Nursing Assessment of the Pupil

by Samantha Rhea, MSN, RN

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    00:01 Now, another really important assessment piece when we're talking about the neurological status of the patient.

    00:07 Now, looking at pupils is very important.

    00:10 These can be subtle changes that can tell us a lot about a patient's condition.

    00:16 So when we talk about pupils, think about a couple of things.

    00:20 So one of these are, are the pupils reactive to light? So for introduced light into the patient's pupils, do they react? And next looking at the response, meaning do they have a consensual response? So what I'm referring to is if I take my penlight in my patient's eyes, go down one side and shine light in one eye, do they both respond? That is meaning a consensual response, and that is good, and that's normal.

    00:47 Now, sometimes you may take your penlight, do the same thing, but both pupils do not respond.

    00:54 That is what we call a nonconsensual response.

    00:57 Now, that is not normal and that needs to be reported to the provider.

    01:01 And one other thing that we note is the size of the pupils.

    01:05 This can also tell us a lot.

    01:07 So it's important to assess these at the beginning of the shift.

    01:10 And as you can see here, there's a guide about what size the pupils are.

    01:14 And if you have a penlight, this guide is usually on that penlight for you to refer to.

    01:20 Now, when we talk about pupils, many times you're gonna hear the word of PERRLA meaning, Pupils are Equal, Round, Reactive and Light Accommodating.

    01:31 So anytime you hear PERRLA that's a very common neurological assessment that includes some of these components.

    01:38 So let's just talk a little bit further about pupils.

    01:41 So anytime you're talking to neuro, we say that, the eyes are the window to the soul, they just tell us a lot.

    01:48 So if the pupils indeed are not PERRLA meaning Pupils are Equal, Round, and Reactive and Light Accommodating, now this can mean a lot of things.

    01:58 This can mean the patient has suffered from a head injury, it could be certain medications or drugs, or a patient could have a severe stroke or a brain bleed that may be changing.

    02:09 Now, just note this some drugs will make pupils very pinpoint meaning very small.

    02:15 Now, some others will actually dilate the pupil and it'll be much larger.

    02:19 Now, this is a good point of reference, especially if you work in the emergency room, for example, and get someone that is in the emergency room and is being treated.

    02:29 Now, let's look more at these pupil assessments.

    02:33 Now, one way that we assess pupil response is, and if you can dim the lights, this really helps you out.

    02:39 So if you can dim the lights, go ahead and do so.

    02:42 Then you're gonna have the client look at an object in the distance kind of like if you were going to go to the eye doctor.

    02:48 And this again is where we get our penlight to shine this into their eyes from each side.

    02:54 Now, here's where we've got to watch their pupils closely.

    02:58 Now, we've got to see that the pupils constrict and respond to the light and making note of the size and shape of their pupils.

    03:06 Now remember, when we shined in one side, we should have a consensual response, meaning both pupils reacted.

    03:14 And remember to go from one side and compare sides to the other.

    03:19 Now let's take a look at pupil sizing.

    03:21 As you can see here, it goes from really smaller 1mm all the way to what we call a blown pupil at 9mm.

    03:29 Now I'll be honest, I don't think I've ever really seen one at 9mm, maybe more like a 6 or 7.

    03:35 But there's a lot of variants in different patients.

    03:38 Now, a blown pupil or pupil variations can be very dangerous and really important to get a baseline and assess these in your patient regularly.

    03:47 especially if you're talking about any neurological patient.

    03:52 Now, when we talk about pupils, if you take a look at the middle of this graphic here, this is really normal size.

    03:59 This is typically what we're going to see as you remember that PERRLA the pupils are equal they're round, and they react normally.

    04:07 Now, if you look at the other side, sometimes pupils can react to light either really slow or even maybe very brisk.

    04:16 So notice, well, you can have pinpoint pupils.

    04:18 This could be because of a certain type of brain damage or drugs.

    04:22 You can have dilated pupils, which can be an issue and also bilateral dilated pupils.

    04:28 Now if they're both dilated, and they're not reactive at all, this is a very ominous sign and can mean a medical emergency for your patient.

    04:38 So let's talk about pupils and when do you even call the health care provider? I know we talked a lot about them, but here's some really just two really easy things to know.

    04:48 Number one, make sure you compare sides.

    04:51 Number two, if the pupils change and are no longer similar size or reactive to light.

    04:58 Call the healthcare provider.

    05:00 Now, if they're no longer responding to light, and you don't have that consensual response, also make sure to call the health care provider.

    05:10 Now, if we take a look at this graphic, now let's ask the question, we've got quite a few size variations here.

    05:17 Now, which of these pupils are someone on opioids? We've got the one very small, more pinpoint, 7 which is pretty large, and 4 somewhere in between.

    05:29 So the 1 mm is again, what we call pinpoint.

    05:32 And this usually means your patient is on opioids of some extent.

    05:37 Now again, you want to assess this especially if someone's coming in the emergency room.

    05:41 And sometimes we may be giving these medications to our patients.

    05:44 So just assess the history.

    05:48 So because the neurological system is so complex.

    05:52 Now, depending on why your patients there, sometimes we have to do specialized neurological assessments.

    05:59 Now, we may need to take a deep dive and maybe assess the patient's reflexes, for example.

    06:04 Now, if you're on a particular unit where that takes care of stroke, you may perform as a nurse and this is a special certification.

    06:12 This is called the NIHSS, or the National Institute of Health Stroke Scale.

    06:19 This is an advanced neurological assessment that the nurse indeed has the scope of practice to use this advanced assessment with their patients.

    06:27 Now, we may also use a specialized medication related assessment like the ICU Coma Scale.

    06:33 And also don't forget about because there's neurological damage, a swallowing assessment is key.

    06:39 So many times a speech therapist is going to be consulted on that patient's case to make sure they've been safely swallowing and they don't aspirate.

    06:48 And lastly, assessment of cranial nerves is also important.

    06:52 And this is typically going to be done by the physician.

    About the Lecture

    The lecture Nursing Assessment of the Pupil by Samantha Rhea, MSN, RN is from the course Assessment of the Neuromuscular and Neurological System (Nursing).

    Included Quiz Questions

    1. Pupils are equal, round, reactive to light, and accommodation
    2. Pupils are equidistant, rigid and round, and light accommodating
    3. Pupils are evidently rigid, round, and light accommodating
    4. Pupils are equal, routinely reactive to light, and atypical
    1. The student nurse turns on the room lights and the client’s bedside lights.
    2. The student nurse asks the client to look at a distant object.
    3. The student nurse shines a penlight into the client’s eye from the side.
    4. The student nurse checks each eye individually and checks for a consensual response.
    1. 1 mm
    2. 4 mm
    3. 6 mm
    4. 9 mm

    Author of lecture Nursing Assessment of the Pupil

     Samantha Rhea, MSN, RN

    Samantha Rhea, MSN, RN

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