Q On our neurological flowsheet, both direct and consensual pupil reactions are to be checked. I have not been able to find evidence in the literature for ongoing routine consensual pupil checks in acute monitoring. The literature addresses the role of pupil checks in retinal or optic nerve defects and disease, but not as an indicator of acute deterioration such as increasing intracranial pressure, which would be detected by the direct pupil reaction. I would appreciate any available information.

A Linda Little johns, RN, MSN, replies:

The value of the consensual pupil reaction in a bedside assessment is an excellent question, because so many aspects of our assessment are routine without much thought given to the reason for the test. The visual and light reflex pathways (optic tract, oculomotor nerve, and nuclei) are among the most complex and important...

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