Overview
This lecture demonstrates how to perform a focused nursing eye assessment, covering inspection steps, cranial nerve checks, and pupil responses.
Preparation & Equipment
- Provide patient privacy and perform hand hygiene before starting.
- Explain the procedure to the patient.
- Required equipment: penlight.
Eye Inspection Steps
- Inspect eyelids for swelling; normal eyelids show no swelling.
- Examine the sclera (white of eye); should be white and shiny, not yellow.
- Check conjunctiva (lining under eyelid); should be pink, not red, with no drainage.
- Assess the position of eyes in the sockets for equality; note any strabismus (misalignment).
- Look for anisocoria (unequal pupil size); normal pupils are equal and 3-5 mm in size.
Cranial Nerve Assessment
- Test cranial nerve III (oculomotor), IV (trochlear), and VI (abducens).
- Use the penlight to perform the six cardinal fields of gaze assessment.
- Instruct patient to follow the penlight with only their eyes, not moving their head.
- Check for nystagmus (involuntary eye shaking) during gaze test.
Pupil Responses
- Dim the room lights and instruct the patient to look at a distant object to dilate pupils.
- Shine penlight from the side into each pupil; pupils should constrict equally.
- Record change in pupil size (e.g., from 3 mm to 1 mm with light).
Accommodation Test
- Return lights to normal.
- Ask patient to focus on a distant object, then move penlight or finger slowly toward their nose.
- Observe for pupil constriction and eye convergence (crossing).
Documentation & Acronym
- Document findings as PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation.
Key Terms & Definitions
- Sclera — The white part of the eye.
- Conjunctiva — The membrane lining the eyelids.
- Strabismus — Misalignment of the eyes.
- Anisocoria — Unequal pupil sizes.
- Nystagmus — Involuntary rapid movement of the eyes.
- PERRLA — Pupils Equal, Round, Reactive to Light and Accommodation.
Action Items / Next Steps
- Review and practice the complete head-to-toe nursing assessment.
- Document eye assessment findings in the patient's chart.