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Nursing Fundamentals/Assessment > Eye Assessment > Flashcards

Eye Assessment Flashcards

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1
Q

Eyelids

A

protects eye, filter out dust and dirt

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2
Q

Palpebral Fissure

A

open space between the eyelids

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3
Q

Limbus

A

border between cornea and sclera

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4
Q

Canthus

A

corner of the eye

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5
Q

Caruncle

A

small fleshy mass at inner corner containing sebaceous glands

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6
Q

Tarsal Plates

A

strips of connective tissue, contain the meibomian glands, secrete oily lubricating material

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7
Q

Conjunctiva

A

thin mucous membrane

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8
Q

The conjunctiva includes

A

palpebral conjunctiva and bulbar conjunctiva

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9
Q

palpebral conjunctiva

A

lines the lids

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10
Q

bulbar conjunctiva

A

overlays the eyeball with the white sclera

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11
Q

lacrimal apparatus

A

provides constant irrigation

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12
Q

puncta

A

absorb tear drainage (upper and lower lids at the inner canthus)

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13
Q

Extraocular Muscles

A

6 muscles attach to the eyeball and give the eye movement

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14
Q

2 Types of Extraocular Muscles

A

rectus and oblique muscles

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15
Q

Rectus Muscles

A

4 straight

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16
Q

Oblique Muscles

A

2 slanting

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17
Q

Internal Eye

A

sphere shaped, consists of 3 layers: sclera, choroid, and retina

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18
Q

Sclera

A

outer fibrous, protective white covering

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19
Q

Choroid

A

middle vascular, dark pigmented layer

delivers blood to the retina and prevents light from reflecting internally

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20
Q

Choroid consists 3 parts

A

pupil, lens (focus) and anterior chamber

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21
Q

anterior chamber of the choroid

A

continuous flow of fluid

serves to deliver nutrients to surrounding tissues and drains metabolic waste.

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22
Q

Retina

A

visual receptive layer of the eye

light waves are changed into nerve impulses

23
Q

Retina includes 2 parts

A

optic disc, macula and retinal vessels

24
Q

optic disc

A

retina fibers converge to form the optic nerve

normal color is yellow-orange to pink

25
Q

macula

A

receives and transduces light from the center of the visual field

26
Q

Cultural Considerations include

A

palpebral fissures, glaucoma and cataracts

27
Q

Cultural Considerations: palpebral fissures

A

narrowed in asian population

28
Q

Cultural Considerations: glaucoma

A

more prevalent in african american population and more severe which can lead to blindness

29
Q

Cultural Considerations: cataracts

A

more prevalent in caucasians

30
Q

What information should you get during the history (subjective) portion of the interview?

A

A. Vision difficulty, decreased visual acuity, blurring, blind spots
B. Eye pain
C. Hx Strabismus, diplopia (double vision)
D. Redness and/or swelling
E. Watering and/or eye d/c
F. Past hx of eye problems (ie.injury or surgery to eye)
G. Hx glaucoma – also include family history of glaucoma
H. Use of glasses and/or contacts
I. Self care behaviors (date of last eye exam)
J. Medications

31
Q

What information should the nurse assess for during a physical exam?

A 
A. Snellen eye chart
B. Near Vision
C. Confrontation Test
D. Corneal Light Reflex (Hirschberg Test)
E. Cover Test
F. Diagnostic Positions Test and 6 cardinal positions of gaze
G. Inspection of External Eye
H. Anterior Eyeball Structures
I. Ocular Fundus - ophthalmoscope
32
Q

Snellen Eye Chart

A

tests visual acuity
the larger the denominator, the poorer the vision
(Normal 20/20)

33
Q

Normal 20/20

A

the top number (numerator) is the distance the person is standing from the eye chart, the bottom number (denominator) is the distance at which a normal eye could have read that line)

34
Q

Near vision

A

hand held vision card

35
Q

Confrontation Test

A

test visual fields, except the temporal visual field (flapping fingers, both pt and nurse cover 1 eye opposite of each other)

36
Q

Corneal Light Reflex (Hirschberg Test)

A

shine light from distance approx. 12-14”

–> at same spot both eyes

37
Q

Cover Test

A

test for lazy eye/strabismus
normal response to the cover test is a steady fixed gaze.
If muscle weakness is present, the covered eye will drift into a relaxed position

38
Q

Diagnostic Positions Test (H) and 6 cardinal positions of gaze

A

EOM function and test for nystagmus

39
Q

Inspection of External Eye includes

A

eyebrows, eyelids and eyelashes, eyeballs, conjunctiva and sclera, eversion of upper eyelid and lacrimal apparatus

40
Q

Assessing Inspection of External Eye: Eyebrows

A

symmetrical movement with facial expressions, no lesions, no scaling, etc.

41
Q

Assessing Inspection of External Eye: Eyelids and Eyelashes

A

upper lids overlap top of iris, skin intact without redness, swelling, d/c or lesions

42
Q

Assessing Inspection of External Eye: Eyeballs

A

alignment, note protrusion or sunken appearance

43
Q

Assessing Inspection of External Eye: Conjunctiva and Sclera

A

color, discharge

44
Q

Assessing Inspection of External Eye: Eversion of Upper Eyelid

A

not performed in lab

45
Q

Assessing Inspection of External Eye: Lacrimal Apparatus

A

palpate with thumb inner eye for lacrimal sac and brow area for lacrimal gland

46
Q

Anterior Eyeball Structures include

A

cornea and lens; iris and pupil

47
Q

Assessing Anterior Eyeball Structures: Cornea and Lens

A

smoothness and clarity

48
Q

Assessing Anterior Eyeball Structures: Iris and Pupil

A

shape, PERRLA

49
Q

accommodation

A

distant object, shift to close object - pupils should constrict

50
Q

Assessing Ocular Fundus

A
  1. red reflex
  2. optic disc
  3. retinal vessels
  4. general color/background, lesions
  5. macula
51
Q

lens

A

refracting medium, keeping a viewed object in continuous focus on the retina

52
Q

iris

A

mediators of light

53
Q

Dark skinned people may normally have

A

small brown macules on the sclera

Nursing Fundamentals/Assessment (24 decks)

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