Ateneo de Zamboanga University

COLLEGE OF NURSING
PERFORMANCE EVALUATION CHECKLIST

NAME: _____________________________________ DATE PERFORMED: _________________

YEAR & SECTION: ______________

PURPOSE:
1. Screen for preexisting eye disease.
2. Assess the extent to which visual impairment affects activities of daily living and
need for nursing care.
3. Determine condition of eye structures.

ASSESSING THE EYE STRUCTURES AND VISUAL ACUITY

PREPARATION 1 2 3 4 5
1. Assemble equipment and supplies:
 Cotton-tipped applicator
 Examination gloves
 Millimeter ruler
 Penlight
 Snellen’s or E chart
 Opaque card
PROCEDURE
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it
is necessary, and how the client can cooperate.
2. Perform hand hygiene and observe other appropriate
infection control procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
 Family history of diabetes, hypertension, or blood
dyscrasia
 Eye disease, injury, or surgery
 Last visit to an ophthalmologist
 Current use of eye medications
 Use of contact lenses or eyeglasses
 Hygienic practices for corrective lenses
 Current symptoms of eye problems

Assessment

External Eye Structures

5. Inspect the eyebrows for hair distribution and
alignment, and for skin quality and movement.
6. Inspect the eyelashes for evenness of distribution
and direction of curl.
7. 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.
8. Inspect the bulbar conjunctiva for color, texture, and
the presence of lesions.
9. Inspect the palpebral conjunctiva by everting the lids.
10. Evert the upper lids if a problem is suspected.
Ask the client to look down while keeping the eyelids
slightly open.
 Gently grasp the client’s eyelashes with thumb and
forefinger. Pull lashes gently downwards.
Place a cotton-tipped applicator stick about 1cm
above the lid margin and push it gently downward
while holding the eyelashes.
Hold the margin of the everted lid or eyelashes
against the ridge of the upper bony orbit with the
applicator stick or your thumb.
Inspect the conjunctiva for color, texture lesions, and
foreign bodies.
11. 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.
12. 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.
13. 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.
14. 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. Approach from behind and
beside the client, and lightly touch the cornea with a
corner of the gauze.
15. Inspect the anterior chamber for transparency and
depth. Use the same oblique lighting used when
testing the cornea.
16. Inspect the pupils for color, shape, and symmetry of
size.
17. Assess each pupil’s direct and consensual reaction
to light.
Partially darken a 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. The pupil 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).
18. Assess each pupil’s reaction to accommodation.

Hold an object about 10 cm from the client’s nose.

Ask the client to look first at the top of the object and
then at a distant object behind the penlight. Alternate
the gaze between the near and far objects.

Observe the pupil response. 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.

Visual Fields
19. Assess peripheral visual fields.
Have the client sit directly facing you at a distance of
60–90 cm.
Ask the client to cover right eye with the card and
look directly at your nose.
Cover or close your eye directly opposite the client’s
covered eye and look directly at the client’s nose.

Hold an object 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.
 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 to the
central point of vision.
 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
edge is in the way.
 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.
 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 because
the nose is in the way.

Repeat the above steps for the right eye.

Extraocular Muscle Tests

20. Assess six ocular movements to determine eye
alignment and coordination.
Stand directly in front of client and hold the penlight
at a comfortable distance, such as 30 cm in front of
the client’s eyes.
Ask the client to hold head in a fixed position facing
you and 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.
Stop the movement s of the penlight periodically so
that the nystagmus can be detected.
21. Assess for location of light reflex by shining a
penlight on the pupil in corneal surface (Hirschberg
Test).
22. Have the client fixate on a near or far object. Cover
one eye and observe for movement in the uncovered
eye (cover test).
Visual Acuity
23. Assess near vision by providing adequate lighting
and asking the client to read from a magazine or
newspaper.
24. Assess distance vision by asking the client to wear
corrective lenses unless they are used for reading
only.
Ask the client to sit or stand 6 meters (20 ft) from
Snellen’s chart, cover the eye not being tested, and
identify the letters or characters.

Take three readings: right eye, left eye, and both

eyes.
25. Perform functional vision tests if the client is unable
to see the top line (20/200) of Snellen’s chart.
26. Document findings in the client record.

TOTAL

________________________
Clinical Instructor
(sign over printed name)