue colour. Visual acuity testing is done with the Snellen’s chart or one of its modifications. Each eye is tested separately, both with and without glasses, if worn. The test is performed at a distance of 6 meters (20 feet). The Snellen’s chart contains rows of letters of varying sizes, arranged so that the normal eye can see them at distances of 6,9,12, 15,21, 30, and 60 meters. (20,30,40,50,70,100, and 200 feet.) If a patient is seated 6 meters (20 feet) from the chart and can read the line of letters or 6 meters, his vision is expressed by the fraction 6/6 (or 20/20). Vision is expressed by a fraction, the numerator denoting the distance at which the test was performed (normally, 6 meters or 20 feet), and the denominator denoting the smallest line of letters which could be read at that distance. If a patient is seated 6 meters from the chart and the smallest line of letters, he is able to read is the one that should be read at a distance of 30 meters, then his vision is expressed at 6/30 (or 20/100). If the largest letters on the chart cannot be read at a distance of 6 meters, the patient is moved toward the chart until he can read the largest letters. Vision is then expressed as a fraction, with the numerator denoting the distance at which the largest line could be read, and the denominator denoting the number of the largest line. If the patient cannot read the largest line at a distance of one meter, the examiner tests the patient’s ability to see hand motion in front of his face. If the patient cannot see the examiner’s hand at a distance of one or two meters, he is tested for light perception. A light is flashed from different directions and the patient is asked from which direction the light appears and when it goes on and, it goes off. If the patient can do this, the examination is recorded as “light perception present”: If no light perception is present, a person is technically blind. | The nearest point at which it is readable is the near point of accommodation. | |
| 5. | Wash hands and replace the articles back in the inventory. | Prevents cross infection. |
| 6. | Record the findings. | Ensures proper documentation. |
Special Considerations
The test for visual acuity and ophthalmoscope examination is usually performed by the eye specialist. However, the steps of the eye examination should be familiar to the nurse.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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