The nurse is assessing a patients ears. which normal findings would the nurse document

This article will explain how to perform an assessment of the eyes as a nurse. This assessment is part of the nursing head-to-toe assessment you have to perform in nursing school and on the job.

The eye assessment includes:

• Inspection of the eyes for abnormalities
• Testing the cranial nerves responsible for eye function: III, IV,  VI
  • Assessing for nystagmus, accommodation, pupil size and reactivity to light etc.

Video Demonstration on the Eye Assessment

Inspect the eyes, eye lids, pupils, sclera, and conjunctiva

• Is there swelling of the eye lids?
• Is the sclera white and shiny?…not yellow as in jaundice

• Is the conjunctiva pink NOT red and swollen?
• Look for Strabismus and Aniscoria:
  • Strabismus: Do the eyes line up with another?
  • Aniscoria: Are the pupils equal in size…or is one pupil larger than the other?

• Are the pupils clear…not cloudy?
  • Normal pupil size should be 3 to 5 mm and equal

Test cranial nerves III (oculomotor), IV (trochlear), VI (abducens)

• Have the patient follow your pen light by moving it 12-14 inches from the patient’s face in the six cardinal fields of gaze (start in the midline)
  • Watch for any nystagmus (involuntary movements of the eye)
• Reactive to light?
  • Dim the lights and have the patient look at a distant object (this dilates the pupils)
  • Shine the light in from the side in each eye.
    • Note the pupil response: The eye with the light shining in it should constrict (note the dilatation size and response size (ex: pupil size goes from 3 to 1 mm) and the other side should constrict as well.
  • Accommodation?
    • Make the lights normal and have patient look at a distant object to dilate pupils, and then have patient stare at pen light and slowly move it closer to the patient’s nose.
      • Watch the pupil response: The pupils should constrict and equally move to cross.

If all these findings are normal you can document PERRLA.

More nursing skill videos.