Normal vision
- 6/6, 6/9 - Normal vision
- 6/12 - Mild impairment
- 6/18 - Moderate impairment
- 6/24, 6/36 - Severe visual impairment
- Less than 6/60 - Blindness
The smaller the denominator, the better the vision. A normal vision is 6/6.
Oct/2008 rangsima@chiangmai.ac.th 56
Contents
History Taking
Ocular Symptomatology
Visual Acuity Test
External Eye Examination
Eye Lids
Eyeball
1. Rangsima Poomsawat
Department of Public Health Nursing
Faculty of Nursing Chiang Mai University
E mail: rangsima@ chiangmai.ac.th
http://www.facebook.com/RangsimaPoomsawat
http://www.slideshare.net/rpoom
http://www.youtube.com/RangsimaPoomsawat
http://www.facebook.com/pages/Nursing-Room-By-Rangsima/109937325743807?v=wall
Oct/2008 rangsima@chiangmai.ac.th 1
2. Contents
1. History Taking
2. Ocular Symptomatology
3. Visual Acuity Test
4. External Eye Examination
1. Eye Lids
2. Eyeball
3. Lacrimal System
4. Conjunctiva
5. Anterior Segment Examination
1. Cornea
2. Anterior Chamber
3. Iris
4. Pupil
5. Lens
6. Testing of Function of Extraocular Muscles
Oct/2008 rangsima@chiangmai.ac.th 2
4. • The purpose of the
interviewing a client is to
obtain a health history.
• Ask about the symptoms or
other phenomena associated
with the client’s chief
problems or concerned and at
the same time observes for
signs in the client’s physical
appearance or behaviors.
Oct/2008 rangsima@chiangmai.ac.th 4
5. • Introductory phase
– To create a climate of trust to promote interaction
– Introduce yourself : your full name, your role
**This greeting respectfully acknowledges the
clients and conveys your accountability as part of
health care team
– Describe your purpose of the interview
Oct/2008 rangsima@chiangmai.ac.th 5
6. • Working phase
– You and the client should both be comfortably seated and
facing each other during the interview.
– To put the client ease, directly state that the information
you obtain will be confidential, recorded in the medical
record,and share with those directly involved in the care
and treatment plan.
– Take some note and complete final record later.
– Eye Practitioner may be skillful in communication
techniques to enable a client to share life experiences
relevant to his health status.
Oct/2008 rangsima@chiangmai.ac.th 6
7. Interview Techniques
Type of Questions
– Opened ended : broad opening statements
• Your concern today is….?
• Tell me what bring you here today?
– Closed ended : requires a response of one or two
words,such as yes or no
• Age, Marital status, Medication
– Directive questions : lead the client to focus on one set of
thought
• Used in review of system or in evaluating functional health status.
• Have you experienced any problem with urination in the past,such
as infection ,unusual frequency, urgency, or difficulty urination?
– Permission-giving questions
• Asks client questions about sensitive area : Sexual transmitted
infection
• Let a client know that it is all right to speak such things to you.
Oct/2008 rangsima@chiangmai.ac.th 7
8. Interview Techniques
Use of Silence
Short period of silence allow the clients organize their
thoughts.
During silence period,you can observe the clients
emotional state and note nonverbal cues.
Silence may also indicate that either you or the client need
time to reflect on what was just said.
Oct/2008 rangsima@chiangmai.ac.th 8
9. Validating Information From the Interview
• Clarification : ask the client to clarify the thought or
feeling
• Restatement : involves repeating what the client has
said using different word.
• Reflection : repeat phrase or sentence the client just
said.
• Confrontation : make the client aware that what you
observe is not consistent with he said.
• Interpretation : share with the client the conclusion
you have drawn from the information you obtained
• Summary : summarize the information when
terminate interview
Oct/2008 rangsima@chiangmai.ac.th 9
10. Nonverbal Communication
• Body language :
– Body Posture, Facial expressions are indicators of emotional
states such as fear anxiety, surprise or joy
• Eye contact
– Avoid eye contact during interviewing may have anxiety
• Interpersonal Distance : vary by the nature or cultural
practice
• Touch : express appreciation and trust by touch
Oct/2008 rangsima@chiangmai.ac.th 10
11. Organization of A History
• Introductory Data
• Chief complaint
• Present illness
• Past History
• Personal History
• Family History
• Review of System
Oct/2008 rangsima@chiangmai.ac.th 11
12. Introductory Data
•Included under general information are the essential facts
– Name, Address, Date of birth , Age,
Sex
– Occupation
• Type of work
• Industrial hazard
Oct/2008 rangsima@chiangmai.ac.th 12
13. Chief Complaint : CC
The main reason for which the patient has come to
the doctor for advice and help
Include a notation of the duration of problem
• Blurred Vision ****
• Ocular pain (ocular ache) , Burn sensation ***
• Discharge
• Red eye
• Itching
• Changes in vision or visual fields
• Difficulty reading
• Oct/2008 cyst , stye , exophthalmos
Etc : rangsima@chiangmai.ac.th 13
14. Example of good statements of CC
• “Blurred vision Right eye for 7 days”
• “Headache and fever for 6 hours.”
• “Vision test needed for work”
Oct/2008 rangsima@chiangmai.ac.th 14
15. Greater detail of
main symptoms Present Illness :PI
• Duration :
– How long has this condition lasted? Is it similar to a
past problem? If so, what was done at that time?
• Onset : sudden or gradually
• Severity/ Character
– How bothersome is this problem? Does it interfere
with your daily activities?
– If they are describing pain, ask them to rate it from 1 to
10 with 10 being the worse pain of their life
– When describing pain, ask if it's like anything else that
they've felt in the past. Knife-like? A sensation of
pressure? A toothache?
– If it affects their activity level, determine to what
Oct/2008
degree this occurs.
rangsima@chiangmai.ac.th 15
16. Present Illness : PI
• Location/ Radiation : unilateral or bilateral
– Is the symptom (e.g. pain) located in a specific place?
Has this changed over time? If the symptom is not
focal, does it radiate to a specific area of the body?
• Pace of illness: Is the problem getting better, worse, or
staying the same? If it is changing, what has been the
rate of change?
• Are there any associated symptoms? If so, what's made it
better (or worse)?
• Have they tried any therapeutic maneuvers? If so, what's
made it better (or worse)?
• What do they think the problem is and/or what are they
worried it might be?
Oct/2008 rangsima@chiangmai.ac.th 16
17. Present Illness : PI
• Why today?
– This is particularly relevant when a
patient chooses to make mention of
symptoms/complaints that appear to be
long standing.
– Is there something new/different today
as opposed to every other day when this
problem has been present?
– Does this relate to a gradual worsening
of the symptom itself?
Oct/2008 rangsima@chiangmai.ac.th 17
18. Past History : PH
• Past Ocular Problem /Trauma / Ocular surgery :
repeat , chronic
• Herpetic stromal keratitis
• Aphakia , Lens Extraction
• Visual acuity in the past / Eye glasses
• Myopia , Presbyopia , Astigmatism
• Past Medical History
• Hypertension, Diabetic Mellitus, Thyrotoxicosis
• Malaria, Tuberculosis **
• Past Surgical History
• Accident and disabling injuries
• Hospitalization (including Blood transfusion)
Oct/2008 rangsima@chiangmai.ac.th 18
19. Past History : PH
• Medications (ocular or other)
• Mydriatics Myotics
• Steroid
• Ethambutol , Quinine, Chloroquine
• Epinephrine , silver nitrate
• Herbal preparation or nutrition supplement
Oct/2008 rangsima@chiangmai.ac.th 19
20. Past History : PH
• Allergies/Reactions
– Environment :Inhalants Contactants
– Food : Ingestants
– Medication
• Pediatric:
– Growth and Development
– Immunization
Oct/2008 rangsima@chiangmai.ac.th 20
21. Personal History
• Habits :Smoking / Alcohol /Caffeine/Drugs
• Sexual Activity
Oct/2008 rangsima@chiangmai.ac.th 21
22. Family History : FH
• Heritable illnesses
• Color blindness , Retinoblstoma
• Myopia ,Glaucoma
• Chronic Disease
• DM Hypertension
• Communicable diseases(including
family Sibling Sex partner)
• HIV
• TB
• Malaria
Oct/2008 rangsima@chiangmai.ac.th 22
23. Review of Systems
• Health History :
– Head and Neck
– Thorax and Lung
– Heart
– Abdomen
– Musculoskeletal
– Neurological
– Mental
Oct/2008 rangsima@chiangmai.ac.th 23
24. Contents
History Taking
Ocular Symptomatology
Visual Acuity Test
External Eye Examination
Eye Lids
Eyeball
Lacrimal System
Conjunctiva
Anterior Segment Examination
Cornea
Anterior Chamber
Iris
Pupil
Lens
Testing of Function of Extraocular Muscles
Oct/2008 rangsima@chiangmai.ac.th 24
45. Contents
History Taking
Ocular Symptomatology
Visual Acuity Test
External Eye Examination
Eye Lids
Eyeball
Lacrimal System
Conjunctiva
Anterior Segment Examination
Cornea
Anterior Chamber
Iris
Pupil
Lens
Testing of Function of Extraocular Muscles
Oct/2008 rangsima@chiangmai.ac.th 45
46. • Assessment of the eye's
ability to distinguish
object details and shape,
using the smallest
identifiable object that can
be seen at a specified
distance (usually 20 ft. or
16 in.).
Oct/2008 rangsima@chiangmai.ac.th 46
47. • Finding normal VA
>>
– Clarity of cornea anterior body Lena Vitreous
Humor
– adequacy of macular (central vision)
– Functioning of nerve fiber from macula to the
occipital cortex
Oct/2008 rangsima@chiangmai.ac.th 47
49. For Near vision:
• Near vision is tested by using a
test card and each eye is tested
individually.
• The card has number of printed
paragraphs with print of varying
sizes. Each paragraph is described
in terms of “points” measuring
the body of the print – where a
“point” is 1/72 of an inch.
• In a common test, N48 is the
largest type, and N5 is the
smallest, which an unimpaired
eye can see, held at a comfortable
reading distance, (usually 14
inches), from the eyes.
Oct/2008 rangsima@chiangmai.ac.th 49
55. Snellen chart
• Distance 6 m. or 20 ft.
• Without glasses SC 6/24 , 6/36
• with glasses CC 6/9 , 6/9
• With pinholes CC PH 6/6 , 6/6
• Interprete VA (visual acuity)
numerator denotes the distance the patient is from the chart letter
denominator denotes the distance from the chart at which normal person
Oct/2008 rangsima@chiangmai.ac.th 55
56. Visual acuity
• 6/6, 6/9, 6/12, 6/18, 6/24, 6/36, 6/60
• 5/60, 4/60, 3/60, 2/60, 1/60
• FC 2 ft, FC 1 ft (finger count)
• HM (hand motion)
• PJ (projection of light)
• PL (perception of light)
• NLP (no light perception)
Oct/2008 rangsima@chiangmai.ac.th 56
57. VA with pinholes
• Improve : R/O refractive error
• No improve or worse : R/O Ocular
disease
SC 6/24 , 6/36 SC 6/12 , 6/9
SC c PH 6/9 , 6/9 SC c PH 6/24 , 6/12
Oct/2008 rangsima@chiangmai.ac.th 57
58. VA Test in Children
Oct/2008 rangsima@chiangmai.ac.th 58
121. Six cardinal direction of gaze
1.Ocular Motility
การตรวจการกลอกตาข้างเดียว = duction
Oct/2008
กลอกตาสองข้างพร้อมกัน = version
rangsima@chiangmai.ac.th 121
123. 2.Corneal light reflex Hirschberg test
• The white spots in each • The main light reflection is
pupil are actually the in the same position in each
reflection of the light from eye. Also note the extra light
the penlight that is being reflections in both eyes that
shined in the eyes. are due to the reflection of
the ceiling light.
Oct/2008 rangsima@chiangmai.ac.th 123
124. • without glasses : left eye corneal light reflection is in the
outer aspect of her left pupil, and the reflection in her right
pupil is centered.
• with glasses both eyes have a symmetrical reflection.
• This illustrates the importance of keeping the child’s
glasses on while administering this screening procedure.
Oct/2008 rangsima@chiangmai.ac.th 124