prep U 13 Eyes Assessment
PERRL
-pupils constrict directly and consensually. Note initial size and the reaction size.
"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'." Floaters (translucent specks that drift across the visual field) are common in people older than 40 years of age and nearsighted patients; no additional follow-up is needed.
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?
corrective lenses Astigmatism is corrected with a cylindrical lens that has more focusing power in one access than the other. These corrective lenses can and should be worn while driving at night. Eye drops and surgery are not usual treatments for this condition
A client has been diagnosed with astigmatism. The nurse should be prepared to teach the client about which treatment for this condition? -Surgery -Daily use of eye drops -Corrective lenses -No night driving
At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet The Snellen chart tests distant visual acuity by seeing how far the client can read the letters standing 20 feet from the chart. The top number is how far the client is from the chart and the bottom number refers to the last line the client can read. A reading of 20/50 means the client sees at 20 feet what a person with normal vision can see at 50 feet. The minus number is the number of letters missed on the last line the client can distinguish.
A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding?
Risk for Injury
A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?
Corneal light reflex-
A clinical test that is used to screen for strabismus.
Consensual reaction The constriction of the contralateral pupil is called the consensual reaction. The response of the ipsilateral eye is the direct response. The dilation of the pupil when focusing on a close object is the near reaction. Accommodation is the changing of the shape of the lens to sharply focus on an object.
A light is pointed at a client's pupil, which then contracts. It is also noted that the other pupil contracts as well, though it is not exposed to bright light. Which of the following terms describes this latter phenomenon?
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. Therefore, the nurse should document this finding and proceed with the examination. There is no need to notify the physician of the finding. Having trouble focusing when reading up close is a sign of presbyopia, or impaired near vision, which is not associated with the finding of pinguecula. A foreign body or lesion may cause irritation, burning, pain and/or swelling of the upper eyelid but would not cause yellowish nodules.
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?
glaucoma. A scotoma is a blind spot that is surrounded by either normal or slightly diminished peripheral vision. It may be from glaucoma.
An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible A. glaucoma. B. increased intracranial pressure. C. bacterial infection. D. migraine headaches.
chronic open-angle glaucoma.
An enlarged physiological cup suggests
hirschberg The corneal light reflex tests for strabismus.
Corneal Light Reflex Test Instruct the patient to stare straight ahead at the bridge of your nose. Stand in front of the patient and shine a penlight at the bridge of the patient's nose. Note where the light reflects on the cornea of each eye
diabetic retinopathy, cataracts, and glaucoma.
Diabetes mellitus increases risks for what?
Presbyopia Presbyopia is indicated when the client moves an object away from the eyes to focus. It is a common condition in clients over age 45. Myopia is impaired far vision. Cataracts typically are associated with painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read. Tropia refers to a misalignment of the eyes. 338
During a health history, a 48-year-old client states, "I've noticed that I need to hold my newspaper farther away so that I can read it." Which of the following would the nurse suspect? A. Myopia B. Presbyopia C. Cataracts D. Tropia
pupils equally round, and reactive to light and accommodation.
PERRLA which stands for
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
Photoreceptors of the eye are located in the eye's
3 to 5 mm
Pupils are normally equal in size and range from
B. Optic chiasm and optic tracts 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.
The neural pathway includes what? A. Optic nerve and peripheral nervous system B. Optic chiasm and optic tracts C. Optic tracts and eyes D. Optic chiasm and cranial nerve VIII
Snellen E The Snellen E chart can be used for people who cannot read or speak English.
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?
4 mm Pupils are normally equal in size and range from 3 to 5 mm. Size outside this range are considered abnormal.
The nurse measures a client's pupils and documents the size. Which size would the nurse document as normal?
direct response.
The response of the ipsilateral eye is the
(1) the corneal light reflex (Hirschberg) test, (2) the cover test, and (3) the cardinal fields of gaze test.
Three basic tests allow examiners to assess the movement of the extraocular muscles
instruct the patient to stare at a distant object for 30 seconds. Hold an index finger, penlight, or other safe object (e.g., pencil) about 36 cm (14 in.) in front of the nose. Ask the patient to focus on your finger as you move it toward the patient's nose
To test for accommodation (CN III),
Myopia
What is impaired far vision?
Exotropia refers to an outward turning of the eyes.
What is the outward turning of the eyes?
Strabismus refers to a constant malalignment of the eyes.
What refers to a constant malalignment of the eyes?
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.
When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? -Medially toward the nose -Laterally toward the ear -Upward toward the forehead -Downward toward the chin
Eye turning inward Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to oscillating or shaking movement of the eye. 339
Which of the following would a nurse expect to assess in a client with esotropia? A. Eye turning outward B. Eye malalignment C. Eye turning inward D. Eye oscillating
Asks the client to fix the gaze upon an object and look straight ahead After turning on the ophthalmoscope, the nurse should ask the client to gaze straight ahead and slightly upward. Ask the client to remove glasses but keep contact lens in place. The nurse should use the right eye to examine the right eye & left eye to examine the client's left eye. This allows the nurse to get as close as possible to the client's eye. Begin about 10-15 inches from the client at a 15 degree angle. The nurse should keep the ophthalmoscope still & ask the client to look into the light to view the fovea and macula.
Which technique by the nurse demonstrates proper use of the ophthalmoscope?
not equal size not reactive to light not round not accommodating to focus on objects near and far
abnormal eye exam perrla
true
t/F The nurse tests the six cardinal directions to test extraocular movement of the eye.
optic chiasm
the point where the optic nerves from each eyeball cross is the
kinetic confrontation
to assess the gross peripheral boundaries Peripheral field deficits
Tropia
what refers to a misalignment of the eyes?
Accommodation occurs
when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict what occurs?
ectropion
when the lower eyelids evert causing exposure and drying of the conjunctiva (older clients)
Subconjunctival hemorrhage A subconjunctival hemorrhage is a leakage of blood outside of the vessels, which produces a homogenous, sharply demarcated bright red area; it fades over several days, turns yellow, then disappears. There is no associated eye pain, ocular discharge, or changes in visual acuity; the cornea is clear. Many times it is associated with severe cough, choking, or vomiting, which increase venous pressure. It is rare for a serious condition to cause it, so reassurance is usually the only treatment necessary.
23s A 15-year-old high school student presents to the emergency department with his mother for evaluation of an area of blood in the left eye. He denies trauma or injury but has been coughing forcefully with a recent cold. He denies visual disturbances, eye pain, or discharge from the eye. On physical examination, the pupils are equal, round, and reactive to light with a visual acuity of 20/20 in each eye and 20/20 bilaterally. There is a homogeneous, sharply demarcated area at the lateral aspect of the base of the left eye. The cornea is clear. Based on this description, what is the most likely diagnosis?
Stye A hordeolum or stye is a painful, tender, erythematous infection in a gland at the margin of the eyelid.
A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?
Exophthalmos In exophthalmos, the eyeball protrudes forward. If it is bilateral, it suggests the presence of Graves' disease, although unilateral exophthalmos could still be caused by Graves' disease. Alternative causes include a tumour and inflammation in the orbit.
A 29-year-old physical therapist presents for evaluation of an eyelid problem. On observation, the right eyeball appears to be protruding forward. Based on this description, what is the most likely diagnosis? Ptosis Exophthalmos Ectropion Epicanthus
Consensual response When a light is shone in one eye, that eye will constrict and the opposite (consensual) eye will also constrict. Shining a light in one eye with the resulting constriction of that eye demonstrates the direct reflex. The optic chiasm is the point where the optic nerves from each eyeball cross. Accommodation occurs when the client moves the focus of vision from a distant point to a near object, causing the pupils to constrict.
A nurse shines a light into one of the client's eyes during an ocular exam and the pupil of the other eye constricts. The nurse interprets this as which of the following?
corneal damage. Improper cleaning or prolonged wearing of contact lenses can lead to infection and corneal damage.
An adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to
ultraviolet light exposure. Exposure to ultraviolet radiation puts the client at risk for the development of cataracts (opacities of the lenses of the eyes). Consistent use of sunglasses during exposure minimizes the client's risk.
An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is
painless blurring, light sensitivity, poor night vision, and a need for a brighter light to read.
Cataracts typically are associated with
a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
Diplopia in adults may arise from
cardinal fields of gaze The cardinal fields of gaze assessment allows you to detect muscle defects that cause misalignment or uncoordinated eye movements.
Further testing of the extraocular muscles assesses for symmetrical movements of the eyes in all nine ________ fields of gaze. Instruct the patient to hold the head steady and to follow the movement of your finger or pen with the eyes. Hold your finger or pen approximately 30-35 cm (12-14 in.) from the patient's face. Move slowly through positions 2 through 9, stopping momentarily in each, and then back to center. Proceed clockwise.
the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel.
If cranial nerve IV is paralyzed,
exotropia.
If the eye turns outward it is called
esotropia.
If the uncovered eye turns inward, it is called
direct reflex
Shining a light in one eye with the resulting constriction of that eye demonstrates the
near reaction.
The dilation of the pupil when focusing on a close object is the
Eye turning inward Esotropia is a term used to describe eyes that turn inward. Exotropia refers to an outward turning of the eyes. Strabismus refers to a constant malalignment of the eyes. Nystagmus refers to an oscillating or a shaking movement of the eye.
The nurse is assessing a client whose electronic health record notes a diagnosis of esotropia. When examining this client, the nurse should expect what finding? Eye turning outward Eye malalignment Eye turning inward Eye oscillating
Arcus senilis Arcus senilis, a normal condition in older clients, appears as a white arc around the limbus. The condition has no effect on vision. Presbyopia, which is impaired near vision, is caused by decreased accommodation and is a common condition in clients over 45 years of age. Ectropion is when the lower eyelids evert, causing exposure and drying of the conjunctiva. This is a normal finding in the older client. Myopia is impaired far vision.
The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?
position the client 609.6 cm (20 ft) away from the chart. Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should A. position the client 609.6 cm (20 ft) away from the chart. B. ask the client to remove his glasses. C. ask the client to read each line with both eyes open. D. instruct the client to begin reading from the bottom of the chart.
position the client 609.6 cm (20 ft) away from the chart. Used to test distant visual acuity, the Snellen chart consists of lines of different letters stacked one above the other. The letters are large at the top and decrease in size from top to bottom. The chart is placed on a wall or door at eye level in a well-lighted area. The client stands 20 feet from the chart and covers one eye with an opaque card (which prevents the client from peeking through the fingers). Then the client reads each line of letters until he or she can no longer distinguish them.
The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should position the client 609.6 cm (20 ft) away from the chart. ask the client to remove his glasses. ask the client to read each line with both eyes open. instruct the client to begin reading from the bottom of the chart.
Far, then near When testing accommodation, the nurse would ask the client to focus on a distant object such as a finger or pencil and to remain focused on that object as the nurse moves it closer to the eyes.
The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test? Far, then near Lateral, then near Near, then far Lateral, then far
Presbyopia Prebyopia denotes an age-related deficit in close vision. It is less likely that cataracts, macular degeneration, or loss of convergence underlie the colleague's visual changes
The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?
a 45-year-old suspected of experiencing a subarachnoid hemorrhage Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup. Increased intracranial pressure is transmitted to the optic nerve, causing edema of the optic nerve. Papilledema often signals serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions. An enlarged physiological cup suggests chronic open-angle glaucoma. If cranial nerve IV is paralyzed, the left eye will deviate from its normal position in that direction of gaze, and the eyes will no longer appear conjugate, or parallel. Diplopia in adults may arise from a lesion in the brainstem or cerebellum, or from weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of cranial nerve (CN) III or VI, or vertical diplopia from palsy of CN III or IV.
The nurse should make it a priority to assess which client for papilledema? a 45-year-old suspected of experiencing a subarachnoid hemorrhage an 80-year-old diagnosed with chronic open-angle glaucoma a 12-year-old demonstrating a deviated left eye a 56-year-old reporting double vision
static confrontation
To screen for differences in the visual field from side-to-side and inferior and superior Visual field deficits
Distant vision To test distant and central vision, the Snellen eye chart is used. The patient is positioned 20 feet from the chart for this part of the examination. To test for near vision, the Rosenbaum chart is used and is held 14 inches from the patient's eyes. To examine peripheral vision, the nurse stands in front of the patient and extends the hands lateral to the patient's ears and wiggles the fingers towards the line of gaze until the patient sees the fingers. When examining the external eye structures, the nurse will focus on the position and alignment of the eyes, the eyebrows, the eyelids, and other eye structures.
What eye function is the nurse preparing to assess when the patient is asked to stand 20 feet from a specific chart that is mounted on the examination room wall?
the brow the medial aspect of the nose the cheek
When assessing the eye, the nurse recognizes that which physical structures of the face limit the normal visual field that a client can experience? Select all that apply. the brow the medial aspect of the nose the cheek the lashes the lacrimal puncta
Exotropia With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
exotropia With the cover test, the eyes of the client should remain fixed straight ahead. If the covered eye moves when uncovered to reestablish focus, it is abnormal. If the eye turns outward it is called exotropia. If the uncovered eye turns inward, it is called esotropia. Strabismus is constant malalignment of the eyes. Presbyopia is impaired near vision.
When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?
up The correct technique to use when examining a patient's sclera and conjunctiva during an eye examination is to instruct the patient to look up. Having the patient look down, to the right, or to the left will not provide visualization of the sclera or conjunctiva during the examination.
When preparing to examine a patient's sclera and conjunctiva during an eye examination, the nurse should instruct the patient to move both eyes to look in which direction?
Pupillary constriction on near gaze; dilation on distant gaze During accommodation, pupils constrict with near gaze and dilate with far gaze.328
When testing the near reaction, an expected finding includes which of the following? A. Pupillary dilation on near gaze; dilation on distant gaze B. Pupillary dilation on near gaze; constriction on distant gaze C. Pupillary constriction on near gaze; dilation on distant gaze D. Pupillary constriction on near gaze; constriction on distant gaze
A client's extraocular movements are asymmetrical and she complains of diplopia. Deficits in cranial nerves III, IV, and VI can manifest as impaired extraocular movements or diplopia. Flashes of light are associated with retinal detachment, while intraocular bleeding and cataracts do not have a neurological etiology.
Which of the following assessment findings suggests a problem with the client's cranial nerves? A client states that he has recently begun seeing lights flashing in his field of vision. A client's extraocular movements are asymmetrical and she complains of diplopia. Fundoscopic examination reveals intraocular bleeding. A client's lens appears cloudy and she claims that her visual acuity has recently declined.
20/200 The reading of 20/200 on a vision acuity test indicates blindness. The reading of 20/20 is considered normal vision. This means that the client being tested can distinguish what a person with normal vision can distinguish from 20 feet away. The top or first number is always 20, indicating the distance from the client to the chart. The bottom or second number refers to the last full line the client could read. The higher the second number, the poorer the vision. 20/40 and 20/100 also denote poor vision.
Which vision acuity reading indicates blindness? 20/20 20/200 20/40 20/100
A left temporal hemianopsia When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what?
A left temporal hemianopsia When the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.
You are assessing visual fields on a patient newly admitted for eye surgery. The patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the patient has what? A. A left temporal hemianopsia B. A homonymous hemianopsia C. A bitemporal hemianopsia D. A quadrantic defect
cardinal fields of gaze abnormal findings
abnormal findings for this test include Document a deficit by noting in which field an abnormality is found. Mild nystagmus at the extreme lateral angles is normal; in any other position it is not.
cover test abnormal findings
abnormal findings for this test include any refixation is from muscle weakness in the covered eye (i.e., while covered, the eye drifted into a relaxed position).
hirschberg abnormal findings
abnormal findings for what indicate improper alignment and appear as asymmetric reflections. Document unexpected findings using the face of the clock as a guide.
Asthenopia-
aka eye strain Eye strain develops after reading, computer work, or other visually tedious tasks from tightening of the eye muscles after maintaining a constant focal distance. Symptoms include fatigue, red eyes, eye strain, pain in or around the eyes, blurred vision, headaches, and, rarely, double vision.
The client and the examiner see the examiner's finger at the same time. The observation that the client and examiner see the examiner's finger at the same time indicates normal peripheral vision. The client not seeing the examiner's finger or a delay in seeing it indicates reduced peripheral vision. Client's consensual pupils constricting in response to indirect light as well as direct light shown into the client's pupils resulting in constriction are observed when testing the pupils for reaction to light. Eyes converging on an object as it is moved towards the nose is a normal result for accommodation.
as part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test? Client's consensual pupil constricts in response to indirect light. Eyes converge on an object as it is moved towards the nose. Direct light shown into the client's pupils results in constriction. The client and the examiner see the examiner's finger at the same time.
cover test The cover test is for presence and amount of ocular deviation. The light level should be low, with no direct light sources shining in the patient's eyes. At rest, the extraocular muscles should have very little activity.
most typically performed on children, helps with assessment of ocular alignment. Stand in front of the patient and ask the patient to focus on a near object (bridge of your nose). Place an opaque card or occluder over the eye; inspect for any movement of the uncovered eye that may indicate refixation of the gaze. Remove the cover and observe the previously covered eye for refixation. Repeat the procedure for the other eye.
Consensual response-
ringing the light in quickly from the side, observe the reaction of the same and then the other pupil for the consensual light reflex. Observe for nystagmus in one or both eyes. PERRL -pupils constrict directly and consensually. Note initial size and the reaction size.
true
t/f A parent is very upset because she is told her child has a refractive error. The nurse reassures the parent that refractive errors are the most common visual change in children.
anterior; posterior; vitreous
what are the 3 chambers in the interior eye:
Superior rectus: elevates upward; adducts, rotates medially (CN III) Inferior rectus: rotates downward; adducts, rotates medially ( CN III) Lateral rectus: moves laterally towards ear (CN VI) Medial rectus: moves medially towards nose Superior oblique: turns downward; abducts, rotates laterally (CN VI) Inferior oblique: turns upward; abducts, turns laterally (CN III)
what are the 6 eye nerves?
Acute glaucoma is caused by an acute blockage of the fluid at the base between the iris and cornea
what is a medical emergency and may result in permanent vision loss if untreated.
Presbyopia
what is impaired near vision, caused by decreased accommodation and is a common condition in clients over 45 years of age.
Accommodation
what is the changing of the shape of the lens to sharply focus on an object.
vitreous
what is the largest chamber of the eye
Superior rectus:
what muscle elevates upward; adducts, rotates medially (CN III)
Lateral rectus
what muscle moves laterally towards ear (CN VI)
Medial rectus
what muscle moves medially towards nose
Inferior rectus
what muscle rotates downward; adducts, rotates medially ( CN III)
Superior oblique
what muscle turns downward; abducts, rotates laterally (CN VI)
Inferior oblique
what muscle turns upward; abducts, turns laterally (CN III)
Nystagmus
what refers to an oscillating or a shaking movement of the eye.
Nystagmus refers to oscillating or shaking movement of the eye.
what refers to oscillating or shaking movement of the eye?
