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    Physical Assessment Guide Eyes PDF

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    ALTHEA BORJA
    This document provides a checklist for performing a physical assessment of a patient's eyes. The checklist includes steps to assess visual acuity, eye movements, the external eye structures like eyelids and conjunctiva, and internal eye structures by examining the fundus using an ophthalmoscope. The assessment is meant to document objective findings which can then be used to formulate nursing diagnoses, identify problems, and determine if any referrals are needed.

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    Physical Assessment Guide Eyes PDF

    Uploaded by

    ALTHEA BORJA
    108 views2 pages
    This document provides a checklist for performing a physical assessment of a patient's eyes. The checklist includes steps to assess visual acuity, eye movements, the external eye structures like eyelids and conjunctiva, and internal eye structures by examining the fundus using an ophthalmoscope. The assessment is meant to document objective findings which can then be used to formulate nursing diagnoses, identify problems, and determine if any referrals are needed.

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    Physical-Assessment-Guide-Eyes (1).pdf

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    This document provides a checklist for performing a physical assessment of a patient's eyes. The checklist includes steps to assess visual acuity, eye movements, the external eye structures like eyelids and conjunctiva, and internal eye structures by examining the fundus using an ophthalmoscope. The assessment is meant to document objective findings which can then be used to formulate nursing diagnoses, identify problems, and determine if any referrals are needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    108 views2 pages

    Physical Assessment Guide Eyes PDF

    Uploaded by

    ALTHEA BORJA
    This document provides a checklist for performing a physical assessment of a patient's eyes. The checklist includes steps to assess visual acuity, eye movements, the external eye structures like eyelids and conjunctiva, and internal eye structures by examining the fundus using an ophthalmoscope. The assessment is meant to document objective findings which can then be used to formulate nursing diagnoses, identify problems, and determine if any referrals are needed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    PATIENT’S NAME: ______________________________________________________ DATE OF ASSESSMENT: __________________________________

    PATIENT AGE: ______________ BIRTHDAY: ________________________________ TIME OF ASSESSMENT: __________________________________

    ASSESSMENT OF THE EYES


    PERFORMING PHYSICAL ASSESSMENT
    Use the following Physical Assessment Checklist to examine the eye of a peer, friend, or family
    member. Column 1 can be used by you to guide your physical assessment. Column 2 may be
    used for your documentation.

    Physical Assessment Checklist

    Physical Assessment Guide to Collect Objective Client Data


    Assessment Skill
    1. Gather equipment (Snellen chart,
    handheld Snellen chart or near-vision
    screener, penlight, opaque card, and
    ophthalmoscope).
    2. Explain procedures to client.
    Perform Vision Tests
    1. Distant visual acuity

    2. Near visual acuity

    3. Visual fields
    Perform Extraocular Muscle Function Tests
    1. Corneal light reflex

    2. Cover test

    3. Positions test
    External Eye Structures
    1. Inspect eyelids and lashes (width and
    position of palpebral fissures, ability to
    close eyelids, direction of eyelids in
    comparison with eyeballs, color, swelling,
    lesions, or discharge)
    2. Inspect positioning of eyeballs (alignment
    in sockets, protruding or sunken)
    3. Inspect positioning of eyeballs (alignment
    in sockets, protruding
    4. Inspect the palpebral conjunctiva
    (eversion of upper eyelid is usually

    ______________________________________
    NAME AND SIGNATURE OF EXAMINER
    PATIENT’S NAME: ______________________________________________________ DATE OF ASSESSMENT: __________________________________
    PATIENT AGE: ______________ BIRTHDAY: ________________________________ TIME OF ASSESSMENT: __________________________________

    performed only with complaints of eye


    pain or sensation of something in eye).
    5. Inspect the lacrimal apparatus over the
    lacrimal glands (lateral aspect eyelid).
    Observe for swelling, redness, or
    drainage.
    6. Palpate the lacrimal apparatus, noting
    drainage from the puncta when palpating
    the nasolacrimal duct
    7. Inspect the cornea and lens by shining a
    light to determine transparency.
    8. Inspect the iris and pupil for shape and
    color of the iris and size and shape of the
    pupil.
    9. Test pupillary reaction to light (in a
    darkened room, have client focus on a
    distant object, shine a light obliquely into
    the pupil, and observe the pupil’s
    reaction to light—normally, pupils
    constrict).
    10. Test accommodation of pupils by shifting
    gaze from far to near (normally, pupils
    constrict).
    Internal Eye Structures
    1. Inspect the fundus for:
    • Optic disk
    • Retinal vessels
    • Fovea and macula
    • Anterior chamber
    Analysis of Data

    1. Formulate a Nursing Diagnosis

    2. Formulate collaborative problems

    3. Make necessary referrals

    ______________________________________
    NAME AND SIGNATURE OF EXAMINER

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