Nurses in the spirit must know: What is the main point of pupil observation
Pupil change is an important observation index in clinical nursing, which is helpful to judge the condition of patients with coma, convulsion, shock and poisoning. Especially for patients with brain lesions, the location of intracranial lesions can be judged. Dynamic, timely and effective observation of pupil changes can not only find the precursors of diseases, seize the best treatment opportunity, but also prevent complications. In clinical nursing, we should ensure the accuracy of pupil observation. The specific points are as follows:
1. Correct understanding of pupil size
Under normal circumstances, the pupil is round, located in the center of the sclera, with neat edges, with a diameter of 2 ~ 5 mm under natural light, and the pupils on both sides are equally round and sensitive to light reflection. Diameter > 5mm, called mydriasis; Diameter < 2mm, called pupillary constriction. The change of pupil shape is often caused by eye diseases; In the case of illness, its size will also change.
There is a trick to improve the accuracy of observing the size. Eight horizontally arranged black dots with diameters of 1, 2, 3, 4, 5, 6, 7 and 8mm are made by computer, and the numbers 1 ~ 8 are respectively marked above the dots. Cut the printed picture into 2cm? 8cm piece of paper, 4cm wide transparent adhesive tape? 1cm, paste a small piece of paper on one side of the plastic pad. First observe the size of the patient's pupil, and then refer to the black dot in the picture to determine which black dot the patient's pupil size is close to, and record the value. This method avoids the difference of records between shifts caused by the difference of nurses' subjective judgment, and is beneficial to judge the changes of patients' pupils and illness.
Second, grasp the opportunity of pupil observation
The change of pupil in neurosurgery often marks the coma state and the degree of brain injury of critically ill patients. Early, timely and accurate pupil monitoring can avoid delaying the best rescue opportunity and avoiding medical disputes. Therefore, timely and accurate observation of pupils is very important in clinical nursing.
Third, evaluate the effect of pupil observation
If the patient is unconscious, the diameter of bilateral pupils < 1mm, needle-like pupil, more common in organophosphorus pesticides, chlorpromazine, morphine poisoning; For example, unilateral mydriasis and fixation often suggest that patients have ipsilateral tentorial hiatus hernia; If bilateral pupils are dilated, the patient may be in the late stage of foramen magnum hernia; Some patients with Horner's syndrome are characterized by one-sided pupil contraction, drooping upper eyelid and anhidrosis on the face. At this time, observing the patient's pupil can not be mistaken for brain hernia. If the patient's unconscious disorder is aggravated, non-brain hernia should be considered.