Eye Structures and Visual Acuity Assessment Script

Good afternoon Mam/ Sir ______. For today, I will demonstrate the Physical
Assessment of the Eye Structures and Visual Acuity.
First and foremost, I will assemble the equipment and supplies that I will use. I will be
using a cotton tip applicator, examination gloves, millimeter ruler, penlight, Snellen’s or
E chart and opaque card.
Knock (2x) Good afternoon Mam, I am Issaiah Nicolle L. Cecilia, a student nurse from
Pamantasan ng Cabuyao. So Mam today, I will be doing an assessment of your eye
structures and visual acuity. I will obtain some of your health history information and
please allow me to inspect and palpate some parts of your body. It is important for us to
do this not only to detect existing and potential eye problems but to also determine
signs of other health complications that may be developing in your body. I hope that you
will cooperate with me.
For the infection control, I will wash my hands and observe other infection control
procedures.
Now, I will provide for the client’s privacy by putting a curtain in the area.
There are some questions that I would like to ask you.
 Do you have family history of diabetes, hypertension, or blood dyscrasia?
 Did you have an eye disease, injury, or surgery?
 When was your last visit to an ophthalmologist?
 Do you use any current eye medications?
 Do you use contact lenses or eyeglasses?
 What are your hygienic practices for corrective lenses?
 Do you experience any current symptoms of eye problems? (e.g., changes in
visual acuity, blurring of vision, tearing, spots, photophobia, itching, or pain).

I will now proceed to the assessment.

1. Inspect the eyebrows for hair distribution and alignment and for skin quality
and movement (ask client to raise and lower the eyebrows).
The hair of the eyebrows are evenly distributed. The skin is intact and has no signs
of scaling and flakiness. The eyebrows are symmetrically aligned and equal.

ABNORMAL: Loss of hair; scaling and flakiness of skin

Unequal alignment and movement of eyebrows

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

The eyelashes are equally distributed. It is curled slightly outward.

ABNORMAL: Turned inward

3. Inspect the eyelids for surface characteristics, position in relation to the
cornea, ability to blink, and frequency of blinking. Inspect the lower eyelids
while the client's eyes are closed.
The skin of the client’s eyelids is intact. There is no any discharge and discoloration.
The eyelids also close symmetrically. So approximately there are 15 to 20
involuntary blinks per minute and the blinking is bilateral. When lids are open, there
is no visible sclera above the corneas, and upper and lower borders of cornea are
slightly covered.

ABNORMAL: Redness, swelling flaking, crusting plaques, discharge, nodules, lesions

Lids close asymmetrically, incompletely, or painfully
Rapid, monocular, absent, or infrequent blinking
Ptosis (drooping or falling of the upper eyelid), ectropion (lower eyelid turns or sags outward,
away from your eye), or entropion (eyelid is rolled inward against the eyeball); rim of sclera
visible between lid and iris

4. Inspect the bulbar conjunctiva for color, texture, and the presence of lesions.
Retract the eyelids with your thumb and index finger, exerting pressure over the
upper and lower bony orbits, and ask the client to look up, down, and from side to
side.
The bulbar conjunctiva is transparent, the capillaries are sometimes evident and the
sclera appears white (darker or yellowish and with small brown macules in dark-
skinned clients). There is no presence of any lesions or nodules.

ABNORMAL: Jaundiced sclera (e.g., in liver disease); excessively pale sclera (e.g., in anemia);
reddened sclera; lesions or nodules (may indicate damage by mechanical, chemical, allergenic,
or bacterial agents)

5. Inspect the palpebral conjunctiva by everting the lids. Evert both lower lids, and
ask the client to look up. Then gently retract the lower lids with the index fingers.
The client has a shiny, smooth, and pink or reddish palpebral conjunctiva. There is
no any lesions or nodules.

ABNORMAL: Extremely pale (possible anemia); extremely red (inflammation); nodules or other
lesions

5.1 Evert the upper lids if a problem is suspected.

• Ask the client to look down while keeping the eyes slightly open. Rationale: Closing
the eyelids contracts the orbicular muscle, which prevents lid eversion.

• Gently grasp the client's eyelashes with the thumb and index finger. Pull the lashes
gently downward. Rationale: Upward or outward pulling on the eyelashes causes
muscle contraction.
• Place a cotton-tipped applicator stick about 1 cm above the lid margin, and push it
gently downward while holding the eyelashes. Rationale: These actions evert the lid,
that is, flip the lower part of the lid over on top of itself.

• Hold the margin of the everted lid or the eyelashes against the ridge of the upper bony
orbit with the applicator stick or the thumb.

• Inspect the conjunctiva for color, texture, lesions, and foreign bodies.

• To return the lid to its normal position, gently pull the lashes forward, and ask the client
to look up and blink.
6. Inspect and palpate the lacrimal gland. Using the tip of your index finger, palpate
the lacrimal gland. Observe for edema between the lower lid and the nose.
There is no presence of any edema or tenderness over the lacrimal gland.
ABNORMAL: Swelling or tenderness over lacrimal gland

7. Inspect and palpate the lacrimal sac and nasolacrimal duct. Observe for
evidence of increased tearing. Using the tip of your index finger, palpate inside the
lower orbital rim near the inner canthus.
The lacrimal sac and nasolacrimal duct has no edema or tearing.

ABNORMAL: Evidence of increased tearing; regurgitation of fluid on palpation of lacrimal sac

8. Inspect the cornea tor 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.
The client’s cornea are transparent, shiny, and smooth. The details of the iris are
also visible. *In older people, a thin, grayish white ring around the margin, called
arcus senilis, may be evident

ABNORMAL: Opaque; surface not smooth (may be the result of trauma or abrasion); Arcus
senilis in clients under age 40

9. Perform the corneal sensitivity (reflex) test to determine the function of the
fifth (trigeminal) cranial nerve. Ask the client to keep both eyes open and look
straight ahead. Extend your hand behind the client's field of vision, then bring the
gauze toward the outer canthus. Lightly touch the cornea with a corner of the gauze.
The client blinks when the cornea is touched, indicating that the trigeminal nerve is
intact.

ABNORMAL: One or both eyelids fail to respond

10. Inspect the anterior chamber for transparency and depth. Use the same
oblique lighting as used to test the cornea.
 The client’s anterior chamber is transparent. There is no shadows of light on the iris
and has a depth of about 3 mm.

ABNORMAL: Cloudy; Crescent-shaped shadows on far side of iris; Shallow chamber

(possible glaucoma)

11. Inspect the pupils for color, shape, and symmetry of size. Pupil charts are
available in some agencies. See 0 for variations in pupil diameters.
The pupil is black in color and equal in size. It is normally 3 to 7 mm in diameter. It is
round, has a smooth border, and the iris is iris flat and round.
ABNORMAL: Cloudiness, mydriasis, miosis, anisocoria; bulging of iris toward cornea

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 straight ahead.
• 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).
Findings: The illuminated pupil constricts (direct response) and the nonilluminated
pupil constricts (consensual response).
ABNORMAL: Neither pupil constricts; Unequal responses; Absent responses

13. Assess each pupil's reaction to accommodation.

• Hold an object (a penlight or pencil) about 10 cm (4 in.) from the bridge of the
client's nose.
• 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. The pupils should constrict when looking at the near
object and dilate when looking at the far object.
• Next, move the penlight or pencil toward the client's nose. The pupils should
converge. To record normal assessment of the pupils, use the abbreviation
PERRLA (pupils equally round and react to light and accommodation).
Findings: The pupils constrict when looking at near object, it laso dilate when
looking at far object and it converge when near object is moved toward the nose.
The pupils are equally round and react to light and accommodation.
 ABNORMAL: One or both pupils fail to constrict, dilate, or converge

I will now assess your visual fields.

14. Assess peripheral visual fields. To determine function of the retina and neuronal
visual pathways to 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 directly at your nose.
• Cover or close your eye directly opposite the client's covered eye (i.e., your left
eye), and look directly at the client's nose.
• Hold an object (e.g., a penlight or pencil) in your fingers, extend your arm, and
move the object into the visual field from various points in the periphery.
• The object should be at an equal distance from the client and yourself. Ask the
client to tell you when the moving object is first spotted.
a. To test the temporal field of the left eye, extend and move your right arm in from
the client's right periphery. Temporally, peripheral objects can be seen at right
angles (90 degrees) to the central point of vision.
b. To test the upward field of the left eye, extend and move the right arm down from
the upward periphery. The upward field of vision is normally 50 degrees because the
orbital ridge is in the way.
c. To test the downward field of the left eye, extend and move the right arm up from
the lower periphery. The downward field of vision is normally 70 degrees because
the cheekbone is in the way.
d. To test the nasal field of the left eye, extend and move your left arm in from the
periphery. The nasal field of vision is normally 50 degrees away from the central
point of vision because the nose is in the way.
e. Repeat the above steps for the right eye, reversing the process.

Findings: When looking straight ahead, client can see objects in the periphery
ABNORMAL: Visual field smaller than normal (possible glaucoma); one-half vision in one or
both eyes (possible nerve damage)

I will now proceed to the Extraocular Muscle test.

15. Assess six ocular movements to determine eye alignment and coordination.
These can be performed on clients over 6 months of age.
• Stand directly in front of the client and hold the penlight at a comfortable distance,
such as 30 cm ( I 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 O and back to the
center.
• Stop the movement of the penlight periodically so that nystagmus can be detected.
• Assess for location of light reflex by shining penlight on pupil in corneal surface
(Hirschberg test).
• Have client fixate on a near or far object.
• Cover one eye and observe for movement in the uncovered eye (cover test).

Findings: Light falls symmetrically on both pupils (e.g., at "6 o'clock" on both pupils)
and the uncovered eye does not move

The six muscles that govern eye movement.

ABNORMAL: Eye movements not coordinated or parallel; one or both eyes fail to follow a
penlight in specific directions, e.g.,strabismus (cross-eye)
Nystagmus (rapid involuntary rhythmic eye movement) other than at end point may indicate
neurologic impairment.
Light falls off center on one eye (indicates misalignment). If misalignment is present, when
dominant eye is covered, the uncovered eye will move to focus on object.

Lastly, is the assessment of the Visual Acuity.

16. 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.
Findings: The client can able to read newsprint.
ABNORMAL: Difficulty reading newsprint unless due to aging process

17. Assess distance vision. (By asking the client to wear corrective lenses, unless
they are used for reading only, i.e., for distances of only 36 cm (12 to 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 and both eyes (i.e., the smallest line from which the
person is able to read one-half or 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 (bottom number) 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., "visual acuity 20/40 - 2 c-c"
indicates that two letters were misread in the 20/40 line by a client wearing corrective
lenses.
Findings: 20/20 vision on Snellen-type chart.
ABNORMAL: Denominator of 40 or more on Snellen-type chart with corrective lenses

18. Perform functional vision tests if the client is unable to see even the top line
(20/200) of the Snellen’s chart.

LIGHT PERCEPTION
Shine a penlight into the client's eye from a lateral position, and then turn the light off.
Ask the client to tell you when the light is on or off. If the client knows when the light is
on or off, the client has light perception, and the vision is recorded as "LP."
HAND MOVEMENTS (H/M)
Hold your hand 30 cm (1 ft) from the client's face and move it slowly back and forth,
stopping it periodically. Ask the client to tell you when your hand stops moving. If the
client knows when your hand stops moving, record the vision as "H/M 1 ft."
COUNTING FINGERS (C/F)
Hold up some of your fingers 30 cm (1 ft) from the client's face, and ask the client to
count your fingers. If the client can do so, note on the vision record "C/F 1 ft.

ABNORMAL: Functional vision only (e.g., light perception, hand movements, counting fingers
at 1 ft)

19. Document findings in the client’s record.

 Ears Structures and Hearing Assessment Script
I will now proceed to the demonstration of the Physical Assessment of the Ears
Structures and Hearing.
First, I will assemble the equipment and supplies that I will use. I will be using an
otoscope with several sizes or ear specula.
Knock (2x) Good afternoon Mam, I am Issaiah Nicolle L. Cecilia, a student nurse from
Pamantasan ng Cabuyao. So Mam today, I will be doing an assessment of your eye
structures and visual acuity. I will obtain some of your health history information and
please allow me to inspect and palpate some parts of your body. It is important for us to
do this not only to detect existing and potential problems but to also determine signs of
other health complications that may be developing in your body. I hope that you will
cooperate with me.
For the infection control, I will wash my hands and observe other infection control
procedures.
Now, I will provide for the client’s privacy by putting a curtain in the area.
There are some questions that I would like to ask you.
 Do you have a family history of hearing problems or loss?
 Are there any presence of ear problems or pain?
 What is your medication history, especially if there are complaints of ringing in ears?
 Do you experience any hearing difficulty: its onset, factors contributing to it, and how
it interferes with activities of daily living?
 Do you use a corrective hearing device: when and from whom it was obtained?

Position the client comfortably, seated if possible. Mam you can seat for you to be
comfortable.

1. Inspect the auricles for color, symmetry of size, and position. To inspect
position, note the level at which the superior aspect of the auricle attaches to the
head in relation to the eye.
NORMAL FINDINGS: The client’s auricle
has the same color to the facial skin. It is
symmetrical and aligned with outer canthus
of eye, about 10° from vertical.
ABNORMAL: Bluish color of earlobes (e.g., cyanosis); pallor (e.g., frostbite); excessive redness
(inflammation or fever); Asymmetry; Low-set ears (associated with a congenital abnormality,
such as Down syndrome)

2. Palpate the auricles for texture, elasticity, and areas of tenderness. Gently pull
the auricle upward, downward, and backward.
* Fold the pinna forward (it should recoil).
* Push in on the tragus.
* Apply pressure to the mastoid process.
NORMAL FINDINGS: The auricle is mobile or movable, firm, not tender and the pinna
recoils after it is folded. There is no any signs of lesions or abnormalities.
ABNORMAL: Lesions (e.g., cysts); flaky, scaly skin (e.g., seborrhea); tenderness when moved
or pressed (may indicate inflammation or infection of external ear)

I will proceed to the External Ear Canal and Tympanic Membrane.

3. Using an otoscope, inspect the external ear canal for cerumen, skin lesions,
pus, and blood.
• Attach a speculum to the otoscope. Use the largest diameter that will fit the ear canal
without causing discomfort. Rationale: This achieves maximum vision of the entire ear
canal and tympanic membrane.
• Tip the client's head away from you, and straighten the ear canal. For an adult,
straighten the ear canal by pulling the pinna up and back. Rationale: Straightening the
ear canal facilitates vision of the ear canal and the tympanic membrane.
• Hold the otoscope either (a) right side up, with your fingers between the otoscope
handle and the client's head or (b) upside down, with your fingers and the ulnar surface
of your hand against the client's head. Rationale: This stabilizes the head and protects
the eardrum and canal from injury if a quick head movement occurs.
• Gently insert the tip of the otoscope into the ear canal, avoiding pressure by the
speculum against either side of the ear canal. Rationale: The inner two-thirds of the ear
canal is bony; if the speculum is pressed against either side, the client will experience
discomfort.

NORMAL FINDINGS: The distal third contains hair follicles and glands. The cerumen is
dry and it has a grayish-tan color; or it has asticky, wet cerumen in various shades of
brown.
ABNORMAL: Redness and discharge; Scaling; Excessive cerumen obstructing canal

4. Inspect the tympanic membrane for color and gloss.

NORMAL FINDINGS: It has a pearly gray color and it is semitransparent.
ABNORMAL: Pink to red, some opacity; Yellow-amber; White; Blue or deep red; Dull
surface

5. Assess client's response to normal voice tones.

NORMAL FINDINGS: The client can able to hear the normal voice tones without any
sign of difficulties.
ABNORMAL: Normal voice tones not audible (e.g., requests nurse to repeat words or
statements, leans toward the speaker, turns the head, cups the ears, or speaks in loud tone of
voice)

5.1 If client has difficulty hearing the normal voice, proceed with the following
tests.
Perform the watch tick test. The ticking of a watch has a higher pitch than the human
voice.
5.2 Have the client occlude one ear. Out of the client's sight, place a ticking watch
2 to 3 cm (1 to 2 in.) from the unoccluded ear.
5.3 Ask what the client can hear. Repeat with the other ear.
Mam can you occlude or cover your right ear. Next, can you occlude or cover your other
ear. So did you hear something?

NORMAL FINDINGS: The client can able to hear ticking in both ears.
ABNORMAL: Unable to hear ticking in one or both ears

I will do the Tuning Fork Tests.

6. Perform Weber's test (to assess bone conduction by examining the lateralization
(sideward transmission) of sounds).
• Hold the tuning fork at its base. Activate it by tapping the fork gently against the back
of your hand near the knuckles or by stroking the fork between your thumb and index
fingers. It should be made to ring softly.
• Place the base of the vibrating fork on top of the client's head 0 and ask where the
client hears the noise.
NORMAL FINDINGS: The sound is heard by the client in both ears or is localized at the
center of the head (meaning, the client is negative to the Weber test)
ABNORMAL: Sound is heard better in impaired ear, indicating a bone-conductive hearing loss;
or sound is heard better in ear without a problem, indicating a sensorineural disturbance (Weber
positive).
7. Conduct the Rinne test (to compare air conduction to bone conduction).
• Ask the client to block the hearing in one ear intermittently by moving a fingertip in and
out of the ear canal.
• Hold the handle of the activated tuning fork on the mastoid process of one ear 0 until
the client states that the vibration can no longer be heard.
Immediately hold the still vibrating fork prongs in front of the client's ear canal.
• Push aside the client's hair if necessary. Ask whether the client now hears the sound.
Sound conducted by air is heard more readily than sound conducted by bone. The
tuning fork vibrations conducted by air are normally heard longer .
NORMAL FINDINGS: The client’s air-conducted (AC) hearing is greater than bone-
conducted (BC) hearing, i.e., AC >BC (meaning, the client is positive to the Rinne test)
ABNORMAL: Bone conduction time is equal to or longer than the air conduction time, i.e., BC >
AC or. BC = AC (negative Rinne; indicates a conductive hearing loss)

8. Document findings in the client’s record.

 Nose and Sinuses Assessment Script
Let’s now mpve on to the demonstration of the Physical Assessment of the Nose and
Sinuses.
I will assemble the equipment and supplies that I will use. I will be using a nasal
speculum and flashlight or penlight.
Knock (2x) Good afternoon Mam, I am Issaiah Nicolle L. Cecilia, a student nurse from
Pamantasan ng Cabuyao. So Mam today, I will be doing an assessment of your nose
and sinuses. I will obtain some of your health history information and please allow me to
inspect and palpate some parts of your body. It is important for us to do this not only to
detect existing and potential problems but to also determine signs of other health
complications that may be developing in your body. I hope that you will cooperate with
me.
For the infection control, I will wash my hands and observe other infection control
procedures.
Now, I will provide for the client’s privacy by putting a curtain in the area.
There are some questions that I would like to ask you.
 Do you have any allergies?
 Do you feel any difficulty breathing through the nose?
 Do you have sinus infections?
 Do you have injuries to nose or face,
 Do you have nosebleeds?
 What are medications you have taken?
 Do you notice any changes in your sense of smell?

Position the client comfortably, seated if possible. Mam you can seat for you to be
comfortable.

1. Inspect the external nose for any deviations in shape, size, or color and flaring
or discharge from the nares.
NORMAL FINDINGS: The external nose is symmetric and straight. It has no any
discharge or flaring and it is uniform in color.
ABNORMAL: Asymmetric; Discharge from nares; Localized areas of redness or presence of
skin lesions
2. Lightly palpate the external nose to determine any areas of tenderness,
masses, and displacements of bone and cartilage.

NORMAL FINDINGS: There is no tenderness and no signs of any lesions.

ABNORMAL: Tenderness on palpation; presence of lesions
3. Determine patency of both nasal cavities.
3.1 Ask the client to close the mouth, exert pressure on one naris, and breathe
through the opposite naris. Repeat the procedure to assess patency of the
opposite naris.
NORMAL FINDINGS: The air moves freely as the client breathes through the nares.
ABNORMAL: Air movement is restricted in one or both nares

4. Inspect the nasal cavities using a flashlight or a nasal speculum.

• Hold the speculum in your right hand to inspect the client's left nostril and your left
hand to inspect the client's right nostril.
• Tip the client's head back.
• Facing the client, insert the tip of the closed speculum (blades together) about 1 cm or
up to the point at which the blade widens. Care must be taken to avoid pressure on the
sensitive nasal septum.
• Stabilize the speculum with your index finger against the side of the nose. Use the
other hand to position the head and then to hold the light.
• Open the speculum as much as possible and inspect the floor of the nose (vestibule),
the anterior portion of the septum, the middle meatus, and the middle turbinates. The
posterior turbinate is rarely visualized because of its position.
• Inspect the lining of the nares and the integrity and the position of the nasal septum.

5. Observe for the presence of redness, swelling,

growths, and discharge.
NORMAL FINDINGS: The mucosa of the client is
pink, clear and has a watery discharge. There is no presence
of any lesions.
ABNORMAL: Mucosa red, edematous; Abnormal discharge (e.g., pus); Presence of
lesions (e.g., polyps)

6. Inspect the nasal septum between the nasal chambers.

NORMAL FINDINGS: The client’s nasal septum is intact and in midline.
ABNORMAL: Septum deviated to the right or to the left
Then, the facial sinuses.
7. Palpate the maxillary and frontal sinuses for tenderness.
NORMAL FINDINGS: There is no any tenderness palpated.
ABNORMAL: Tenderness in one or more sinuses

8. Document findings in the client’s record.