Jensen: Chapter 13 - Eyes Assessment

Stye

hordeolum; acute, localized swelling of the eyelid that may be external or internal

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

Condition in which the vision in one eye is reduced because the eye and the brain are not working together. It is the most common cause of visual impairment in children

Amblyopia (Lazy eye)

Goal: Reduce occupational eye injury and increase the use of appropriate personal protective eyewear in recreational activities and hazardous situations around the home Intervention?

Assess with each patient the use of safety equipment in occupational settings

Opacity of the crystalline lens of the eye, which obstructs the passage of light

Cataract

Leading cause of blindness in United States Age-Related Macular Degeneration (AMD)

Cataracts

Cyst (Meibomian gland lipogranuloma) in the eyelid resulting from inflammation of the Meibomian gland

Chalazion

Covers the recessed portion of the eye

Choroid

Contains the muscle that controls the shape of the lens

Ciliary body

Peripheral vision is evaluated by the nurse using the

Confrontation test

Which of the following teaching points would the nurse emphasize related to eye health?

Always wear eye protection for occupational exposures

Goal: Reduce blindness and visual impairment in children and teens 17 and younger Intervention?

Assess for family history of blindness or visual impairment

Eye strain

Asthenopia

Inflammation of the margin of the eyelid

Blepharitis

Loss of direct pupillary light reflex

CN II Lesion

Loss of consensual pupillary light reflex

CN III Lesion

Detects muscle defects that cause misalignment or uncoordinated eye movements

Cardinal Fields of Gaze (EOM)

Assessment of the positions to which the eye may normally be moved by the extraocular muscles

Cardinal fields of gaze test

Inflammation or infection of the transparent membrane (conjunctiva) that lines the eyelid and part of the eyeball

Conjunctivitis

Is transparent and avascular

Cornea

A clinical test that is used to screen for strabismus

Corneal light reflex test

A clinical assessment that is used to test for the presence and degree of ocular deviation

Cover test

Disease in which the optic nerve is damaged, leading to progressive, irreversible loss of vision. It is often, but not always, associated with increased pressure of the eye.

Glaucoma

Increased pressure in the eye

Glaucoma

Cranial nerves involved in Cardinal Fields of Gaze (EOM)

III - Oculomotor IV - Trochlear VI Abducens

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

Moves the eye laterally

Lateral rectus

Refracts and focused light on to the retina

Lens

The acronym that stands for "Pupils Equal, Round, Reactive to Light and Accommodation."

PERRLA

The nurse assesses the response of the eye to light and documents normal findings as

PERRLA

Test using a Snellen chart to measure visual activity

Snellen Test

Anterior, posterior, vitreous

Three chambers of the eye

Almond-shaped open space between the eyelids

palpebral fissure

A patient asks a nurse if any food promotes eye health. What food would the nurse include as a response?

Deep water fish Carrots Spinach

Goal: Reduce uncorrected visual impairment due to refractive errors Intervention?

Discuss with patients the need for vision screens

Goal: Increase the proportion of adults with diabetes who have an annual clinical eye assessment Intervention?

Discuss with patients the purpose and need for a dilated eye examination to establish the health of the retina

Goal: 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 Intervention?

Emphasize proper eye protection, which can prevent many sports-related eye injuries

Keep furniture out of pathways and keep cords against walls Ensure access to eyeglasses or magnifiers if as needed

Examples of Nursing Interventions

Patient will remain safe in home environment Patient will state measures to reduce risk of visual loss

Examples of Nursing Outcomes

Bulging of the eye anteriorly out of the orbit

Exophthalmos

Test cardinal fields of gaze

Extra-ocular eye movements

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 and people who are nearsighted

Floaters

When working with an older adult, what would the nurse emphasize as increased risk for the patient ?

Glaucoma and cataracts

Farsightedness

Hyperopia

Outer: Sclera, cornea Middle (vascular): iris, ciliary body, choroids Inner: (neural): retina

Intraocular structures

Regulates the amount of light that enters the pupil

Iris

Used to test for color vision

Ishihara plates

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 for this to happen. They are called floaters

Test near vision

Jaeger Chart

Acuity test for near vision

Jaeger test

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

Lacrimal apparatus

Physiological system containing the orbital structures for production and drainage, consists of the lacrimal gland and its excretory ducts, lacrimal cuniculi, lacrimal sac, nasolacrimal duct, and nerve supply

Lacrimal apparatus

Eye sits deeper in orbits Eyebrows thin Conjunctiva thin; may yellow Irregular iris pigmentation Decreased tear formation Vision may decline Smaller pupils Loss of accommodation Decreased night vision Decreased depth perception Lens enlarges Transparency decreased

Lifespan Considerations of Older Adults

Structure lateral to the optic disk, the area with the greatest concentration of cones

Macula

Disease that gradually causes loss of sharp central vision, needed for common daily tasks

Macular degeneration

Moves the eye medially

Medial rectus

Blockage of fluid: base between iris, cornea Severe eye pain Visual disturbances Headache Nausea/Vomiting Can result in permanent vision loss

Medical Emergency - Acute glaucoma

Nearsightedness

Myopia

Optic nerves --> optic chiasm --> optic tracts --> continue into optic region of cerebral cortex)

Neural Pathway (part of CNS)

Gradual vision loss

Nonemergent

Both pupils constrict at the same time when light is directed at one

Normal Pupillary Reflex

Opening for optic nerve head

Optic disc

Considered a natural part of aging. A condition that results from loss of elasticity of the crystalline lens. As this happens, the ciliary muscles that bend and straighten the lens lose their power to acomodate

Presbyopia

Permits light to enter the eye

Pupil

Eye trauma Injuries Foreign bodies Lacerations Hyphema (blood pooling in eye)

Rapid Assessment

Receives/transmits stimuli to brain

Retina

Damage to retinal blood vessels. The two most common causes are diabetes and hypertension

Retinopathy

Goal: Reduce visual impairment due to diabetic retinopathy, glaucoma, and cataracts Intervention?

Review importance of maintain blood glucose levels in the normal range to reduce eye damage

Recommended eye exam every 6 months Diabetic retinopathy Diabetes mellitus Increase eye problem risk

Risk Reduction & Health Promotion

Helps to maintain the size and shape of the eye

Sclera

Test distance vision

Snellen Chart

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

Stimuli enters structure via cornea; refracted, inverted, reversed Focused on retina; communicated via visual pathway to brain Image returns in original form in brain

Structure/Function of Vision

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

Detects light Perceives color Provides vision Sends electrical impulses along the optic nerve to the visual receptor of the brain (Occipital lobe)

The Eyes

The most complex organ(s) in the body

The Eyes

The nurse recognizes that the 60 year old patient may have difficulty reading the fine print because of

The loss of accommodation

A patient has a nursing diagnosis of disturbed 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 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 your eye checked