N109: Foundations in Nursing Practice

N109: Foundations in Nursing Practice Study Guide

Race/Ethnicity African Americans and Hispanics have a higher risk of vision impairment, but a lower risk for hearing impairment compared to Caucasians. The increased risk for vision loss among Hispanics occurs primarily among those in middle adulthood. 5.8 The Nursing Process Assessment Assessment of sensory abilities can be a difficult task since senses can be very subjective. However, there are a few simple tools the nurse can use to determine if more focused testing by an expert should be recommended. • Ask about presence or history of: o Hypertension o Diabetes o Eye disease or surgery o Use of eye medications o 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 able to see the top line of the Snellen chart, perform a functional vision test. (Can the patient see light, movement, or the 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 the patient 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; far vision is 20/20 using the Snellen chart o Deviations from normal: Not able to read magazine at distance of 14 inches; denominator is greater than 40 on the Snellen eye test (e.g. 20/60) • Assess visual fields: Have the patient seated facing the nurse and cover one eye. The nurse should cover the eye directly across from the patient's covered eye. This 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 and objects in his peripheral vision. o Deviations from normal: Peripheral vision is less than expected or the patient has half vision in 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.

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