Document 18

EYE ASSESSMENT (SCRIPT)
▪ Dangal Greetings, I am Marian Kyla Mariano from Pamantasan ng Cabuyao, and I will
be your student nurse for today. For today’s assessment, I will assess your eyes to
evaluate your current condition, and if there are any developing early signs of health
problems, we will take note of that to prevent further complications.
(Performing hand hygiene for infection control and to prevent the risk of transmitting of bacteria to
the client)
(Closing the curtain or door, to provide the privacy of the client)
▪ Okay ma’am before we proceed to the assessment, May I confirm your name, age, and
birthday? What do you want me to call you?
▪ Okay ma’am, I will be asking you some questions regarding to your health history, Is it
okay?
A. Ma’am do you have any trouble with your eyesight?
B. Do you experience swelling, redness, or watering in your eye?
B. Do you have any eye disease, injury, or surgery that you went through?
C. How about your family, do you have any history of:
a. Diabetes - a chronic (long-lasting) health condition that affects how your body
turns food into energy. Your body breaks down most of the food you eat into sugar
(glucose) and releases it into your bloodstream. When your blood sugar goes up, it
signals your pancreas to release insulin.
b. Hypertension – high blood pressure
c. Blood dyscrasias - any condition that affects the blood, bone marrow, or lymph
tissue. Before modern medicine, it meant an imbalance of four body fluids: blood, bile,
lymph, and phlegm.
D. When was the last time you visited an ophthalmologist?
E. Do you use any contact lenses or eyeglasses? (When do you usually wear it?)
F. Do you use any eye medications like eye drops?
▪ Okay, ma’am, I am done asking you, so now I will do the eye assessment. First, I will
inspect your external eye structure, including your eyebrow, eyelashes, and eyelids
Findings: Upon inspecting the external eye structure, the distribution of the hair in the eyebrows
is evenly distributed, the skin is intact. They are symmetrical to one another with equal
movement. Your eyeball is globe and firm
The eyelashes are equally distributed as well and are curled slightly outward
The eyelids seem normal, there are no signs of swelling, or any discharge and discoloration. The
skin of the eyelids is intact, it is close symmetrically with involuntary blinks 15-20 blinks per
minute and the blinking is bilateral. Also, the eyelids cover the top quarter of the iris which is
normal.
▪ Now ma’am, I am going to inspect your bulbar conjunctiva for its color, texture, and if
there is any presence of lesions. Can you please look up, down, and side to side?
▪ Okay now ma’am, I am going to inspect your palpebral conjunctiva. Can you please look
up?
Findings: Upon inspecting your palpebral conjunctiva, there is no jaundice, redness, or
swelling. It is shiny/glistening, and its color is pinkish peach. For your bulbar conjunctiva, there
is no such things like swelling and redness in your sclera
▪ Next one ma’am, I am going to inspect and palpate your lacrimal apparatus, Is it okay?
Findings: Upon inspecting and palpating your lacrimal gland, there is no swelling and presence
of edema, also in your lacrimal sac, there is no edema and tearing. In your puncta, it is visible
and has no signs of swelling and redness.
▪ Okay for the next assessment, I will be inspecting your cornea. Can you please look
straight ahead?
Findings: Upon inspecting your cornea, it is transparent, there are no corneal opacities, and it
is not rough or dry.
▪ Now ma’am, we will perform corneal sensitivity eye reflex to determine the function of
the fifth cranial nerves which is the trigeminal nerves.
Findings: Upon observing, the alignment of your cornea is on the same spot which is normal,
and it is symmetric. There is no indication of strabismus (a condition wherein both eyes do not
line up in the same direction.
▪ Okay now ma’am, I will be inspecting your pupils for its color, shape, and symmetry.
Findings: Okay, as I observed, your pupil is round, black, and it is equal in size.
▪ So now, to assess the pupil’s direct and consensual reaction to light, I will turn off the
lights. Can you stare at the far distance? Okay, can you stare at a not too far distance?
▪ Okay now ma’am for the accommodation of your pupil, can you follow this object using
your eye only?
Findings: Okay, so as I observed, your pupil is reactive to light. It is constricted (miosis) by
looking at near object and dilated by looking at far object, also it is converged when near object
is moved toward the nose.
▪ Now ma’am, we are going to do the assessment of the peripheral visual fields, by doing
this, can you please look straight ahead and only use your peripheral vision and say stop
when you see my hand coming from the side.
Findings: Upon doing the assessment, your peripheral vision is normal.
▪ Now ma’am, we are going to do the extraocular muscle tests by doing the 6-cardinal field
of gaze.
Findings: Your both eyes are coordinated, and it moves in unison which is normal.
▪ Now for the last procedure, we are going to do assessment for the visual acuity. Ma’am
can you read this one? (Near vision)
▪ Okay, now ma’am, can you read what is written on the Snellen's chart from the top line to
the bottom line?

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EYE ASSESSMENT (SCRIPT)

(Closing the curtain or door, to provide the privacy of the client)

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