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?