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

[OnlybyHisgraceRN]

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.

[Esme12, ASN, BSN, RN]

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.

What is your definition of accommodation to light. It is not only the ability to focus far and near....it can also be tested when you flash the light in one pupil and the opposite pupil responds as well....equally.

[turnforthenurse, MSN, NP]

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.

I agree. I had a patient who came from ICU and within two hours got shipped back to ICU because they coded on my floor...when I finally had a chance to document my assessment leading up to calling RR and a code blue, I saw the RN accepting the patient documented "PERRLA at 3mm" when in reality, the pupils were more like 5mm and non-reactive." The RN then changed their assessment once I put mine in.

[blondesareeasy]

HAVE to check or NEED to check? There ain't no stone etchings here.

[Jarreux]

That's the consensual light reflex. Accommodation is the narrowing or widening of the pupil to accommodate focusing near and far respectively. I just say PERRL unless I actually assessed for accommodation.

Cough/gag/pupils are assessed and charted Q15,30min,1,2,4hrs as ordered. I only check gag when appropriate (during oral care on vented pts, etc), or otherwise chart deferred. I first check lids when checking pupils by moving my other hand towards their eyes fast enough to illicit the reflex, and then progress by least invasive first as noted above. I only have to chart that once then chart 'no changes to prior assessment' and typically don't formally check it again unless there has been a change in the pt's condition.

[Nurse_]

Anytime there's a neurological impairment, we usually check every hour.

[Here.I.Stand, BSN, RN]

We document presence/absence of cough and gag with every neuro check, whether that's q 15 min if getting tPA or q 2 hr for a week old stable injury. Like a PP said, you can assess this easily with routine oral care, turning etc. If nothing else, you can suction them and see if they cough.

We don't check corneals unless they're progressing toward declaration of brain death. It's checked then w/ the oculocephalic and cold caloric exams (done by the NSG provider). This is a late sign of worsening neuro status after all. They're going to have GCS changes long before they lose their corneal reflex.

[JeanOfAllTraits]

That's the consensual light reflex. Accommodation is the narrowing or widening of the pupil to accommodate focusing near and far respectively. I just say PERRL unless I actually assessed for accommodation.

THANK YOU! PERRLA is a huge pet peeve of mine in the vented ICU population.