EYE ASSESSMENT
EYE ASSESSMENT
I.
Patient Profile:
Name of Patient :
Age :
Sex :
Ward :
Unit :
MRD Number :
Marital Status ;
Educational qualification:
Religion :
Occupation :
Family Income :
Address :
Date of Admission :
Medical Diagnosis :
II.
Reason for Hospitalization:
III.
Present health history : COLDSPA
Visual Problems:
·
Describe any recent changes in Sudden changes in
vision are
your vision. Where they sudden or
gradual? Associated with
acute problems
such
as head trauma or increased
intracranial
pressure.
·
Do you see spots or floaters in
front Mopia.
Your eyes?
·
Do you experience blind spots? Are glaucoma / vascular spasms
They constant or intermittent? Retinal
detachment.
·
Do you se halos or rings around
lights? Narrow angle glaucoma.
·
Do you have trouble seeing at night? Night blindness / optic
atrophy
Glaucoma, vitamin A deficiency.
·
Do you experience double vision? Diplopia may indicate increased
Intracranial pressure / injury /tumor.
Other symptoms:
·
Do you have any eye pain or itching? Allergies / foreign body
·
Do you have any redness or swelling
in allergies / foreign body / viral
Your eys? Bacterial
infections.
·
Do you experience excessive watering
Tearing of the eye? One or both?
·
Have you had any eye discharge? Bacterial viral infections.
PAST HEALTH HISTORY: Previous
eye problems
Eye surgery / discontinuing of treatment. Hospitalization /
HT
Diabetes
FAMILY HISTORY: Any
family history of
Glaucoma, refraction errors, allergies.
PERSONAL HISTORY wearing
sunglass / medications
Vision
loss affect daily activities.
Last
eye examination / contact
Lense. Smoking /
alcohol /veg /
Non vegetarian.
SOCIO ECONOMIC HISTROY :
SPIRITUAL HISTORY :
PHYSICAL ASSESSMENT
HEAD TO FOOT ASSESMENT
1. General
appearance : Thin / Moderate built / obese
2. Height :
in cm
3. Weight : in
kg
Head
1. Face : Symmetrical / asymmetrical
2. Oedema : present / absent
Eye
1. Eyebrow : Equal distribution of hair / sparingly Distributed
/ seborrheic dermatitis.
2. Eyelashes : Equal distribution of hair / sparingly Distributed
/ absent
3. Conjunctiva : Pale / yellow / pink
4. Eyelid : Able to open & close / ptosis /
Entropion
Ectropion / Lid Retraction and Exophthalmos
5. Pupils : Anisocoria / oculomotor nerve
paralysis.
Ear
1. Position :
Above the level of outer canthus / At the
Level of outer cantus, below the level of outer canthus
2. Drainage : present / absent
3. Nostrils : patent / obstructed
4. Septum : Centre / deviated
5. Discharge : present / absent
6. Mouth
7. Lips :
Dry / moist
8. Gums : Healthy / swollen
9. Odour : present / absent
10.
Throat : Normal / inflammed
Neck
1. Trachea : Midline / deviated
2. Neck Muscle
3. Retraction : present / absent
Chest
1. Inspection : chest movement: Symmetrical / asymmetrical
2. Auscultation : . S1 S2 heard
3. Lung sound
4. Percussion : Hyper resonant / resonant / dull
5. Palpation : mass / tenderness
Upper
Extremity
1. Rom : Full / limited
2. Abdomen :
3. Inspection : Shape
/ scar / lesion
4. Auscultation : Bowel sound: absent / borborgymi
5. Percussion : Tympany / resonant / dull
6. Palpation : Organomegaly / tenderness
Lower
Extremity
1. Rom : Full / limited
2. Capillary refill : <
3 Seconds / > 3 seconds
Genitalia
1. External : drainage
/ edema /
2. Inflammation / odor :
XII.
Systematic
Assessment:
Respiratory System:
Observation :
symmetrical / Asymmetrical / Rate / Rhythm
/ pattern of Respiration
Auscultation : Rhonchi, Creptus,
Wheeze,
Percussion :
Cardiovascular System:
Inspection : Apical
pulse
Auscultation : S1,S2,
Murmur, Friction rub Heart sound.
Palpation :
Gastro-Intestinal System:
Inspection : pigmentation / ascites / distension
Auscultation : bowel movement
Percussion : perforation / obstruction / fluid thril
Palpation : soft / smooth / tender / mass
Musculo-Skeletal System: Range of motion / Normal / abnormal
Endocrine System :
Lymphatic System :
Genito-Urinary System : Nocturia / Ployurea / Anurea / edema
Integumentary System : colour, moisture / Texture / turgor
Central Nervous System :
Level of consciousness :
Eye examination :
Visual Acuity : Myopia / presbyopia
Visual fields By Confrontation : left temporal hemianopsia
Glaucoma / Optic neuritis /
Papilledema.
Position and Alignment of the
Eyes :
abnormal protrusion (Graves’ disease
Ocular tumors.
Perform corneal light reflex test :
symmetric / Asymmetric
Cover test : Phoria / Strabismus / Tropia
Positions test : Nystagmus / sclerosis / brain lesions
(assesses eye muscle strength and narcotics use.
Cranial nerve function.
INSPECTION AND PALPATION :
Eyelids and eyelashes : Ptosis / Entropion / Ectropion
-assess ability of eyelids to close
-assess the position of the eyelids
-observe for redness, swelling,
Discharge, or lesions.
Observe the position and alignment
Of the eye ball in the eye socke. :
Exophthalmoses / sunken eye
Inspect the bulbar conjunctiva
And sclera : conjunctivitis / allergies / Episcleritis.
Inspect the palpebral conjunctiva : Cyanosis / swelling
Inspect the Lacrimal apparatus : Swelling / redness
Palpate the lacrimal apparatus : drainage present / absent /
expressed drainage
Inspect the cornea and lens : Cataract / Arcus senilis
Inspect the iris and pupil :
unshaped irises, / miosis / mydriasis /
Anisocoria.
Test papillary reaction to light : Present / Absent
Papillary Gauge Measurement:
1 2
3 4 5 6 7
Test accommodation of pupils : constrict / Not constrict
Inspect the optic disc : Papilledema / Glaucoma
/ Optic atrophy
Inspect the retinal vessels : constrict / dilated veins /
absent.
Inspect retinal background : Normal / abnormal
Inspect fovea and macula : Normal / abnormal
Inspect anterior chamber : Hyphemia / Hypopyon
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