Now let's talk about
pupils, this is so fun.
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.
Now, here's the goal.
Both pupils should be the same shape, the
same size and react equally to light.
Now, unless they have some
weird pre-existing condition,
they should both be the same size, the
same shape and react equally to light.
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.
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.
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.
So don't just copy and paste or
trust the assessment before you.
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.
When I went into the patient, they've had
double amputations, they didn't even have feet.
So if I would have just copied and pasted the previous
nurse's assessment, I would have looked really ridiculous.
So, do your own assessment and document
clear, concise and objectively.
So, both pupils should be the same shape,
the same size and react equally to light.
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.
Also, think about medications that they're on
because medications can affect the pupils.
So, like narcotics for example,
the pupils will be constricted.
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.
So narcotics will cause tiny,
pinpoint pupil constriction.
Now, some medications
will dilate pupils.
Some people are sensitive to SSRIs which
are a type of medication for depression.
Tricyclics, atropine definitely will dilate your
pupils or some other sympathomimetic drugs.
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.
I just wanted to add it in
when you and I are talking.
But tricyclics, atropine and sympathomimetics
will definitely dilate pupils.
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.
Change in pupil size, shape or reactivity can say we've
got some big problems going on with intracranial pressure.
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.
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.
Intracranial pressure is
made up of three things.
It's made up of cerbro-spinal fluid, blood
and then the mass of your brain tissue.
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
You will likely see changes in the
pupils but that's a very late sign.
Sharp nurses pay attention long before the
pupils change and know that you're in trouble.
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.
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.
It's a great reference.
So, normal sized pupils are 2 to 5
millimeters, okay, that's normal.
Now let's look at the constricted,
notice the difference in the size.
Now, mildly dilated, you'll see it
sometimes with patients with glaucoma.
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.
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.
So hey, here's another great
skill for nursing school.
Always know what
normal is, right?
whether we're talking about
lungs, feet, whatever.
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.
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.
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.
So don't just say that they're equal, say that
both left and right pupils are 5 millimeters.
or say left pupil-4 millimeters, right
pupil-irregularly shaped from previous eye procedure.
Be precise, clear,
concise and objective.
I promise, it makes you a better nurse,
gets better care for your patient
and protects both you and
your patient in the future.