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How to Assess the Eyes (Nursing)

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

Eyes:

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

head to toe assessment eyes, nursing

  • 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?

anisocoria, strabismus, nursing, assessment

  • 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.

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