Eye Assessment Nursing | How to Assess Eyes for Head-to-Toe Assessment

The eye assessment in nursing is a way to gauge the patient's eye health. You'll generally perform a nursing eye assessment as a part of your general head-to-toe nursing assessment.

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While checking the eye, you'll want to note several things. How does the eye look? Do the eyelids look swollen or red? Does the sclera of the eye look nice and white, or does it have a yellow appearance, which is common in patients with jaundice?

You'll want to check for strabismus, which is a misalignment of the eye. Anisocoria is another thing you'll want to check, which is unequal pupil dilation.

You'll want to assess the pupil accommodation, reflex, dilation/constriction as well. Are the pupils an appropriate size (3-5 mm)? Are they both equal? Do both pupils constrict when exposed to light and dilate in its absence?

This eye assessment will also assess the cranial nerve III (oculomotor), cranial nerve IV ( trocklear), and cranial nerve VI (abducens).

To perform the eye exam, you'll want to have your penlight handy. Remember the acronym PERRLA, which stands for Pupils Equal, Round, Reactive to Light, and Accommodation.

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