Pupils – Assessment (Nursing)

by Rhonda Lawes, PhD, RN

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    00:00 Now let's talk about pupils, this is so fun.

    00:04 So like you should try this with people that are in your circle, your friends and your family 'cause this is kinda fun stuff to look at.

    00:10 Now, here's the goal.

    00:12 Both pupils should be the same shape, the same size and react equally to light.

    00:19 Now, unless they have some weird pre-existing condition, they should both be the same size, the same shape and react equally to light.

    00:28 I remember the first patient I looked at that had had surgery on their eye and they had this really jaggedly-shaped pupil and I literally went running out of the room to find my preceptor because I was scared to death.

    00:40 And then I learned that it was just because they had surgery so I never forgot that lesson because I can still see that pupil in my brain when I think about it.

    00:49 But know that if someone has had a pre-existing irregularity they've had, cataracts or eye surgery, don't panic, right? but make sure you note that on your charting because you don't wanna have a patient who has had eye surgery on the right eye then has a normal pupil on the left and you chart something silly, like pupils equal and reactive to light because they're not if the patient has had surgery.

    01:15 So don't just copy and paste or trust the assessment before you.

    01:20 It's kind of an awkward thing to talk to you about but I've followed nurses before where they documented their pedal pulses in their feet, that they're both palpable and equal bilaterally.

    01:31 When I went into the patient, they've had double amputations, they didn't even have feet.

    01:36 So if I would have just copied and pasted the previous nurse's assessment, I would have looked really ridiculous.

    01:43 So, do your own assessment and document clear, concise and objectively.

    01:50 So, both pupils should be the same shape, the same size and react equally to light.

    01:56 You wanna make sure you're aware if the patient has any pre-existing irregularity of their pupils because they've had eye surgery or a procedure.

    02:02 Also, think about medications that they're on because medications can affect the pupils.

    02:08 So, like narcotics for example, the pupils will be constricted.

    02:12 That's why sometimes we have people come into the ER setting and you ask them if they've taken any medication and then they say, "No," and then their pupils are just pinpoint, you're like, hmm, might not be fully disclosing everything that they've done before they come.

    02:27 So narcotics will cause tiny, pinpoint pupil constriction.

    02:32 Now, some medications will dilate pupils.

    02:35 Some people are sensitive to SSRIs which are a type of medication for depression.

    02:40 Tricyclics, atropine definitely will dilate your pupils or some other sympathomimetic drugs.

    02:48 So you've got, add in SSRIs for me 'cause I just wanted to trigger that for you that you've got that into because some people are sensitive to that, not everyone on SSRIs will do that which is why I didn't include them on the slide.

    03:00 I just wanted to add it in when you and I are talking.

    03:03 But tricyclics, atropine and sympathomimetics will definitely dilate pupils.

    03:09 So if you notice abnormally small or abnormally large pupils, make sure to look at the medication list and see if there's any, even the medications that they're on could be the cause.

    03:21 Change in pupil size, shape or reactivity can say we've got some big problems going on with intracranial pressure.

    03:30 Now, this is a late sign, you don't want to rely on seeing pupil changes as being your first indication that your patient's in trouble.

    03:39 This can change rapidly, I've had this happen from neuro assessment to neuro assessment but we knew something was evolving with the patient's brain.

    03:49 Intracranial pressure is made up of three things.

    03:52 It's made up of cerbro-spinal fluid, blood and then the mass of your brain tissue.

    03:58 if any one of those three things gets bigger, so I said remember, it's made of cerebrospinal fluid, blood and tissue If any one of those 3 things gets bigger, you're risking brain herniation, that means the brain will squish through the holes in your skull and it could lead to death, so obviously, we're on the lookout for that but if I have extra cerebrospinal fluid for some reason it's not draining, if I have extra blood, I have a bleed in my head, I've had a trauma or I've just had an aneurysm burst or I had my head's been knocked around, and now I have tissue that's been bounced and it's swelling, that's gonna raise the intracranial pressure.

    04:41 You will likely see changes in the pupils but that's a very late sign.

    04:47 Sharp nurses pay attention long before the pupils change and know that you're in trouble.

    04:52 It doesn't mean you can stop it but you wanna be aware of what's going on, work with the healthcare team and do everything you can to prevent that from happening.

    05:00 Now, this is a super cool slide like I really like this 'cause we put everything together for you and I'm so excited for you to have this.

    05:08 It's a great reference.

    05:09 So, normal sized pupils are 2 to 5 millimeters, okay, that's normal.

    05:15 Now let's look at the constricted, notice the difference in the size.

    05:19 Now, mildly dilated, you'll see it sometimes with patients with glaucoma.

    05:24 Really dilated pupils that with somebody like, can you remember what would be a drug, try to remember two drugs without looking at your notes, What are examples of 2 drugs that can cause dilated pupils? Now, look at the unequal-sized pupils, that is wierd, right? That's somebody who's probably had a head trauma.

    05:45 Now, we would know they had a head trauma before we look at their pupils but when we saw this, this would definitely something that we would want to track.

    05:53 So hey, here's another great skill for nursing school.

    05:55 Always know what normal is, right? whether we're talking about lungs, feet, whatever.

    06:02 Know what normal is, be rock solid on that, that you will know when something is different and what you need to follow up on.

    06:09 Now I would take a look at this, you should be able to look at the pupils, we gave you a great reference here, that's what 1 millimeter looks like up to 9 millimeters, right? So you know what constricted pupils look like, you know what normal size pupils look like and you know what dilated pupils look like.

    06:26 So when you document about the pupils, one way to be clear, concise and objective is to document the size of each pupil, the left and the right.

    06:38 So don't just say that they're equal, say that both left and right pupils are 5 millimeters.

    06:44 or say left pupil-4 millimeters, right pupil-irregularly shaped from previous eye procedure.

    06:50 Be precise, clear, concise and objective.

    06:55 I promise, it makes you a better nurse, gets better care for your patient and protects both you and your patient in the future.

    About the Lecture

    The lecture Pupils – Assessment (Nursing) by Rhonda Lawes, PhD, RN is from the course Neurological Assessment (Nursing) .

    Included Quiz Questions

    1. Both pupils should be the same shape and size and have the same reactivity to light.
    2. It is normal for pupils to be different sizes as long as they are both reactive to light and the same shape.
    3. It is normal for pupils to be different shapes as long as they are both reactive to light and the same size.
    4. Pupils are independent of each other, and each will have their own unique shape, size, and reactivity to light.
    1. Narcotics can cause pupil constriction, and sympathomimetics can cause pupil dilation.
    2. Narcotics can cause pupil dilation, and sympathomimetics can cause pupil constriction.
    3. Narcotics and sympathomimetics should have no effect on pupil dilation.
    4. Narcotics and sympathomimetics can cause either a pupil dilation or a pupil constriction.
    1. Increased intracranial pressure
    2. Mental health status
    3. Electrolyte disturbances
    4. Decreased urine output

    Author of lecture Pupils – Assessment (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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    Great Lecturer
    By Sweta G. on 18. March 2021 for Pupils – Assessment (Nursing)

    Really appreciate Rhonda. Very thorough and cares about the way information is given. Thank you.

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