The Client’s identity using agency protocol

Prior to performing the procedure, introduce yourself and verify the client’s identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can participate. Discuss how the results will be used in planning further care or treatments

2. Perform hand hygiene, apply gloves, and observe other appropriate infectionprevention procedures.

3. Provide for client privacy.

4. Inquire if the client has any history of the following: family history of diabetes, hypertension, blood dyscrasia, or eye disease, injury, or surgery; client’s last visit to a provider who specifically assessed the eyes (e.g., ophthalmologist or optometrist); current use of eye medications; use of contactlenses or eye glasses; hygienic practices for corrective lenses; current symptoms of eye problems(e.g., changes in visual acuity,blurring of vision,tearing, spots, photophobia, itching, or pain).

5. Inspect the eyebrows for hair distribution and alignment and skin quality and movement (ask client to raiseand lower the eyebrows).

6. Inspect the eyelashes for evenness of distribution and direction of curl.

7. Inspect the eyelids for surface characteristics (e.g., skin qualityand texture), positionrelation to the cornea, ability to blink, and frequency of blinking.Inspect the lower

eyelids while the client’s eyes are closed.

8. Remove and discard gloves.

• Perform hand hygiene.

9. Inspect the bulbar conjunctiva (that lying over the sclera) for color, texture, and the presence of lesions.

10. Inspect the cornea for clarity and texture. Ask the client to look straight ahead. Hold a penlight at an oblique angle to the eye, and move the light slowly across the corneal surface.

11. Inspect the pupils for color, shape, and symmetry of size. Pupil charts are available in some agencies.

12. Assess each pupil’s direct and consensual reaction to light to determine the function of the third (oculomotor) and fourth (trochlear) cranial nerves.

• Partially darken the room.
• Ask the client to look straightahead.
• Using a penlight and approaching from the side, shine a light on the pupil.
• Observe the response of the illuminated pupil. It should constrict(direct response).
• Shine the light on the pupil again, and observe the response of the other pupil. It should also constrict (consensual response)

13. Assess each pupil’s reactionto accommodation.

• Hold an object (a penlight or pencil) about 10 cm (4 in.) from the bridge of the client’snose.
• Ask the client to look first at the top of the object and then at a distant object (e.g., the far wall) behind the penlight. Alternate the gaze from the near to the far object.Observe the pupil response.
• Next, ask the client to look at the near object and then move the penlightor pencil toward the client’s nose,  ‘

14. Assess peripheral visual fields to determine function of the retina and neuronal visual pathwaysto the brain and second (optic)

cranial nerve.

• Have the client sit directly facing you at a distance of 60 to 90 cm (2 to 3 ft).
• Ask the client to cover the right eye with a card and look directlyat your nose.
• Cover or close your eye directlyopposite the client’s covered eye (i.e., your left eye), and look directlyat the client’s nose.
• Hold an object (e.g.,a penlight or pencil) in your fingers,extend your arm, and move the objectinto the visualfield from variouspoints in the periphery. The objectshould be at an equal distancefrom the client and yourself. Ask the client to tell you when the moving object is first spotted.
  1. To test the temporal field of the left eye, extend and move your right arm in from theclient’s right periphery.
  2. To test the upward field of the left eye, extend and move the right arm down from the upward periphery.
  3. To test the downward field of the left eye, extendand move the right arm up from the lower periphery.
  4. To test the nasal field of the left eye, extend and move your left arm in from the periphery.
• Repeat the above steps for the right eye, reversing the process.

15. Assess six ocular movements to determine eye alignment and coordination.

• Stand directly in front of the client and hold the penlight at a comfortable distance, such as 30 cm (1 ft) in front of the client’s eyes.
• Ask the client to hold the head in a fixed position facing you and to follow the movements of the penlight with the eyes only.
• Move the penlight in a slow, orderly manner through the six cardinal fields of gaze, that is, from the center of the eye along the lines of the arrows in and back to the center.
• Stop the movement of the penlightperiodically so that nystagmus can be detected.

16. Assess for location of light reflex by shining

penlight on the cornealsurface (Hirschberg test).

17. Have client fixate on a near or far object. Cover one eye and observe for movement in the uncovered eye (cover test).

18. f the client can read, assess near vision by providing adequate lighting and asking the client to read from a magazine or newspaper held at a distance of 36 cm (14 in.). if the client normally wears corrective lenses, the glasses or lenses should be worn during the test. The document must be in alanguage the clientcan read.

19. Assess distancevision by askingthe client to wear corrective lenses, unless they are used for readingonly (i.e., for distances of only 36 cm [14 in,]).

• Ask the client to stand or sit 6 m (20 ft) from a Snellen or character chart, cover the eye not being tested, and identify the letters or characters on the chart.
• Take three readings: right eye, left eye, both eyes.
• Record the readings of each eye andboth eyes (i.e., the smallest line from which the person is able to read one-halfor more of the letters).

At the end of each line of the chart are standardized numbers (fractions). The top line is 20/200. The numerator (top number) is always 20, the distance the person stands from the chart. The denominator (bottomnumber) is the distance from which the normal eye can read the chart. Therefore, a person who has 20/40 vision can see at 20 feet from the chart what a normal-sighted person can see at 40 feet from the chart. Visual acuity is recorded as “s- -c” (without correction), or “c-c” (with correction). You can also indicate how many letters were misread in the line, e.g., “visualacuity 20/40 – 2 c-c” indicates that two letters were misread in the 20/40 line by a client wearing corrective lenses.

20. If the client is unable to see even the top line (20/200) of the Snellen-type chart, perform selected vision tests

21.  Document findings in the client’srecord using printedor electronic forms or checklists supplemented by narrative notes when appropriate.