Eye Assessment Demonstration

Introduction

• Demonstration by Cereth, a registered nurse
• Focus: Eye assessment
• Mention of a complete head-to-toe nursing assessment video available

Preparation Steps

• Provide privacy for the patient
• Wash hands
• Explain procedure to patient
• Equipment needed: penlight

Eye Inspection

• Areas to Inspect:
  • Eyelid
  • Sclera (white of the eye) should be white and shiny
  • Iris
  • Pupil
  • Conjunctiva (should be pink, not red, without drainage)
• Eye Position:
  • Check for strabismus (cross-eye)
  • Ensure eyes are normally set without irregularities

Pupil Size and Anisocoria

• Normal pupil size: 3-5 millimeters
• Anisocoria: Unequal pupil size
• Example: Pupils at 3 mm and equal

Cranial Nerve Assessment

• Cranial Nerves Involved:
  • CN III: Oculomotor
  • CN IV: Trochlear
  • CN VI: Abducens
• Tests Performed:
  • Check for nystagmus (involuntary eye shaking)
    • Use penlight 12-14 inches from nose
    • Perform test in six cardinal fields of gaze

Pupil Reaction to Light

• Dim lights
• Patient stares at distant object to dilate pupils
• Shine penlight at side of eyes
• Check for pupil constriction
  • Example: From 3 mm to 1 mm

Accommodation Test

• Turn lights back on
• Patient stares at distant object
• Move penlight towards patient's nose
• Pupils should constrict and accommodate, eyes should cross

Documentation

• Document using acronym PERRLA:
  • Pupils are Equal, Round, Reactive to Light and Accommodation

Conclusion

• Eye assessment process completed
• Reminder to watch complete head-to-toe assessment video
• Subscribe for more educational videos