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
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.