NURS 267: Ch. 13
A 52-year-old patient with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?
"It is not an uncommon finding in people older than 40 years of age for this to happen. They are called 'floaters'."
A patient comes to the clinic, reporting that he woke up this morning with a painful right eye. What would be the most appropriate response from the nurse?
"You will need to see the doctor to have you eye checked out"
Which of the following scores for distance vision indicates the patient with the poorest vision?
20/100
Which of the following patients would require immediate nursing care?
A 20-year-old man with sudden visual loss after playing football
This person can read at about 6 m (20 ft.) what the normal person can read at about 6 m (20 ft.).
A patient with 20/20 vision
Which of the following teaching points would the nurse emphasize related to eye health
Always wear eye protection for occupational exposures
the use of protective eyewear for contact sports and occupational exposure.
An important health promotion activity
Reduce blindness and visual impairment in children and teens 17 years and younger
Assess for family history of blindness or visual impairment
Reduce occupational eye injury and increase the use of appropriate personal protective eyewear in recreational activities and hazardous situations around the home
Assess with each patient the use of safety equipment in occupational settings
Allows you to detect muscle defects that cause misalignment or uncoordinated eye movements
Cardinal fields of gaze
Covers the recessed portion of the eye
Choroid
Contains the muscle that controls the shape of the lens
Ciliary body
vision include pain, trauma, visual change, blind spots, floaters, halos, discharge, and a related change in ADLs.
Common symptoms related to the eye and vision
include being nearsighted or farsighted, astigmatism, ptosis, and nystagmus.
Common unexpected findings
Peripheral vision is evaluated by the nurse using the
Confrontation test
Is transparent and avascular
Cornea
Tests for strabismus
Corneal light reflex
Test for presence and amount of ocular deiviation
Cover test
include CN II (optic nerve), III (oculomotor), IV (trochlear), and VI (abducens).
Cranial nerves involved with the eyes
A patient asks a nurse if any foods promote eye health. What food would the nurse include as a response?
Deep-water fish
Reduce uncorrected visual impairment due to refractive errors
Discuss with patients the need for vision screens
Increase proportion of adults with diabetes who have an annual clinical eye assessment
Discuss with patients the purpose and need for dilated eye examination to establish the health of the retina
Remove hazards from room, such as razors and matches
Disturbed Sensory Perception
Converse with touch and patient frequently
Disturbed Visual Sensory Perception
Sudden visual loss is an
Emergency
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
Emphasize proper eye protection, which can prevent many sports-related eye injuries
Loose and mobile structures that protect the eye from foreign bodies
Eyelids
A patient has been found to have abnormal vision. What would be the nurse's next step?
Facilitate a referral to an ophthalmologist
Which of the following symptoms would the nurse expect the patient to report as translucent specks that drift across the visual field
Floater
(translucent specks that drift across the visual field) common in people older than 40 years of age and nearsighted patients
Floaters
When working with an older adult what would the nurse emphasize as increased risks for the patient?
Glaucoma and cataracts
The cranial nerves involved with eye movement include
III, IV, and VI
Turns the eye upward and abducts and turns the eye laterally
Inferior oblique
Rotates the eye downward and adducts and rotates the eye medially
Inferior rectus
Regulates the amount of light that enters the pupil
Iris
A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?
Lacrimal apparatus
This protects and lubricates the cornea and conjunctiva by producing and draining tears
Lacrimal apparatus
Moves the eye laterally
Lateral rectus
Refracts and focuses light on to the retina
Lens
The lower eyelid's margin is at the ___________, which is the border between the cornea and sclera
Limbus
Moves the eye medially
Medial rectus
Jerking movement of the eye that can be quick and fluttering or slow and rolling, similar to a tremor
Nystagmus
Cataracts, glaucoma, and macular degeneration are more common in
Older adults
The nurse assesses the response of the eye to light and documents normal findings as
PERRLA
is documented when the pupils are equal, round, and reactive to light and accommodation
PERRLA
Is the almond-shaped open space between the eyelids
Palpebral fissure
often have a decreased ability to accommodate, moving the object further away to read.
Patients older than 40 years of age
Drooping of the eyelids
Ptosis
Permits light to enter the eye
Pupil
Reduce visual impairment due to diabetic retinopathy, glaucoma, and cataracts
Review importance of maintaining blood glucose levels in the normal range to reduce eye damage
Teach patient to clear cords and furniture from pathways, and use good lighting
Risk for injury
Helps to maintain the size and shape of the eye
Sclera
The nurse is caring for a 63-year-old client who can neither read nor speak English. What would be the appropriate chart to use to assess this patient's vision?
Snellen E
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?
Snellen chart
measure peripheral vision
Static and kinetic confrontation tests
Turns the eye downward and abducts and rotates the eye laterally
Superior oblique
Elevates the eye upward and adducts and rotates the eye medially
Superior rectus
used to assess far vision
The Snellen chart
allows you to detect muscle defects that cause misalignment or uncoordinated movement of the eyes.
The cardinal fields of gaze test
A patient has a nursing diagnosis of disturbed visual sensory perception. Which of the following is the most appropriate outcome for this patient's care planning?
The patient will remain free from harm resulting from a loss of vision
A higher number at the bottom of the recording for the Snellen chart indicates
Worse vision
Assessment of the eye with an ophthalmoscope is considered an
advanced skill
Cloudiness in the lens may indicate a
cataract
is used for near vision
the Jaeger test
The nurse recognizes that the 60-year-old patient may have difficulty reading fine print because of
the loss of accomodation