{"id":2282,"date":"2024-03-12T15:09:04","date_gmt":"2024-03-12T19:09:04","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/cranial-nerve-cn-ii-optic-nerves-2\/"},"modified":"2024-06-01T09:51:07","modified_gmt":"2024-06-01T13:51:07","slug":"cranial-nerve-cn-ii-optic-nerves-2","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/chapter\/cranial-nerve-cn-ii-optic-nerves-2\/","title":{"raw":"CN II \u2013 Optic Nerves","rendered":"CN II \u2013 Optic Nerves"},"content":{"raw":"<span style=\"color: #000000\">The optic nerves (CN II) can be tested in several ways. Nurses often assess for visual acuity using the Snellen eye chart, and peripheral vision using the confrontational visual field exam.<\/span>\r\n\r\n<span style=\"color: #000000\"><strong>Visual Acuity Testing<\/strong><\/span>\r\n<span style=\"color: #000000\">Steps for evaluating visual acuity and the functioning of the CN II include:<\/span>\r\n<ol>\r\n \t<li><span style=\"color: #000000\">In a well-lit environment, have the client stand 20 feet away from the Snellen eye chart (see <strong>Figure 7<\/strong>). The chart should be placed on the wall at about 5 to 6 feet from the floor (at eye level). The client should keep their glasses on or their contact lenses in if they are used for distance. Snellen eye charts are also available in 10 feet formats; in this case, the client stands 10 feet away from the chart.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Ask the client to cover one eye with the palm of their hand.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Ask the client to read as many lines as they can, without squinting, beginning with the top line and reading one line at a time. Typically, you will stand to the side of the chart, and if necessary, you may point to the line.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">When the client has read as far as they can, ask them to try to read the next line.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">If they make an error on a line, ask them to repeat the line. They can make a maximum of two errors on a line in order for their visual acuity to be identified on that line. If they make more than two errors, then their visual acuity is noted as the line above.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Note the client\u2019s visual acuity using a fraction: the numerator (top number) is the distance the client is standing from the chart and the denominator (bottom number) is the distance at which a person with normal vision can read that line, as noted on the Snellen eye chart (Canadian Association of Optometrists, 2023; Porter, 2022). Normal vision is 20\/20 on the Snellen eye chart. The denominator should be reported as the last line the client could read, even if they made two errors on the line (e.g., they couldn\u2019t read two of the letters or they made an error with two of the letters). Report the eye (i.e., left or right), how many letters they missed, and whether they were wearing glasses or contact lenses (see <strong>Clinical Tip textbox<\/strong> for more information).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Repeat steps 2 to 6 for the other eye.<\/span>\r\n<ul>\r\n \t<li><span style=\"font-size: 1em;color: #000000\">Normal visual acuity is 20\/20, which means that the client can read at 20 feet what a person with normal\/good vision can read at 20 feet (Porter, 2022).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Abnormal visual acuity can involve situations where the denominator is bigger, and sometimes where the numerator is smaller. For example, 20\/60 means that the client can read at 20 feet what a person with normal\/good vision can read at 60 feet. Sometimes a client cannot read any of the letters at 20 feet. If so, they should move closer to the chart (e.g., 10 feet) and attempt to read the chart. In this case, the numerator would be 10. As an example, you may report vision as 10\/80, meaning that the client can read at 10 feet what a person with normal\/good vision can read at 80 feet.<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n \t<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:<\/span>\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normal findings might be documented as: \u201cCNII exam: visual acuity 20\/20 -1 in both eyes with contact lenses.\u201d (NOTE: -1 represents the number of letters they missed with each eye).<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cCNII exam: 20\/20 -2 in left eye, 20\/200 in right eye with no glasses\/contact lenses.\u201d (This reflects abnormal findings in the right eye).<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\n<ol>\r\n \t<li style=\"list-style-type: none\">\r\n<ol>\r\n \t<li style=\"list-style-type: none\"><\/li>\r\n<\/ol>\r\n<\/li>\r\n<\/ol>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/03\/Snellen-Chart-1.png\" alt=\"\" width=\"600\" height=\"847\" class=\"aligncenter wp-image-509\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 7<\/strong>: Snellen eye chart (By Khex14 \u2013 Own work, CC BY-SA 3.0,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=31308551\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=31308551<\/a><span style=\"color: #000000\">)<\/span>\r\n<div class=\"textbox textbox--examples\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\nVisual acuity is noted on the line where the client can read all of the letters with a maximum of two errors.\r\n\r\n<strong>Example 1<\/strong>: If the client incorrectly identifies two of the five letters on the 20\/40 line, this means they were unable to correctly read all of the letters on this line except two. Thus, their visual acuity is noted as 20\/40 - 2. Recall, they can make a maximum of two errors on a line.\r\n\r\n<strong>Example 2<\/strong>: If the client can accurately read all of the letters on the 20\/30 line and only 3 of the 7 letters on the next line (20\/25 line), this means they made more than two errors on the 20\/25 line. Thus, their visual acuity is noted as 20\/30 +3.\r\n\r\n<\/div>\r\n<\/div>\r\n<div class=\"textbox shaded\">\r\n<h2 style=\"text-align: center\"><span style=\"color: #000000\">Contextualizing Inclusivity<\/span><\/h2>\r\n<span style=\"color: #000000\">Some clients may be unable to stand due to muscle weakness, fatigue, balance problems, or being in wheelchair. If so, lower the Snellen eye chart so that it is located on the wall at about their eye level.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">Several alternatives are available for young children or individuals who are unable to read letters, including the<\/span> <a href=\"https:\/\/professional.ocusoft.com\/eye-chart-tumbling-e-10-ft-ea\" target=\"_blank\" rel=\"noopener\">Tumbling E chart<\/a> <span style=\"color: #000000\">or a<\/span> <a href=\"https:\/\/www.accutome.com\/kindergarten-test\" target=\"_blank\" rel=\"noopener\">chart with pictures<\/a>.\r\n\r\n<\/div>\r\n<h3><span style=\"color: #000000\"><strong>Confrontational Visual Field Exam<\/strong><\/span><\/h3>\r\n<span style=\"color: #000000\">Peripheral vision can be evaluated using the confrontational visual field exam. The exam can be conducted in several ways including client peripheral vision compared to examiner, wiggle finger method, and counting finger method. For each of these tests, you move your arm\/hand into three peripheral vision fields as per <strong>Figure 8<\/strong>: superior, eye level, inferior.\u00a0<\/span>\r\n\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-300x169.jpg\" alt=\"\" width=\"700\" height=\"394\" class=\"alignnone wp-image-2281\" \/>\r\n\r\n<span style=\"color: #000000\"><strong>Figure 8<\/strong>: Peripheral vision fields<\/span>\r\n\r\n<span style=\"color: #000000\">This exam should take place in a well-lit environment in which the client\u2019s eye level is at the same level as your eyes. Both you and the client can stand as long as eye levels match or you can stand and raise or lower the exam table so that the client\u2019s eye level matches your eye level. Position yourself about three to four feet away from the client.<\/span>\r\n\r\n<span style=\"color: #000000\">Ask the client to remove anything that could interfere with peripheral vision such as a hat with a rim, and then to look at your face: ask if they can clearly see your face with no difficulties and no blurring.<\/span>\r\n\r\n<span style=\"color: #000000\">The next set of steps are as follows:<\/span>\r\n<ol>\r\n \t<li><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>Client peripheral vision compared to examiner<\/strong>: <\/span><\/span>Stand about one foot away from the client. Cover your own right eye and ask the client to cover their left eye with the palm of their hand and stare directly at your open eye; you will also stare at their open eye. Stretch your left arm\/hand out laterally as far as you can in the superior field, at the client\u2019s eye level, midway between you and the client. Begin to move your arm\/hand inward. Ask the client to state \u201cnow\u201d when they first see your hand: they should see it at the same time you see it. Repeat this by stretching your arm\/hand into the inferior field and moving your arm\/hand inward. Then, repeat a third time with your arm\/hand stretched out laterally at the client\u2019s eye level, but this time closer to them as opposed to midway between you. Then, repeat the same three steps on the opposite eye. The validity of this exam is based on the assumption that the examiner has normal peripheral vision, which is about 90 degrees.<\/li>\r\n \t<li><span style=\"color: #000000\"><strong>Wiggle finger method<\/strong>: Now position yourself about three to four feet away from the client. Ask the client to fixate (focus) on your nose. Stretch both of your arms out to the side, pointed diagonally into the superior quadrants. Wiggle\/flex the index finger on one of your hands and ask the client to point to the side that they see your finger moving. Then repeat with your other hand. Repeat the same steps with your arms stretched out to the side laterally at eye level and then out to the side pointed diagonally into the inferior quadrants. The client should be able to identify the correct hand that is moving each time (see <strong>Video 3<\/strong>).<\/span><\/li>\r\n<\/ol>\r\n[embed]https:\/\/youtu.be\/pP7Jw85XejE[\/embed]\r\n\r\n<span style=\"color: #000000\"><strong>Video 3<\/strong>: Wiggle finger method.<\/span>\r\n<ol start=\"3\">\r\n \t<li><span style=\"color: #000000\"><strong>Counting finger method<\/strong>: Remain about three to four feet away from the client. To test the client\u2019s right eye: Close or cover your own right eye and ask the client to cover their left eye with the palm of their hand and stare directly at your open eye; you should do the same. Now, stretch your left arm\/hand out pointed diagonally into the superior quadrant, then laterally out at the eye level, and then diagonally down into the inferior quadrant. In each of these fields, hold up 1\u20135 fingers (use a different number each time) and ask the client how many fingers they see. Your hand should be midway (equidistant) between you and the client (i.e., not closer to you, nor closer to them) with the palm of your hand facing the client, so they can tell how many fingers you are holding up. Repeat the same steps to test the client\u2019s other eye; this time asking them to cover their right eye, and use your right arm\/hand (see <strong>Video 4<\/strong> as an example of testing the right eye).<\/span><\/li>\r\n<\/ol>\r\n[embed]https:\/\/youtu.be\/gAVlvTql7Gk[\/embed]\r\n\r\n<span style=\"color: #000000\"><strong>Video 4<\/strong>: Counting finger method for testing the right eye.<\/span>\r\n<ol start=\"4\">\r\n \t<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:<\/span>\r\n<ul>\r\n \t<li><span style=\"color: #000000\">Normal findings might be documented as: \u201cConfrontational visual field exam: client able to identify correct numbers and hand wiggling in all three peripheral positions on left and right sides. Client\u2019s peripheral vision intact (equal to the examiner\u2019s).\u201d<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cConfrontational visual field exam: client unable to see correct numbers displayed by examiner\u2019s fingers and examiner\u2019s hands wiggling in superior and inferior fields bilaterally. Client\u2019s peripheral vision less than the examiner\u2019s.\u201d<\/span><\/li>\r\n<\/ul>\r\n<\/li>\r\n<\/ol>\r\n<div class=\"textbox textbox--learning-objectives\"><header class=\"textbox__header\">\r\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\r\n<\/header>\r\n<div class=\"textbox__content\">\r\n\r\n<span style=\"color: #000000\">Clients who have decreased visual acuity or decreased peripheral vision should be encouraged to see an eye doctor. However, new onset and sudden loss of vision such as blurred vision, a dark spot or shadow, or double vision requires emergency care as these symptoms could be related to a stroke or [pb_glossary id=\"2411\"]retinal detachment[\/pb_glossary]. In these cases, stay with the client, notify the physician or nurse practitioner STAT, take the client\u2019s blood pressure, and perform a primary survey. <\/span>\r\n\r\n<\/div>\r\n<\/div>\r\n<h2><span style=\"color: #000000\">References<\/span><\/h2>\r\n<span style=\"color: #000000\">Campbell, W., &amp; Barohn, R. (2020). DeJong\u2019s The Neurological Examination. Wolters Kluwer.<\/span>\r\n\r\n<span style=\"color: #000000\">Canadian Association of Optometrists (2023). 20\/20 vision: What it\u2019s really telling you.<\/span> <a href=\"https:\/\/opto.ca\/eye-health-library\/2020-vision-what-its-really-telling-you\" target=\"_blank\" rel=\"noopener\">https:\/\/opto.ca\/eye-health-library\/2020-vision-what-its-really-telling-you<\/a>\r\n\r\n<span style=\"color: #000000\">Porter, D. (2022). Visual acuity.<\/span> <a href=\"https:\/\/www.aao.org\/eye-health\/tips-prevention\/visual-acuity-3\" target=\"_blank\" rel=\"noopener\">https:\/\/www.aao.org\/eye-health\/tips-prevention\/visual-acuity-3<\/a>","rendered":"<p><span style=\"color: #000000\">The optic nerves (CN II) can be tested in several ways. Nurses often assess for visual acuity using the Snellen eye chart, and peripheral vision using the confrontational visual field exam.<\/span><\/p>\n<p><span style=\"color: #000000\"><strong>Visual Acuity Testing<\/strong><\/span><br \/>\n<span style=\"color: #000000\">Steps for evaluating visual acuity and the functioning of the CN II include:<\/span><\/p>\n<ol>\n<li><span style=\"color: #000000\">In a well-lit environment, have the client stand 20 feet away from the Snellen eye chart (see <strong>Figure 7<\/strong>). The chart should be placed on the wall at about 5 to 6 feet from the floor (at eye level). The client should keep their glasses on or their contact lenses in if they are used for distance. Snellen eye charts are also available in 10 feet formats; in this case, the client stands 10 feet away from the chart.<\/span><\/li>\n<li><span style=\"color: #000000\">Ask the client to cover one eye with the palm of their hand.<\/span><\/li>\n<li><span style=\"color: #000000\">Ask the client to read as many lines as they can, without squinting, beginning with the top line and reading one line at a time. Typically, you will stand to the side of the chart, and if necessary, you may point to the line.<\/span><\/li>\n<li><span style=\"color: #000000\">When the client has read as far as they can, ask them to try to read the next line.<\/span><\/li>\n<li><span style=\"color: #000000\">If they make an error on a line, ask them to repeat the line. They can make a maximum of two errors on a line in order for their visual acuity to be identified on that line. If they make more than two errors, then their visual acuity is noted as the line above.<\/span><\/li>\n<li><span style=\"color: #000000\">Note the client\u2019s visual acuity using a fraction: the numerator (top number) is the distance the client is standing from the chart and the denominator (bottom number) is the distance at which a person with normal vision can read that line, as noted on the Snellen eye chart (Canadian Association of Optometrists, 2023; Porter, 2022). Normal vision is 20\/20 on the Snellen eye chart. The denominator should be reported as the last line the client could read, even if they made two errors on the line (e.g., they couldn\u2019t read two of the letters or they made an error with two of the letters). Report the eye (i.e., left or right), how many letters they missed, and whether they were wearing glasses or contact lenses (see <strong>Clinical Tip textbox<\/strong> for more information).<\/span><\/li>\n<li><span style=\"color: #000000\">Repeat steps 2 to 6 for the other eye.<\/span>\n<ul>\n<li><span style=\"font-size: 1em;color: #000000\">Normal visual acuity is 20\/20, which means that the client can read at 20 feet what a person with normal\/good vision can read at 20 feet (Porter, 2022).<\/span><\/li>\n<li><span style=\"color: #000000\">Abnormal visual acuity can involve situations where the denominator is bigger, and sometimes where the numerator is smaller. For example, 20\/60 means that the client can read at 20 feet what a person with normal\/good vision can read at 60 feet. Sometimes a client cannot read any of the letters at 20 feet. If so, they should move closer to the chart (e.g., 10 feet) and attempt to read the chart. In this case, the numerator would be 10. As an example, you may report vision as 10\/80, meaning that the client can read at 10 feet what a person with normal\/good vision can read at 80 feet.<\/span><\/li>\n<\/ul>\n<\/li>\n<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:<\/span>\n<ul>\n<li><span style=\"color: #000000\">Normal findings might be documented as: \u201cCNII exam: visual acuity 20\/20 -1 in both eyes with contact lenses.\u201d (NOTE: -1 represents the number of letters they missed with each eye).<\/span><\/li>\n<li><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cCNII exam: 20\/20 -2 in left eye, 20\/200 in right eye with no glasses\/contact lenses.\u201d (This reflects abnormal findings in the right eye).<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<ol>\n<li style=\"list-style-type: none\">\n<ol>\n<li style=\"list-style-type: none\"><\/li>\n<\/ol>\n<\/li>\n<\/ol>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/03\/Snellen-Chart-1.png\" alt=\"\" width=\"600\" height=\"847\" class=\"aligncenter wp-image-509\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 7<\/strong>: Snellen eye chart (By Khex14 \u2013 Own work, CC BY-SA 3.0,<\/span> <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?curid=31308551\" target=\"_blank\" rel=\"noopener\">https:\/\/commons.wikimedia.org\/w\/index.php?curid=31308551<\/a><span style=\"color: #000000\">)<\/span><\/p>\n<div class=\"textbox textbox--examples\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Clinical Tip<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p>Visual acuity is noted on the line where the client can read all of the letters with a maximum of two errors.<\/p>\n<p><strong>Example 1<\/strong>: If the client incorrectly identifies two of the five letters on the 20\/40 line, this means they were unable to correctly read all of the letters on this line except two. Thus, their visual acuity is noted as 20\/40 &#8211; 2. Recall, they can make a maximum of two errors on a line.<\/p>\n<p><strong>Example 2<\/strong>: If the client can accurately read all of the letters on the 20\/30 line and only 3 of the 7 letters on the next line (20\/25 line), this means they made more than two errors on the 20\/25 line. Thus, their visual acuity is noted as 20\/30 +3.<\/p>\n<\/div>\n<\/div>\n<div class=\"textbox shaded\">\n<h2 style=\"text-align: center\"><span style=\"color: #000000\">Contextualizing Inclusivity<\/span><\/h2>\n<p><span style=\"color: #000000\">Some clients may be unable to stand due to muscle weakness, fatigue, balance problems, or being in wheelchair. If so, lower the Snellen eye chart so that it is located on the wall at about their eye level.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">Several alternatives are available for young children or individuals who are unable to read letters, including the<\/span> <a href=\"https:\/\/professional.ocusoft.com\/eye-chart-tumbling-e-10-ft-ea\" target=\"_blank\" rel=\"noopener\">Tumbling E chart<\/a> <span style=\"color: #000000\">or a<\/span> <a href=\"https:\/\/www.accutome.com\/kindergarten-test\" target=\"_blank\" rel=\"noopener\">chart with pictures<\/a>.<\/p>\n<\/div>\n<h3><span style=\"color: #000000\"><strong>Confrontational Visual Field Exam<\/strong><\/span><\/h3>\n<p><span style=\"color: #000000\">Peripheral vision can be evaluated using the confrontational visual field exam. The exam can be conducted in several ways including client peripheral vision compared to examiner, wiggle finger method, and counting finger method. For each of these tests, you move your arm\/hand into three peripheral vision fields as per <strong>Figure 8<\/strong>: superior, eye level, inferior.\u00a0<\/span><\/p>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-300x169.jpg\" alt=\"\" width=\"700\" height=\"394\" class=\"alignnone wp-image-2281\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-300x169.jpg 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-1024x576.jpg 1024w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-768x432.jpg 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-65x37.jpg 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-225x127.jpg 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields-350x197.jpg 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-content\/uploads\/sites\/421\/2024\/05\/Peripheral-vision-fields.jpg 1440w\" sizes=\"auto, (max-width: 700px) 100vw, 700px\" \/><\/p>\n<p><span style=\"color: #000000\"><strong>Figure 8<\/strong>: Peripheral vision fields<\/span><\/p>\n<p><span style=\"color: #000000\">This exam should take place in a well-lit environment in which the client\u2019s eye level is at the same level as your eyes. Both you and the client can stand as long as eye levels match or you can stand and raise or lower the exam table so that the client\u2019s eye level matches your eye level. Position yourself about three to four feet away from the client.<\/span><\/p>\n<p><span style=\"color: #000000\">Ask the client to remove anything that could interfere with peripheral vision such as a hat with a rim, and then to look at your face: ask if they can clearly see your face with no difficulties and no blurring.<\/span><\/p>\n<p><span style=\"color: #000000\">The next set of steps are as follows:<\/span><\/p>\n<ol>\n<li><span style=\"color: #000000\"><span style=\"color: #000000\"><strong>Client peripheral vision compared to examiner<\/strong>: <\/span><\/span>Stand about one foot away from the client. Cover your own right eye and ask the client to cover their left eye with the palm of their hand and stare directly at your open eye; you will also stare at their open eye. Stretch your left arm\/hand out laterally as far as you can in the superior field, at the client\u2019s eye level, midway between you and the client. Begin to move your arm\/hand inward. Ask the client to state \u201cnow\u201d when they first see your hand: they should see it at the same time you see it. Repeat this by stretching your arm\/hand into the inferior field and moving your arm\/hand inward. Then, repeat a third time with your arm\/hand stretched out laterally at the client\u2019s eye level, but this time closer to them as opposed to midway between you. Then, repeat the same three steps on the opposite eye. The validity of this exam is based on the assumption that the examiner has normal peripheral vision, which is about 90 degrees.<\/li>\n<li><span style=\"color: #000000\"><strong>Wiggle finger method<\/strong>: Now position yourself about three to four feet away from the client. Ask the client to fixate (focus) on your nose. Stretch both of your arms out to the side, pointed diagonally into the superior quadrants. Wiggle\/flex the index finger on one of your hands and ask the client to point to the side that they see your finger moving. Then repeat with your other hand. Repeat the same steps with your arms stretched out to the side laterally at eye level and then out to the side pointed diagonally into the inferior quadrants. The client should be able to identify the correct hand that is moving each time (see <strong>Video 3<\/strong>).<\/span><\/li>\n<\/ol>\n<p><iframe loading=\"lazy\" id=\"oembed-1\" title=\"Wiggle Finger Method\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/pP7Jw85XejE?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"color: #000000\"><strong>Video 3<\/strong>: Wiggle finger method.<\/span><\/p>\n<ol start=\"3\">\n<li><span style=\"color: #000000\"><strong>Counting finger method<\/strong>: Remain about three to four feet away from the client. To test the client\u2019s right eye: Close or cover your own right eye and ask the client to cover their left eye with the palm of their hand and stare directly at your open eye; you should do the same. Now, stretch your left arm\/hand out pointed diagonally into the superior quadrant, then laterally out at the eye level, and then diagonally down into the inferior quadrant. In each of these fields, hold up 1\u20135 fingers (use a different number each time) and ask the client how many fingers they see. Your hand should be midway (equidistant) between you and the client (i.e., not closer to you, nor closer to them) with the palm of your hand facing the client, so they can tell how many fingers you are holding up. Repeat the same steps to test the client\u2019s other eye; this time asking them to cover their right eye, and use your right arm\/hand (see <strong>Video 4<\/strong> as an example of testing the right eye).<\/span><\/li>\n<\/ol>\n<p><iframe loading=\"lazy\" id=\"oembed-2\" title=\"Counting Finger Method\" width=\"500\" height=\"281\" src=\"https:\/\/www.youtube.com\/embed\/gAVlvTql7Gk?feature=oembed&#38;rel=0\" frameborder=\"0\" allowfullscreen=\"allowfullscreen\"><\/iframe><\/p>\n<p><span style=\"color: #000000\"><strong>Video 4<\/strong>: Counting finger method for testing the right eye.<\/span><\/p>\n<ol start=\"4\">\n<li><span style=\"color: #000000\">Note the <strong>findings<\/strong>:<\/span>\n<ul>\n<li><span style=\"color: #000000\">Normal findings might be documented as: \u201cConfrontational visual field exam: client able to identify correct numbers and hand wiggling in all three peripheral positions on left and right sides. Client\u2019s peripheral vision intact (equal to the examiner\u2019s).\u201d<\/span><\/li>\n<li><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cConfrontational visual field exam: client unable to see correct numbers displayed by examiner\u2019s fingers and examiner\u2019s hands wiggling in superior and inferior fields bilaterally. Client\u2019s peripheral vision less than the examiner\u2019s.\u201d<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ol>\n<div class=\"textbox textbox--learning-objectives\">\n<header class=\"textbox__header\">\n<h2 class=\"textbox__title\" style=\"text-align: center\"><strong>Priorities of Care<\/strong><\/h2>\n<\/header>\n<div class=\"textbox__content\">\n<p><span style=\"color: #000000\">Clients who have decreased visual acuity or decreased peripheral vision should be encouraged to see an eye doctor. However, new onset and sudden loss of vision such as blurred vision, a dark spot or shadow, or double vision requires emergency care as these symptoms could be related to a stroke or <button class=\"glossary-term\" aria-describedby=\"2282-2411\">retinal detachment<\/button>. In these cases, stay with the client, notify the physician or nurse practitioner STAT, take the client\u2019s blood pressure, and perform a primary survey. <\/span><\/p>\n<\/div>\n<\/div>\n<h2><span style=\"color: #000000\">References<\/span><\/h2>\n<p><span style=\"color: #000000\">Campbell, W., &amp; Barohn, R. (2020). DeJong\u2019s The Neurological Examination. Wolters Kluwer.<\/span><\/p>\n<p><span style=\"color: #000000\">Canadian Association of Optometrists (2023). 20\/20 vision: What it\u2019s really telling you.<\/span> <a href=\"https:\/\/opto.ca\/eye-health-library\/2020-vision-what-its-really-telling-you\" target=\"_blank\" rel=\"noopener\">https:\/\/opto.ca\/eye-health-library\/2020-vision-what-its-really-telling-you<\/a><\/p>\n<p><span style=\"color: #000000\">Porter, D. (2022). Visual acuity.<\/span> <a href=\"https:\/\/www.aao.org\/eye-health\/tips-prevention\/visual-acuity-3\" target=\"_blank\" rel=\"noopener\">https:\/\/www.aao.org\/eye-health\/tips-prevention\/visual-acuity-3<\/a><\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"2282-2411\" hidden><p>is an emergency situation when the retinal tissue pulls away from the back of the eye (without immediate treatment it can result in permanent loss of vision).<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":9,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by-nc"},"chapter-type":[],"contributor":[88],"license":[56],"class_list":["post-2282","chapter","type-chapter","status-publish","hentry","contributor-june-2024-cu3e0lrwrt","license-cc-by-nc"],"part":2261,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2282","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":8,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2282\/revisions"}],"predecessor-version":[{"id":2499,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2282\/revisions\/2499"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/parts\/2261"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapters\/2282\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/media?parent=2282"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/pressbooks\/v2\/chapter-type?post=2282"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/contributor?post=2282"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursingmain\/wp-json\/wp\/v2\/license?post=2282"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}