ASSESSING EYES

LEGEND:
 5 – Excellent – Able to perform correctly all task at a given time
 4 – Very Satisfactory – Able to perform correctly almost all task at a given time
 3 – Satisfactory – Able to perform correctly some/moderate task at a given time
 2 – Fair – Able to perform correctly few/ very little task at a given time
 1 – Unsatisfactory – Unable to perform correctly all task at a given time.
PROCEDURE 1 2 3 4 5

1. Prior to performing the procedure, introduce self and verify the client’s
identity using agency protocol. Explain to the client what you are going to do,
why it is necessary, and how he or she can participate. Discuss how the results
will be used in planning further care or treatments.
2. Perform hand hygiene and observe other appropriate infection prevention
procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following: family history of
diabetes, hypertension, blood dyscrasia, or eye disease, injury, or surgery;
client’s last visit to a provider who specifically assessed the eyes (e.g.,
ophthalmologist or optometrist); current use of eye medications; use of contact
lenses or eyeglasses; hygienic practices for corrective lenses; current
symptoms of eye problems (e.g., changes in visual acuity, blurring of vision,
tearing, spots, photophobia, itching, or pain).
EXTERNAL STRUCTURES
5. Inspect the eyelids and eyelashes
 Note width and position of palpebral fissures.
 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
 Observe for redness, swelling, discharge or lesions
6. Observe the position and alignment of the eyeball in the eye socket.
7. 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.
8. Inspect palpebral conjunctiva.
 Put on gloves for this assessment procedure.
 First inspect the palpebral conjunctiva of the lower eyelid.
o Place your 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.
o Ask the client to look up as you observe the exposed areas.
 Evert the upper eyelid.
o Ask the client to look down with his or her eyes slightly open.
Gently grasp the client’s upper eyelashes and pull the lid
downward.
o Place a cotton-tipped applicator approximately 1cm above the
eyelid margin and push down with applicator while still holding
the eyelashes.
 o Hold the eyelashes against the upper ridge of the bony orbit just
below the eyebrow, to maintain the everted position of the eyelid.
o Examine the palpebral conjunctiva for swelling, foreign bodies, or
trauma.
o 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.
9. Inspect the lacrimal apparatus.
 Assess the areas over the lacrimal glands (lateral aspect of upper eyelid)
and puncta (medial aspect of the lower eyelid).
10. Palpate the lacrimal apparatus
 Put on disposable gloves to palpate the nasolacrimal duct to assess for
blockage.
o Use one finger and palpate just inside the lower orbital rim.
11. Inspect the cornea and lens.
 Shine a from the side of the eye for an oblique view.
o Look through the pupil to inspect the lens.
12. Inspect the iris and pupil.
 Inspect shape and color of iris and size and shape of pupil. Measure pupils
against a gauge.
13. Test pupillary reaction to light.
 Test for direst response by darkening the room and asking the client to
focus on a distant object.
 To test the direct pupil reaction, shine a light obliquely into the pupil and
asking the client to focus on an object in the distance.
 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.
14. Test accommodation of pupils.
 Accommodation occurs when the client moves his or her focus of vision
from a distant point to a near object, causing the pupils to constrict.
o Hold your finger or a pencil about 12 – 15 inches from the client.
Ask the client to focus on your finger or pencil and to remain
focused as you move it closer in toward the eyes.
INTERNAL EYE STRUCTURE
 Using an ophthalmoscope, inspect the internal eye. To observe the red
reflex, set the diopter at 0 and stand 10 – 15 inches 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.
 Shine a light beam toward the client’s pupil.
15. 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 3-5cm), almost
touching the eye lashes.
 Rotate the diopter setting to bring the retinal structures into sharp focus.
 The diopter should be 0 if either the examiner nor the client has refractive
errors.
 Note shape, color, size, and physiologic cup.
16. 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 arterioles and venules.
 Also note color and diameter of the arterioles.
 Observe the arteriovenous ratio.
 Look at AV crossing.
17. 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.
18. Inspect fovea and macula.
 Remain in the same position described previously.
 Shine he 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.
19. Inspect anterior chamber.
 Remain in the same position described previously.
 Rotate the lens wheel slowly to +10, +12, or higher to inspect the anterior
chamber of the eye.
EXTRAOCULAR MUSCLE TEST
20. Perform corneal light reflex Test.
 Hold a penlight approximately 12 inches 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.
21. Perform the cover test.
 Ask the client to stare straight ahead and focus on a distant object.
 Cover one of client’s eyes with an opaque card.
 As you cover the eye, observe the uncovered eye for movement.
 Remove the opaque card and observe the previously covered eye for any
movement.
 Repeat the test on the opposite eye.
22. Assess six ocular movements to determine eye alignment and coordination.
 Stand directly in front of the client and hold the penlight at a comfortable
distance, such as 30 cm (1 ft) in front of the client’s eyes.
 Ask the client to hold the head in a fixed position facing you and to follow
the movements of the penlight with the eyes only.
 Move the penlight in a slow, orderly manner through the six cardinal fields
of gaze, that is, from the center of the eye along the lines of the arrows in
and back to the center.
 Stop the movement of the penlight periodically so that nystagmus can be
detected.
EVALUATING VISION
23. If the client can read, assess near vision by providing adequate lighting and
asking the client to read from a magazine or newspaper (Jaeger Reading Card,
Snellen Card, or Compatible Chart) held at a distance of 36 cm (14 in.). If the
client normally wears corrective lenses, the glasses or lenses should be worn
during the test. The document must be in a language the client can read.
 Have the client read cover one eye with an opaque card.
 Read from top to bottom.
 Repeat test for other eye.
24. Test distant visual acuity.
 Assess distance vision by asking the client to wear corrective lenses,
unless they are used for reading only (i.e., for distances of only 36 cm [14
in.])
 Ask the client to stand or sit 6 m (20 ft) from a Snellen or character chart,
 cover the eye not being tested, and identify the letters or characters on the
chart.
 Take three readings: right eye, left eye, both eyes.
 Record the readings of each eye and both eyes (i.e., the smallest line from
which the person is able to read one-half or more of the letters).
25. Assess peripheral visual fields to determine function of the retina and neuronal
visual pathways to the brain and second (optic) cranial nerve.
 Have the client sit directly facing you at a distance of 60 to 90 cm (2 to 3
ft).
 Ask the client to cover the right eye with a card and look directly at your
nose.
 Cover or close your eye directly opposite the client’s covered eye (i.e.,
your left eye), and look directly at the client’s nose.
 Hold an object (e.g., a penlight or pencil) in your fingers, extend your arm,
and move the object into the visual field from various points in the
periphery. The object should be at an equal distance from the client and
yourself. 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 the right arm
down from the upward periphery.
c. To test the downward field of the left eye, extend and move the 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.
 Repeat the above steps for the right eye, reversing the process.
26. If the client is unable to see even the top line (20/200) of the Snellen-type
chart, perform selected vision tests.
 LIGHT PERCEPTION (LP)
o Shine a penlight into the client’s eye from a lateral position, and
then turn the light off.
o Ask the client to tell you when the light is on or off.
o If the client knows when the light is on or off, the client has light
perception, and the vision is recorded as “LP.”
 HAND MOVEMENTS (H/M)
o Hold your hand 30 cm (1 ft) from the client’s face and move it
slowly back and forth, stopping it periodically.
o Ask the client to tell you when your hand stops moving.
o If the client knows when your hand stops moving, record the
vision as “H/M 1 ft.”
 COUNTING FINGERS (C/F)
o Hold up some of your fingers 30 cm (1 ft) from the client’s face,
and ask the client to count your fingers.
o If the client can do so, note on the vision record “C/F 1 ft.”
27. Document findings in the client record using printed or electronic forms or
checklists supplemented by narrative notes when appropriate.

Score
135 – 129 1.0
128 – 122 1.25
121 – 115 1.50
114 – 108 1.75
 107 – 101 2.0
100 – 94 2.25
93 – 87 2.5
86 – 80 2.75
79 – 74 3.0

STUDENT:

RATE:

CLINICAL INSTRUCTOR/FACILITATOR:

References
Berman, A., Snyder, S., & Frandsen, G. (2015). Kozier and Erb's Fundamentals of Nursing Tenth Edition. Pearson.

Weber, J. B., & Kelley, J. H. (2018). Health Assessment in Nursing Sixth Edition. Philadelphia: Wolters Kluwer HEalth.