N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide o Deviations from normal: Absence of the lateral third of the eyebrows (e.g., myxedema), uneven alignment, unequal or absent movement as facial expression changes, and scaling • Assess the eyelashes. o Normal: Eyelashes present and evenly distributed along the eyelid margins o Deviations fromnormal: Eyelashes absent or unevenly distributed alongthe eyelidmargins • Assess the eyelids. o Normal: Skin intact, similar in color to the face, smooth and uniform, no sclera visible above the corneas and irises when the eyelids are open, able to completely close the eyelids, and upper eyelid margins at or near the limbus (the border between the cornea and sclera). When the eyelids are open they are blinking, symmetrical, and present at 15-20 blinks per minute. o Deviations from normal: Lid lag (a rim of sclera visible above the corneas and irises), ptosis (drooping of upper eyelid), Epicanthus fold (vertical fold of skin that lies over the inner canthus), ectropion (margin of the lower eyelid is turned outward), entropion (margin of the lower eyelid is turned inward), periorbital edema (swelling around the eyelid), blepharitis (inflammation of the eyelid), sty (redness, swelling, and tenderness around a hair follicle on the eyelid margin), chalazion (nodule on the skin around the eyelid), xanthelasma (raised, yellow plaques on the skin around the eyelid), and blinking is absent, asymmetrical, or less than 15 or more than 20 blinks perminute. • Assess the lacrimal glands. o Normal: Absence of a bulge in the outer third of the upper eyelids; no discharge or tearing o Deviations from normal: Pain, redness, and swelling in the outer third of the upper eyelids or between the nose and lower eyelid • Assess the conjunctiva and sclera. o Normal: Bulbar conjunctiva (over the sclera) is transparent with tiny vessels; sclera is blue- white, shiny, smooth and moist; palpebral conjunctiva (liningthe eyelids) is pink, shiny, smooth, andmoist NOTE: To inspect the lining of the eyelid, the lid must be everted. To evert the lid:  Ask the patient to look down  With one hand, hold the eyelashes of the upper eyelid between thumb and index finger  With the other hand, place a cotton tipped applicator midway fromthe eyelid margin  Turn the eyelid against steady and gentle pressure on the uppereyelid  On completion of the examination, have the patient look up and down to return the eyelid to its normal position o Deviations from normal: Jaundice or yellowing of the sclera, subconjunctival hemorrhage, and triangular thickening of the bulbar conjunctiva that grows across the cornea • Assess the cornea, anterior chamber, and lens using a penlight to provide indirect lighting on the eye. o Normal: The cornea will be transparent and smooth, with a transparent anterior chamber and transparent lens o Deviations from normal: The cornea or lens is not transparent and cornea is not smooth changes

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