Assessing pupil size - Sounds simple, but...

1. I have worked at two equally well recognized teaching hospitals in an ICU setting. Most everything is the same, but I've noticed a difference in how pupil size is assessed.

Hosp#1 - Assess size of pupil as it reacts to pen light so as to eliminate variation in room lighting.

Hosp#2 - Assess size of pupil upon initial inspection, regardless of room lighting, etc. (and before using pen light).

I do look at the pt's pupils initially, but I make my measurement based on the size to which they constrict.

So I am wondering - how does everyone else do it?
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3. Your assessment should include both. For example if pupils are constricted or dilated without stimulation - and - do they constrict with stimulation - and - are they equal/unequal in both situations.
4. I check the pupils without the pen light, say they are a 4, they constrict to a 3 with the pen light, so I will say pupils reactive 4->3
5. I assess the size of them in regular lighting, how fast they react to my pen light is the ERRL part.
6. In response to the above replies:

But how do you standardize on "regular lighting"? Day vs night, different light switches (we have about 8 lighting options in each room - it's ridiculous), if pt's eyes were open or closed prior to exam?

That's what I'm getting at. If we report the size upon initial inspection that can be incredibly variable based on external factors. Do your units have a standard set for this? I know mine doesn't and the results are all over the place.

I don't have any issues with the reactivity and regularity... it's just a specific question of timing that pupil size is measured.
7. You adopt a relative norm...you know that completely dilated pupils in any light is abnormal...you know if one pupil is larger than the other that's not good...you know what size pupils should be based on what meds the patient is receiving. There's no hard and fast rule.
8. I think you're making it out to be a bit harder than it really is.
9. It should be based on what size they are without a bright light being shined right in them. Yes, it can be a little variable.
10. You are over thinking the issue. If you are checking the pupils at 0800 the "norm" is that it is daylight. YOu look at the pupils in ambient light comparing size and shape. Are the irregular in size? are they unequal? Do they both react equally and at the same time to light?(accommodation). Pupillary response changes can be, and usually is, a late sign of increasing intracranial pressure and there should be other more subtle signs of increasing pressure such as confusion and lethargy or agitation. The checking of pupils is obtaining a baseline and reporting changes. People who have had cataract surgery will not have much of a pupillary response and there is an anomaly the can be normal, anisocoria.

Get a base line, look for differences.....the subtle changes due to time of day are understood.