ICU nurses: Do you check cornea reflex and gag reflex q4h ?

  1. 0
    On our flow sheet we have to document cornea reflex and gag reflex every 4 hours. I often see nurses document + cornea and gag without really assessing.

    My question is do you check cornea and gag every 4 hours and if so what is your technique. If you don't check it how do you document?

    I've mainly had patients on vents so checking gag is easy. However, I don't check cornea reflex except for once a shift. When I assess cornea reflex I use the corner of a sterile guauze to touch cornea, usually pt. blinks way before I get to the cornea. When I don't assess cornea I usually document that patient is able to blink eyes or deferred.

    I don't want check cornea reflex every 4 hours because there was a legal case against a nurse who documented a positive cornea reflex, and the patient had received some kind of injury to the eye and the nurse was blamed.

    Thank for you input.
  2. 18 Comments so far...

  3. 1
    Peds ICU here. Our flowsheet is set up the same way- pupillary response, glasgow and gag q 4 hours. However, it's our floor policy that we only have to document once per shift unless the patient's condition warrants more frequent checks. So for our asthmatic patients, it would be once per shift. For our neuro patients, it's minimum q4 and usually q 1-2 depending on their stability. Vented patients is q4. Obviously if the patient is on a paralytic they won't have gag or movement, so we just note that on the flowsheet.
    OnlybyHisgraceRN likes this.
  4. 1
    Quote from Ashley, PICU RN
    Peds ICU here. Our flowsheet is set up the same way- pupillary response, glasgow and gag q 4 hours. However, it's our floor policy that we only have to document once per shift unless the patient's condition warrants more frequent checks. So for our asthmatic patients, it would be once per shift. For our neuro patients, it's minimum q4 and usually q 1-2 depending on their stability. Vented patients is q4. Obviously if the patient is on a paralytic they won't have gag or movement, so we just note that on the flowsheet.
    Thanks! I just want to be cautious on what I document. So many nurses document " normal" when the assessment is not being done. I just see it coming back to hunt nurses in the future.
    meandragonbrett likes this.
  5. 2
    We don't do corneal or gag reflexes, but are *supposed* to check pupils Q2h. I do Q4h unless they're neuro then I will do more often. I've sadly followed several nurses who will document "PERRLA at 3mm" for an entire shift...and the patient has a glass eye, or cataracts, or something else along those lines.
    sethmctenn and OnlybyHisgraceRN like this.
  6. 1
    We only did corneal or gag on our really bad neuro pts ie: potential donors. Normal vented pts, we do not regularly check. Corneal and gag are the last things we check unless the person comes in with TBI and does not "do" anything else. Of course if the pt can not open their eyes, follow commands etc with sedation off or light we will check further.
    OnlybyHisgraceRN likes this.
  7. 0
    Quote from sapphire18
    We don't do corneal or gag reflexes, but are *supposed* to check pupils Q2h. I do Q4h unless they're neuro then I will do more often. I've sadly followed several nurses who will document "PERRLA at 3mm" for an entire shift...and the patient has a glass eye, or cataracts, or something else along those lines.
    I have seen that too. I've also seen nurses document perrla who did not have a pen light on flash light.
  8. 0
    You should know the gag reflex because of the care you give. Moving the patient, doing oral care, suctioning, all lets you observe the gag reflex. I agree that the possibility of causing injury to the cornea is a real concern. Many intubated patients suffer corneal abrasions from the lack of normal lubrication of the eye. I would bring this up with your boss or educator. What valuable information are you gaining for this assessment versus the risk? I'm used to seeing it associated with neuro patients, not all patients.
  9. 5
    To assess corneal reflexes I start non-invasive and become more invasive if I cannot elicit a response. I start by touching their eyelashes - if they try to blink they have an intact corneal reflex. From there I do saline drops in the eyes and if that doesn't work I do the cotton wisp. The eyelash or saline drops almost always work if their reflex is intact.
  10. 2
    Quote from Carrig RN
    To assess corneal reflexes I start non-invasive and become more invasive if I cannot elicit a response. I start by touching their eyelashes - if they try to blink they have an intact corneal reflex. From there I do saline drops in the eyes and if that doesn't work I do the cotton wisp. The eyelash or saline drops almost always work if their reflex is intact.
    This makes since. I still write " blinks eyes...."
    MoshRN and sethmctenn like this.
  11. 2
    Quote from sapphire18
    We don't do corneal or gag reflexes, but are *supposed* to check pupils Q2h. I do Q4h unless they're neuro then I will do more often. I've sadly followed several nurses who will document "PERRLA at 3mm" for an entire shift...and the patient has a glass eye, or cataracts, or something else along those lines.
    The PERRLA is a pet peeve of mine. I find it interesting working in the ICU where patients are comatose and barely respond to anything, somehow are able to follow commands to test accommodation.
    mbrookeRN and sapphire18 like this.


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