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Eye%20Validation%20Example%20MW%202003%20NUR%20207 -...

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NURSING 207 Assessment of the __Eyes ___________________ History: Client complains of itching and burning in eye for one week due to exposure at work. Client also stated eyes have been dry and has been rubbing eyes. Denies wearing contacts and glasses. Denies eye injuries or surgeries. Client states mom and dad wear glasses and aunt has cataracts. States last eye exam July 1995. Client states pain associated with eye is 3 on a scale of 1 to 10. Client uses eye drops to treat pain. Eye drops are effective in treating dryness but do not stop irritation. Physical Findings: Distant visual acuity both 20/10, right 20/15 +6, left 20/10. Near visual acuity read two lines of newsprint accurately. Peripheral visual field corresponds to examiners. Extraocular muscles functioning with equal response as indicated by cardinal fields of gaze and corneal light reflex. Pupils dilate and accommodate equally as indicated by direct and consensual pupil response and pupil accommodation test. Hair distribution on eyebrows and
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Unformatted text preview: eyelashes full and equal. Eyelids and lacrimal apparatus normal = not puffy. Eyeball: no abnormalities. Conjunctiva: red in color, no inflammation. Cornea responded to cotton test with appropriate blink reflex. Sclera: white to blue white in color, not blood shot at anterior chamber. Iris and pupil: brown iris with equally dilated black pupils. Lacrimal apparatus: not swollen, no discharge. Upper and lower lids and eyebrows normal, not swollen. Bony orbit: firm, no chips or abnormalities. Retina: appeared intact, red reflex seen. Could not see optic disk. Problem Statement: High risk for injury related to rubbing of eye after dust exposure at work. Nursing Plan: Diagnosis: inspect conjunctiva for inflammation, inspect cornea and sclera for scratches Treatment: use eyedrops prn Education: teach proper handwashing techniques; teach proper way to clean eye (in to out) and no rubbing; inform about use of safety glasses when working; remind re importance of yearly checkups. Signature...
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