Open Resources for Nursing (Open RN)
Use the checklist below to review the steps for completing an “Eye and Ear Assessment.”
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Gather supplies: penlight, Ishihara plates, Snellen chart, Rosenbaum card, or a newspaper to read.
- Perform safety steps:
- Perform hand hygiene.
- Check the room for transmission-based precautions.
- Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
- Confirm patient ID using two patient identifiers (e.g., name and date of birth).
- Explain the process to the patient and ask if they have any questions.
- Be organized and systematic.
- Use appropriate listening and questioning skills.
- Listen and attend to patient cues.
- Ensure the patient’s privacy and dignity.
- Assess ABCs.
- Use effective interview questions to collect subjective data about eye or ear problems.
- Inspect the external eye. Note any unexpected findings.
- Assess that pupils are equally round and reactive to light and accommodation (PERRLA).
- Assess extraocular movement.
- Inspect the external ear. Note any unexpected findings.
- Assess distance vision acuity using the Snellen eye chart and proper technique.
- Assess near vision acuity using a prepared card or newspaper.
- Asses for color blindness using the Ishihara plates.
- Assess hearing by accurately performing the whisper test.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- Ensure safety measures when leaving the room:
- CALL LIGHT: Within reach
- BED: Low and locked (in lowest position and brakes on)
- SIDE RAILS: Secured
- TABLE: Within reach
- ROOM: Risk-free for falls (scan room and clear any obstacles)
- Perform hand hygiene.
- Document the assessment findings. Report any concerns according to agency policy.
