NURB 3060 Exam 4: Assessing Eyes

Which question should the nurse ask when assessing a client for a possible detached retina?

"Are you seeing flashing lights?" Flashing lights suggest detachment of vitreous from retina. Slow central loss of vision is associated with macular degeneration. Peripheral loss in advanced open-angle glaucoma. Bilateral loss is often related to a chemical exposure.

middle layer of the eye

-anterior= iris and ciliary body -posterior= choroid

Jaeger test/pocket screener

-assesses for *near vision acuity* in clients over 40/middle aged -hold 14 in from eye, cover one eye with opaque card, read top to bottom (largest to smallest), repeat on other eye -patients with decreased accommodation will have to move the card further away to see it

what does a normal optic disc look like?

-cream or orange-colored optic disc that is 1.5 mm wide -toward the medial side -where the optic nerve enters the eyeball -normally oval with distinct margins -physiologic cup= indented/lighter part

how often should patients have an eye exam?

-healthy= every 2 years (18-60 years) -annually for anyone 61+

cataracts

-leading cause of blindness, often preventable -clouding/opacities of the usual clear lens of the eye -person sees as though they are looking through a frosty window, especially at night

how do we test visual fields for gross peripheral vision?

-nurse/examiner positions themselves 2 feet away at eye level -have client over their left eye, cover your right, looking at each other -fully extend left arm at midline and move pencil/finger up -normal= client sees examiner's finger at the same time as the examiner -delayed or absent perception of finger= reduced peripheral vision

normal pupil size

3-5 mm

aqueous humor

Aqueous humor is a clear liquid substance produced by the ciliary body that fills the anterior and posterior chambers of the eye. It helps to cleanse and nourish the cornea and lens as well as maintain intraocular pressure

Testing for accommodation

Ask person to focus on distant object, which should dilate the pupils. Then have the person shift their gaze to a near object such of your finger held about 3 inches away from their nose. Normal response includes 1) pupillary constriction and 2) convergence of the axes of the eyes

A nurse assesses a client's pupils for the reaction to light and observes that the pupils are of unequal size. What should the nurse do next in relation to this finding?

Ask the client about previous trauma to the eyes Unequal pupil size is termed anisocoria. Often it is a normal finding but it can indicate trauma to the parasympathetic nerve supply to the iris. The nurse should ask the client about previous trauma to the eye to determine whether this is a new finding or new onset

hyphemia

Bleeding into the anterior portion of the eye

A client tells the nurse that his eyes "are not working right." When the nurse asks what the client means, the client states, "It is like one eye is moving faster than the other." What test would be most appropriate for the nurse to use to assess this client?

Cardinal fields The cardinal fields of gaze allow the nurse to detect muscle defects that cause misalignment or uncoordinated movement of the eyes. Kinetic and static confrontation tests are used to test peripheral vision. The cover test is for accommodation.

What is tonometry used for?

Determining intraocular pressure -normal pressure= 10-21 mmHg -eye pressures >22 mmHg could increase risk for glaucoma

A nurse is inspecting the bulbar conjunctiva and sclera of a 67-year-old client, and notices yellowish nodules on the medial side of the iris. Which of the following is the most appropriate nursing action at this time?

Document the finding and proceed with the examination Yellowish nodules on the bulbar conjunctiva are called pinguecula. These harmless nodules are common in older clients and appear first on the medial side of the iris and then on the lateral side.

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

Glaucoma Seeing rings around lights or halos is associated with narrow angle glaucoma. Diabetes produces change in the retina that can cause blurred vision. Cataracts are caused by clouding of the lens of the eyes. Hypertension affects the blood vessels of the eyes which may not cause any eye symptoms until the damage is severe

A patient is diagnosed with an obstruction of the canal of Schlemm affecting the left eye. What assessment data concerning the left noted in the patient's medical record supports this diagnosis?

Increased intraocular pressure Aqueous humor is produced by the ciliary body, circulates from the posterior chamber through the pupil into the anterior chamber, and drains out through the canal of Schlemm. This system controls the pressure within the eye. If there is an obstruction of the canal of Schlemm, aqueous humor will not drain, increasing pressure within the eye

nystagmus

Involuntary rapid eye movements -may be due to inner ear disorder, brain lesion, narcotics

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc?

Medially toward the nose Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure (which is the optic disc)

What are the glands that are located on the tarsal plates and open on the lid margins?

Meibomian glands Within the eyelids lie firm strips of connective tissue called tarsal plates. Each plate contains a parallel row of meibomian glands, which open on the lid margin.

extra ocular muscles

Muscles surrounding the eye that allow it to move within the eye socket -control 6 different directions of eye movement (lateral, medial, superior, inferior) -each muscle corresponds with muscle in opposite eye= parallel movement -innervated by cranial nerves III (oculomotor), IV (trochlear), and VI (abducens)

optic disc

Region at the back of the eye where the optic nerve meets the retina. It is the blind spot of the eye because it contains only nerve fibers, no rods or cones, and is thus insensitive to light

A nurse is inspecting a client's eyes to assess for the possibility of detached retinas. The nurse is aware that which of the following is the function of the retina?

Transforms light rays into nerve impulses that are conducted to the brain Visual perception occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted. The lens functions to refract (bend) light rays onto the retina. Muscles in the iris adjust to control the pupils size, which controls the amount of light entering the eye. The cornea permits the entrance of light, which passes through the lens to the retina.

Snellen chart

Used to test *distant visual acuity* -normal is 20/20 -top # always 20 (20 feet away); lower the bottom #, the worse their vision is -number of missed is recorded like "20/30 -2" -refer any client with worse than 20/30 vision for further evaluation -note any behaviors during test (like squinting)

what does discharge from the eye(s) suggest?

a bacterial or viral infection of some kind

what does throbbing, stabbing, or deep pain in the eye usually indicate?

a foreign body or changes within the eye (assess!!) -immediately refer reports of eye pain

E chart

a tool used to test visual acuity, especially useful for patients who cannot read or speak english

exophthalmos

abnormal protrusion of the eyeball -characteristic of graves disease/hyperthyroidism

what does burning or itching of the eye usually indicate?

allergies or superficial irritation

what is a visual impairment?

any visual condition that impacts an individual's ability to successfully complete ADLs -can be low vision, functional blindness, or total blindness -can be congenital (during fetal development) or adventitious (through hereditary condition or trauma)

anterior chamber

between cornea and iris, filled with aqueous humor

posterior chamber

between iris and lens, also filled with aqueous humor

scotoma

blind spot in vision (could be indication of glaucoma, vascular spasms, or pressure on optic nerve from tumor or increased ICP; consistent blind spots could mean retinal detachment) -any reports of blind spots= seek immediate attention and referral to ophthalmologist

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client?

brain tumor Double vision (diplopia) may indicate increased intracranial pressure due to injury or a tumor. Vitamin A deficiency is a cause of night blindness. Allergies are usually indicated by burning or itching pain in the eye. Viral infection is usually indicated by redness or swelling of the eye.

Bulbar vs palpebral conjunctiva

bulbar covers most of the anterior eyeball, palpebral lines the eyelids

open-angle glaucoma

characterized by patchy blind spots in peripheral or central vision (usually in both eyes) -tunnel vision eventually

iris

colored portion of the eye

ciliary body

controls thickness of lens to adapt to focus on objects near and far away

what tests do we perform to assess extra ocular muscle function?

corneal light reflex test, cover test, and cardinal gaze test

what would we assess in a more focused/specialty assessment?

corneal light reflex test, cover test, cardinal fields of gaze, palpate lacrimal apparatus, inspect cornea and lens, assess accommodation, use ophthalmoscope to inspect vessels, optic disc, macula, anterior chamber, etc.

how do we test for corneal reflex?

cotton swab causes eye to blink

strabismus

crossed eyes

what could sunken eyes indicate?

dehydration or chronic wasting

sclera

dense, protective white covering of the eye that supports internal structures

cover test

detects deviation in alignment or strength and slight deviation in eye movement -ask patient to stare ahead and focus on a distant object -cover one eye with opaque card and repeat on opposite eye -uncovered eye should remain fixed ahead -if the uncovered eye moves to establish focus when the opposite eye is covered or if the covered eye moves to reestablish focus after being uncovered, there is a deviation

A nurse examines a client's retina during the ophthalmic examination and notices light-colored spots on the retinal background. The nurse should ask the client about a history of what disease process?

diabetes Exudates appear as light-colored spots on the retinal background and occur in individuals with diabetes or hypertension.

diplopia

double vision -may indicate increase in ICP due to injury or tumor!!

presbyopia

farsightedness (caused by aging/decreased accommodation) -common in 45 +

accommodation

functional reflex allowing the eyes to focus on near objects through movement of ciliary muscles (increasing curvature of lens) -not visible to the eye

glaucoma

group of eye diseases that damage the optic nerve due to high intra-ocular pressure -usually no warning signs and very gradual; many don't notice until it is very advanced -*not* reversible -2nd leading cause of blindness!! -open-angle or acute angle-closure

inspecting bulbar conjunctiva and sclera:

have patient look side to side and then up to the ceiling -should be blear, moist, and smooth -redness = conjunctivitis (pink eye) -dryness could be from allergies or trauma -yellow could mean jaundice or be normal for dark-skinned patients

Retracted lid margins, which allow for viewing of the sclera when the eyes are open suggest

hyperthyroidism

retina

innermost layer that receives visual stimuli and sends it to the brain -contains rods (dim light, black and white) and cones (bright light, color)

ophthalmoscope

instrument used to examine the interior/fundus of the eye -have client fix gaze on object straight ahead -darken room to allow pupils to dilate -put in right hand to your right eye to examine the patient's right eye and vice versa -start 10-15 inches from the client at a 15 degree angle -focus on red reflex as you move closer; rotate dipper setting to see optic disk

esotropia

inward turning of the eye

the sclera is a good place to assess for what?

jaundice or icterus

OS

left eye

age-related macular degeneration (AMD)

major cause of visual impairment that affects the *macula* portion of the retina -remember that this is where sharp, clear, straight-ahead vision is processed so damage here would cause blind spots and distorted/blurred vision -leading cause of vision loss in Americans 60+ -dry or wet kind

what if a patient is seeing halos or rings around lights?

narrow-angle glaucoma

what would we look for in a general routine screening of the eyes?

near and distant visual acuity, visual fields (for gross peripheral vision), look at their eyelids/eyelashes, observe position of the eye in its socket, inspect iris and pull, conjunctiva, pupillary reaction to light

myopia

nearsightedness -second number in distant visual acuity test is higher than 20 (like 20/30)

visual perception

occurs as light rays strike the retina, where they are transformed into nerve impulses, conducted to the brain through the optic nerve, and interpreted -the image is upside down and revered right to left

pupil

opening in the center of the iris; controls amount of light entering the eye -contract for near vision -dilate for far vision

what is night blindness associated with?

optic atrophy, glaucoma, and/or vitamin A deficiency

exotropia

outward turning of the eye

optic atrophy

pallor of the optic disc due to partial or complete death of optic nerve -lack of disc vessels

lens

posterior to iris -refracts light rays onto the retina depending on distance of object being viewed -bulges to focus on close objects, flattens to focus on far objects (remember the shape is controlled by the ciliary body!!)

drooping of the eyelid

ptosis/blepharoptosis -could mean MG, oculomotor nerve damage, weakened muscle

how do we document pupillary reaction

pupil eye at rest/ constricted size -ej: "left eye 3/2, right eye 3/1"

red reflex

red glow that appears to fill the person's pupil when first visualized through the ophthalmoscope

Photoreceptors of the eye are located in the eye's

retina. The innermost layer, the retina, extends only to the ciliary body anteriorly. It receives visual stimuli and sends it to the brain. The retina consists of numerous layers of nerve cells, including the cells commonly called rods and cones. These specialized nerve cells are often referred to as "photoreceptors" because they are responsive to light

the left side of the brain sees the ______ side of the world

right

OD

right eye

macula

round darker area of the ocular fundus that mediates vision only from the central visual field

external layer of eye

sclera and cornea

acute angle-closure glaucoma

severe headache, eye pain, n/v, blurred vision, halos around lights, eye redness

inspecting cornea and lens

shine a light from the side of the eye -should be transparent, no opacities -arcus senilis= white arc; normal for older clients

What are xanthelasma?

soft, raised yellow plaques occurring on the lids at the inner canthus -normal variations a/w increasing age or high lipid levels

cyanosis of the lower lid

suggests a heart or lung disorder

papilledema

swelling of the optic disc -blurred margins -visible blood vessels

what is the Amsler test used for?

test for macular degeneration -have patient cover one eye, look at dot, note any areas of distortion, graying, blurring, or blank spots

cardinal fields of gaze test

tests eye muscle strength and cranial nerve function -six cardinal positions

Vitreous humor

the clear and gelatinous substance that fills the vitreous chamber, the largest chamber of the eye, which is located in the area behind the lens to the retina.

optic chiasma

the crossing of the optic nerves from the two eyes at the base of the brain

ectropion

the eversion of the edge of an eyelid

entropion

the inversion of the edge of an eyelid

vitreous chamber

the main interior portion of the eye, filled with vitreous humor

what if a patient complains of seeing spots or floaters?

these are common/normal findings among clients with myopia (nearsightedness) or over 40 years old

conjunctiva

thin, continuous membrane lining the eyelids

how does light pass into the eyes?

through the lens to the retina

corneal light reflex

to assess *parallel alignment of the eyes* -hold penlight 12 in from face, shine light onto bridge of the nose while they stare ahead -note light reflected on corneas (should be in the exact spot on both eyes= parallel alignment) -if it is asymmetric, this indicates deviated alignment of the eyes due to either muscle weakness or paralysis

what do we use an ophthalmoscope for?

to assess internal eye structures such as: -optic fundus or disc (look for color, size/DD, abnormalities) -retinal vessels (note number, color, diameter, AV ratio; should be four sets -retinal background (should be consistent in texture, exudates will be light-colored spots) -fovea and macula -anterior chamber (at +10 or +20 setting; should be transparent)

cornea

transparent "window of the eye" that *permits entrance of light* -responsive to pain and touch bc of nerve endings

inspecting the palpebral conjunctiva:

uncomfortable for client- only do this if they complain that something is in their eye!!! -should be free of swelling, foreign bodies, or trauma

anisocoria

unequal pupil size (less than 0.5 mm difference) -normal condition

legal blindness

visual acuity of 20/200 or less

visual field

what a person sees with one eye -each eye sees slightly different views, but these overlap (why we have binocular vision)

pupillary light reflex

what causes pupils to immediately constrict when exposed to bright light; mediated by oculomotor nerve -direct (one eye at a time) -indirect or consensual (one eye affects the other) -this reflex protects the photoreceptors from excessive light -should be simultaneously

Pinguecula

yellowish mass on the conjunctiva -harmless and common in older clients