1. Chapter 13—Eyes Assessment

2. Structure and Function
Eye: sensory organ of sight
Orbital socket: protects complex internal eye structures
Approximate diameter of 1 in. (2.5 cm)
Extraocular structures: support, protect eyeball
Eyelids
Palpebral fissure
Lid margins; limbus
Conjunctiva; sclera
Lacrimal apparatus

3. Structure and Function—(cont.)

4. Structure and Function—(cont.)
Extraocular muscle function: six muscles
Superior rectus: elevates upward; adducts, rotates medially
Inferior rectus: rotates downward; adducts, rotates medially
Lateral rectus: moves laterally
Medial rectus: moves medially
Superior oblique: turns downward; abducts, rotates laterally
Inferior oblique: turns upward; abducts, turns laterally

5. Structure and Function—(cont.)

6. Structure and Function—(cont.)
Intraocular structures
Three layers of tissue
Outer: sclera; cornea
Middle (vascular): iris; ciliary body; choroids
Inner (neural): retina
Three chambers: anterior; posterior; vitreous
Retina: receives/transmits stimuli to brain
Optic disc: opening for optic nerve head
Macula: area of greatest cone concentration

7. Structure and Function—(cont.)

8. Structure and Function—(cont.)
Vision
Stimuli enters structure via cornea; refracted, inverted, reversed
Focused on retina; communicated via visual pathway to brain
Image returns in original form in brain
Neural pathway (part of CNS)
Optic nerves; optic chasm; optic tracts (continue into optic region of cerebral cortex)

9. Structure and Function—(cont.)

10. Lifespan Considerations: Older Adults
Changes in eye structure and vision
Eyes sit deeper in orbits; eyebrows thin
Conjunctiva thin, may yellow
Iris: irregular pigmentation
Decreased tear formation
Vision may decline
Smaller pupils  loss of accommodation; decreased night vision; decreased depth perception
Lens enlarges, transparency decreases

11. Urgent Assessment Gradual vision loss: nonemergent
Eye trauma, injuries
Rapid assessment of the eye
Foreign bodies; lacerations; hyphema
Testing ocular movements; examining optic disc
Acute glaucoma (medical emergency)
Blockage of fluid: base between iris, cornea
Can result in permanent vision loss, if untreated

12. Subjective Data Collection
Assessment of risk factors
Past medical history
Eye: conditions, surgery, health; allergies
Corrective prescriptions; eye protection
Nutritional status
Medications
Family history
Risk factors
Exposure: viruses; environmental

13. Risk Reduction and Health Promotion
Diabetes mellitus: increase eye problem risk
Diabetic retinopathy; cataracts; glaucoma
Sunlight exposure
Poor diet
Foods: promote eye health
Deep-water fish; fruits/vegetables (carrots, spinach)
Hydration
Visual health goals

14. Common Symptoms Pain Trauma or surgery Visual change
Blind spots, floaters, halos
Discharge
Change in ADLs
Lifespan considerations: older adults
Cultural considerations

15. Question The neural pathway includes what?
Optic nerve and peripheral nervous system
Optic chiasm and optic tracts
Optic tracts and eyes
Optic chiasm and cranial nerve VIII

16. Answer
Rationale: The neural pathway consists of the optic nerves, optic chiasm, and optic tracts that continue into the optic region of the cerebral cortex. The neural pathway is part of the central nervous system.

17. Objective Data Collection
Common and specialty or advanced techniques
Equipment
Preparation
Assessment of visual acuity
Distance vision: Snellen test; Allen test
Near vision: Jaeger chart
Color vision: Ishihara cards

18. Objective Data Collection—(cont.)
Assessment of visual fields
Static confrontation
Kinetic confrontation
Assessment of extraocular muscle movements
Corneal light reflex (Hirschberg): strabismus
Cover test: ocular deviation
Cardinal fields of gaze: misalignment, uncoordinated eye movements
Documentation of normal findings

19. Assessment of External Eyes
External eye structures
Lacrimal apparatus; Bulbar conjunctiva
Sclera; cornea; lens
Assessment of exterior ocular structures
Iris; pupils
Special techniques
Eversion of the eyelid
Fluorescein examination: cornea

20. Assessment of Internal Ocular Structures
Domain of APRN
Ophthalmoscope: light source; viewing aperture; lens refraction adjustment
Mydriatic drops: short-acting ciliary muscle paralytics to dilate pupil
Not used: neurological assessment
Fundus examination
Optic disc inspection
Blood vessels (retina)
Macula examination

21. Lifespan Considerations: Older Adults
Occur slowly, often overlooked: age-related visual changes + consequences
Presbyopia: normal aging
Leading causes of blindness in United States
Cataracts; age-related macular degeneration (AMD)
Central vision acuity loss
Diabetic retinopathy
Testing older adults with dementia: Strategies
Cultural considerations

22. Critical Thinking
Diagnostic reasoning: Nursing Diagnoses, Outcomes, Interventions
Outcomes (partial list)
Patient will remain safe in home environment.
Patient will state measures to reduce risk of visual loss.
Nursing interventions (partial list)
Keep furniture out of pathways and keep cords against walls.
Ensure access to eyeglasses or magnifiers as needed.

23. Question
When inspecting the bulbar conjunctiva, what would you expect to find?
A pink to light red color
Small areas of rough tissue
Small blood vessels
An opaque membrane

24. Answer
Bulbar conjunctiva is normally transparent with small blood vessels visible.

25. NCLEX-Style Review Questions
Which of the following patients would require immediate nursing care?
An 8-year-old girl with pink conjunctivae and ­drainage
A 20-year-old man with sudden visual loss after playing football
A 52-year-old woman with clouding of vision
A 77-year-old man with loss of vision in his peripheral fields

26. NCLEX-Style Review Questions
Rationale: Sudden loss of vision is an emergency, especially following a potentially traumatic injury; this patient is at risk for retinal detachment. The 8-year-old girl may have conjunctivitis. The 52-year-old woman has symptoms of cataract, and the 77-year-old man has symptoms of macular degeneration.

27. NCLEX-Style Review Questions
Which of the following teaching points would the nurse emphasize related to eye health?
Always wear eye protection for occupational ­exposures.
Eat a diet high in animal protein and dairy.
Exercise five times a week for at least 20 minutes.
Get at least 7 hours of sleep each night.

28. NCLEX-Style Review Questions
Rationale: Two health goals are to (1) increase the proportion of public and private schools that require use of appropriate head, face, eye, and mouth protection for students participating in school-­sponsored physical activities and (2) reduce occupational eye injury and increase the use of appropriate personal protective eyewear in recreational activities and hazardous situations around the home.

29. NCLEX-Style Review Questions
Which of the following symptoms would the nurse ­expect the patient to report as translucent specks that drift across the visual field?
Blind spot
Ptosis
Halo
Floater

30. NCLEX-Style Review Questions
Rationale: A blind spot may be related to a problem of the optic nerve (CN II). Ptosis is usually related to stroke or paralysis in the eye area. A halo is seen in patients with glaucoma, lens opacities, and some drug toxicities.

31. NCLEX-Style Review Questions
When working with an older adult, what would the nurse emphasize as increased risks for the patient?
Myopia and strabismus
Blepharitis and chalazion
Glaucoma and cataracts
Exophthalmos and presbyopia

32. NCLEX-Style Review Questions
Rationale: Glaucoma, cataracts, and macular degeneration are all more common in the elderly. Myopia is nearsightedness; with strabismus, a person cannot align both eyes simultaneously under normal conditions (cross eyes). Blepharitis is inflammation of the margin of the eyelid; chalazion is a cyst in the eyelid. Exophthalmos is anterior protrusion of the eyeball out of the socket; presbyopia is believed to be caused by the loss of elasticity of the crystalline lens.

33. NCLEX-Style Review Questions
A public health nurse is performing annual vision screening for residents in senior housing. Which of the following charts would the nurse most likely be using?
Allen chart
Snellen chart
Ishihara cards
Confrontation cards

34. NCLEX-Style Review Questions
Rationale: The Allen chart is used to test near vision. Ishihara cards are used to test color blindness. Confrontation is a test for peripheral vision.

35. NCLEX-Style Review Questions
Which of the following scores for distance vision ­indicates the patient with the poorest vision?
200/20
18/20
24/20
20/100

36. NCLEX-Style Review Questions
Rationale: Normal refractive index is 20/20. Visual acuity for distance vision is documented in reference to what a person with normal vision can see standing 6 meters (20 feet) in front of the test (which is the numerator). The numerator is compared to what a person with normal visual acuity could read on that particular line (which is the denominator). Someone with 20/20 vision can read at 20 feet what a person with normal vision can read at 20 feet.

37. NCLEX-Style Review Questions
The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of
the loss of accommodation.
anisocoria.
amblyopia.
asthenopia.

38. NCLEX-Style Review Questions
Rationale: Loss of the ability to accommodate (contract the pupil for near ­vision) begins at around age 40 years, when many patients start using reading glasses. Unequal pupils usually are from a defect in efferent nervous pathways controlling the oculomotor nerve. ­Amblyopia (lazy eye) is used to describe a condition in which vision in one eye is reduced because the eye and brain do not work together correctly. Asthenopia (eye strain) develops after reading, computer work, or other visually tedious tasks.

39. NCLEX-Style Review Questions
Peripheral vision is evaluated by the nurse using the
corneal light test.
cover test.
confrontation test.
cardinal fields of gaze test.

40. NCLEX-Style Review Questions
Rationale: The corneal light reflex is a test for strabismus. The cover test is to assess the presence and amount of ocular deviation. The cardinal fields of gaze test is used to evaluate motor function in the eyes.

41. NCLEX-Style Review Questions
The cranial nerves involved with eye movement include
II, V, and VII.
III, IV, and VI.
IV, V, and VIII.
V, VI, and VII.

42. NCLEX-Style Review Questions
Rationale: The cranial nerves for the eye include II, III, IV, and VI. The optic nerve is in the central nervous system, whereas cranial nerves III, IV, and VI control the muscles of the eye.

43. NCLEX-Style Review Questions
The nurse assesses the response of the eye to light and documents normal findings as
PEERLA.
PERRLA.
PERLLA.
PERLAA.

44. NCLEX-Style Review Questions
Rationale: The pupils are equal, round, and reactive to light and accommodation. This is abbreviated as PERRLA.