N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide • Provide a quiet, well-lit, and private place for theexam. • Ensure that the examination room is warm since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about the presence or history of: o Hypertension o Diabetes o Eye disease, eye surgery, or use of eye medications o Current signs or symptoms of eye problems (blurred vision, tearing, itching, pain, redness, spots, or floaters) o Any corrective lenses that are used • Assess visual acuity by asking the patient to read from a magazine held at a distance of 14 inches (near vision) and using a Snellen chart (distance vision). If the patient is not ableto see the top line of the Snellen chart, perform a functional vision test. This includes checking to see if the patient can see light, movement, and number of fingers held up by the nurse. To assess distance vision using the Snellen chart, the chart must be twenty feet from the patient. Have thepatient cover one eye and read the smallest line on the chart that can be seen. Cover the other eye and repeat the process. Repeat the process with both eyes uncovered. Record the top number as 20 and the bottom number that corresponds to the reading on the chart for the smallest line the patient can read. o Normal: Able to read a magazine at 14 inches with or without corrective lenses; far vision 20/20 using the Snellen chart o Deviations from normal: Not able to read magazine at distance of 14inches; denominator is greater than 40 on the Snellen eye test (e.g., 20/60) • Assess visual fields: Have the patient, seated facing the nurse, cover one eye. The nurse should cover the eye directly across from the patient's covered eye. The nurse should hold a pencil and extend an arm to the covered eye side, then begin to move the object from the periphery and instruct the patient to say "now" when the object comes into sight. o Normal: When looking straight ahead, the patient can see movement andobjects in his peripheral vision. o Deviations from normal: Peripheral vision is less than expected or half visionin one or both eyes. • Assess extraocular muscles: Standing in front of the patient, hold a penlight one foot in front of the patient's eyes. Instruct the patient to follow the light with her eyes only, keeping her head and body still. Move the light across and diagonal to the outside of the eye and back to the center pausing occasionally to check for nystagmus. o Normal: Eyes are coordinated and move inunison o Deviations from normal: Nystagmus present, eye movements not coordinated, or eyes do not move in unison when following a penlight • Assess the eyebrows. o Normal: Even hair distribution, even alignment, and equal movement as facial expression

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