Abnormal pupil shape/response

[Staragate, ADN, ASN, RN]

As a nursing student who works as a CNA in a Alz ward, I want to put out a theory. If I am totally off base, please tell me.

You said these pts were in a LTC, but you did not mention if they had a shared diagnosis. If they are there for dementia/Alz reasons, then I would relate the lack of PERRLA to the neuro dx. The damage done to Alz cells come from a warping of the shape of the neurons. I would think that could translate to the brainstem or transmission of the cranial nerve impulse to the brain. The tone of the pupils could be compromised from a interruption in neuro transmissions, resulting in a change in pupil shape, rxn to light, etc.

I've noticed from working with developmental disabled kids, that when there is a neuro deficit in one place, there is often one in another. (Nystagmus = balance issues)

Am I close or am I off base?

[LouisVRN, RN]

I have also encountered this problem. Most recently with a woman admitted for what should have been outpatient surgery but due to a long list of co-morbidities, including multiple MVAs with head injuries she was admitted. Noticed on my initial assessment one pupil probably 6mm than other one maybe 2mm. Promptly went back to review the previous charting - she had been cared for by 2 different nurses and both charted pupils WNL. Looked at MD note and no mention. Pt had hx of memory loss and could not tell me if this was her baseline.

The fact that you said that you were surprised the MD did not assess and correctly document makes me wonder if you are either new or optimistic, I saw not that long ago a MD document PERRLA on a patient with a prosthetic eye. And frequently see them document S1/S2 RRR with no adventitious sounds when the closest they came to listening to the patient was from 4 ft away.

[LouisVRN, RN]

As a nursing student who works as a CNA in a Alz ward, I want to put out a theory. If I am totally off base, please tell me.

You said these pts were in a LTC, but you did not mention if they had a shared diagnosis. If they are there for dementia/Alz reasons, then I would relate the lack of PERRLA to the neuro dx. The damage done to Alz cells come from a warping of the shape of the neurons. I would think that could translate to the brainstem or transmission of the cranial nerve impulse to the brain. The tone of the pupils could be compromised from a interruption in neuro transmissions, resulting in a change in pupil shape, rxn to light, etc.

I've noticed from working with developmental disabled kids, that when there is a neuro deficit in one place, there is often one in another. (Nystagmus = balance issues)

Am I close or am I off base?

I just have to point out that your observation that one neuro deficit frequently equals another neuro deficit is only some of the time. My husband has nystagmus which is quite pronounced and has no other neuro deficits, he is however a Type II OCA albino and that is what causes his visual abnormalities. Also in patients with a long removed history of neurological insult you may be more likely to see only one neuro deficit as they have frequently compensated for some of the other ones that may have initially been present.

[dthfytr, ADN, LPN, RN, EMT-B, EMT-I]

Lots of excellent information here, so I'm gonna just muddy the water. Assesing trauma pt in ambulance, one pupil would constrict then rapidly dilate again. Documented it. Passing neurosurgeon said to "look up Hippus in Tabers." That was when we used books, and computers were just predictions in Popular Science.

2 years ago eating supper with coworker who suddenly says "OMG what's wrong with your eye!" My right pupil was dilated to the point of looking blown. Resolved in 12 to 16 hours, saw to eye docs, one admitted she had no answer, the other just made up some BS. A year later a Rheumatologist said easily explained by my newly dx'd rare auto-immune problem (oh joy).

Anyway, I've never had any problems for documenting them as I see them. Then it's accurate. Blowing off abnormalities and just charting PERLA is falsifying a chart. Just not worth it to go down that road.