N104: Essentials of Nursing Care - Health Safety

N104: Essentials of Nursing Care – Health Safety Study Guide Assess the pupils. o Normal: Black pupils, equal in size (diameter usually 3-7 mm), and a smooth border o Deviations from normal: Mydriasis (pupil diameter fixed and greater than 7mm), miosis (pupil diameter fixed and less than 3mm), and irregular pupil borders • Assess the pupils’ reaction to light and accommodation: Turn off overhead lights to partially darken the room. Instruct the patient to stare straight ahead. Using a penlight, shine the light on the eye from the side of the patient's face and observe the pupillary response. Repeat the process and watch the other pupil for consensual response. o Normal: Pupil constricts when illuminated and constricts when not illuminated. Pupils constrict when viewing a nearby object and dilate when looking at an object at a distance o Deviations from normal: Pupils do not constrict when illuminated or are unequal in response. Pupils do not constrict or dilate appropriately when looking at near and far objects. Evaluation It is important to compare all findings with previous findings to determine if there are changes to any abnormal eye or vision findings. Record and report any significant deviations from the normal. 2.6 Nose Since the patient's head must be still during the exam, the room should have a bed for the patient to lie on, or a chair with a headrest to support the patient's head in one position. Equipment needed for the nose and sinus exam includes a nasal speculum and a penlight. Information and abnormal findings provided by unlicensed personnel should be verified during this exam. Implementation • Wear gloves and any other appropriate infection control gear (mask, protective eyewear, gown, etc.). • Wash hands before starting the exam, any time the hands or gloves become soiled, and upon completion of the exam. • Provide a quiet, well-lit, and private place for the exam. • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about presence or history of: o Allergies to foods or environmental allergens o Sinus infections •

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