EYE IRRIGATION Materials: A lined tray with the ff: An irrigating solution (Normal saline solution) Sterile Kelly

straight forceps soaked in a sterile solution 1 sterile kidney basin 1 clean kidney basin Sterile dry cotton balls 10-cc sterile syringe A pair of sterile gloves Waste receptacle PROCEDURE 1. Check patients chart for doctors order. 2. Perform medical hand washing. 3. Go to patients room. Explain the procedure and its purpose. 4. Take patients vital signs. 5. Go back to the station and gather the materials needed. 6. Perform medical hand washing. 7. Bring materials to the patients room. Check the patients name by its identification bracelet and asking the patients name. 8. Position patient upright/Fowlers position. 9. Place towel under the patients chin. 10. Offer tissue paper and clean kidney to the patient. 11.Open sterile packs. 12.Do open gloving. 13.With a dry cotton ball moistened in normal saline solution, gently clean the eyelid margins from inner to outer canthus, and eyelashes from inner to outer side. Throw the cotton ball into the waste receptacle. 14.Instruct patient to place the clean kidney basin below his/her cheek on the side of the affected eye. 15.With the non-dominant gloved finger, get 1 dry cotton ball then gently retract upper and lower eyelids to expose the conjunctival sac. To holds lid open, apply pressure to lower RATIONALE To determine or verify the purpose Reduce spread of microorganisms Reduce anxiety and gain cooperation of the patient To gather baseline data Save time and energy Reduce the spread of microorganisms save time and energy, ensures that the medication is given to right patient gravity aids flow of solution protect patient from discharges Remove excess solution or ointment that leaks from the eyes For aseptic purposes To protect self from discharges Cleaning protect nasolacrimal duet and other eye from lashes or other materials lodged on the affected eye To catch irrigating fluid

Solution should be directed into lower conjunctival sac, prevents reflex blinking

bony orbit and bony prominence beneath eyebrow. Do not apply pressure over the eye 16.With your dominant hand, aspirate the irrigating fluid using the sterile syringe. Then hold the irrigating syringe approximately 1 inch or 2.5 cm from inner canthus. 17.Ask the patient to look up. Gently irrigate with steady stream toward the lower conjunctival sac to the outer canthus. 18.Allow patient to close his/her eye periodically. 19.Continue irrigation until all solution is used or secretions have been removed. 20.Dry eyelids and facial area with the dry cotton ball from your non-dominant hand. 21.Position the patient comfortably. 22.Assess patients reaction and response. Urge verbalization from patient regarding the procedure. 23.Impart health teachings like eye care, etc. 24.Do aftercare. 25.Do documentation, including the special interventions you have done to the patient during the procedure.

Minimizes risk of injury to the eye

Direct contact may cause injury to the tissues of eye and conjunctiva Helps to move secretions

Leaving the skin moist uncomfortable to the patient

is

To determine/ see patients response and effects of the procedure

Provides accurate documentation

EYE INSTILLATION

Materials: A lined tray with: Cotton balls Eye medication with dropper PROCEDURE 1. Check patients chart for doctors order. 2. Compare the medicine ticket with the order. 3. Perform medical hand washing. 4. Go to patients room. Explain the procedure and its purpose. 5. Take patients vital signs. 6. Go back to the station and gather the materials needed. 7. Compare ophthalmic medicine with medication ticket before taking the medicine RATIONALE ensures that the patient is correct and receives right medicine reduces spread of microorganism reduce anxiety to gather baseline data save time and energy ensures that the medication is given correct

from the cubicle. 8. Perform medical hand washing. 9. Bring materials to the patients room. Check the patients name by his identification bracelet and by asking the patients name. 10.Position patient to a supine or sit back on a chair with neck slightly hyperextended. 11.Place towel under the patients chin, on the affected side. 12.Compare medicine with medication ticket for the second time. To instill eyedrops: 1. Compare medicine with the medication ticket for the third time. 2. With the non-dominant hand, get 1 dry cotton ball then gently retract upper and lower eyelids to expose the conjunctival sac. To holds lids open, apply pressure to lower bony orbit and bony prominence beneath eyebrow. 3. Rest your non-dominant hand gently over the bony prominence of the eye. Do not put pressure directly on the eye. 4. With your dominant hand, hold filled dropper with the ophthalmic medication approximately 1 to 2 cm (1/2 to inch) above conjunctival sac. 5. Ask patient to look up.

to deter spread microorganism save time and energy

of

makes it easier to reach the conjunctival sac prevent solution or tears from flowing towards other eye ensure that it is the correct medication

ensure that it is the correct medication for better exposure of the conjunctival sac

prevents injury

6. Drop prescribed number of medication drops into the conjunctival sac. 7. Apply gentle pressure to the patients nasoiacrimal duct with the cotton ball for 3060 seconds. 8. After instilling, instruct patient to blink. 9. Dry eyelids and facial area with the dry cotton ball from your non-dominant hand. 10.Put patient in a comfortable position. 11.Assess patients reaction and response. Urge verbalization from patient regarding the procedure.

focus on something else, makes procedure less traumatize does not allow medication to fall on cornea to prevent the solution from entering the system to spread the medication

for documentation

prevents injury and irritation

12.Impart health teachings regarding the side Effects of the medication, eye care, etc. 13.Do aftercare. 14.Do documentation, including the special interventions you have done to the patient during procedure. To instill eye ointments: 1. With the non-dominant finger, get 1 dry cotton ball then gently retract upper and lower eyelids to expose the conjunctival sac. To hold lids open, apply pressure to lower Bony orbit and bony prominence beneath eyebrow. 2. Ask patient to look up. 3. With your dominant hand, hold ointment applicator above lid margin, and apply thin stream of ointment evenly on conjunctiva from inner to outer canthus. 4. After instillation, instruct patient to close eyes and roll his/her eyeballs. 5. If excess medication is on eyelid, gently wipe it from inner to outer canthus with another dry cotton ball. 6. If patient has an eye patch, apply a clean one by placing it over affected eye so entire eye is covered. Tape securely without applying pressure to the eye. 7. Put patient in a comfortable position. 8. Assess patients reaction and response. Urge verbatization from patient regarding the procedure. 9. Impart health teachings about the side Effects of the medication, eye care, etc. 10.Do. aftercare. 11.Do documentation, including the special Interventions you have done to the patient during the procedure.

prevents medication errors to prevent medication errors

teaching can contaminate the medication

to make traumatic

procedure

less

to spread the medication for hygienic purposes

to secure the eye

to note any adverse effects

prevents safety

injury,

promotes

prevent medication legal purposes

errors,

EAR IRRIGATION

Materials:

A lined tray with:

Warm irrigating solution(PNSS) Sterile asepto syringe 2 kidney basins(1 sterile, 1 clean) Towel A pair of sterile gloves PROCEDURE 1. Read and check for doctors order. 2. Explain the procedure to the client. 3. Do medical hand washing.

Cotton balls Tissue paper Waste receptacle Cotton applicator

4. Prepare necessary materials. Warm the prescribed irrigating solution. 5. Bring the materials to the patients room. 6. Position patient in a sitting or supine position. Place towel over patients shoulder. 7. Unwrap the sterile kidney basin. 8. Pour the irrigating solution into the sterile kidney basin and be careful not to touch the lid of the bottle with the kidney basin. 9. Place tissue wipes on the clean kidney basin and instruct patient to support the basin under the ear for irrigation. 10.Loosen the wrapper of the sterile asepto syringe. 11.Don gloves. 12.Check for the temperature of the irrigation solution by dipping gloved hand. 13.Clean external ear with cotton applicator. 14.Fill asepto syringe with irrigating solution up to 50 ml. 15.Instruct client to tilt head towards unaffected side, marking the affected side higher. 16.Gently grasp auricle and straighten ear canal by pulling it down and back (for children 3 yrs. Old and below) or upward and outward (for adults). 17.Place tip of syringe 1 cm (1/2 inch) above the ear canal. 18.Introduce fluid slowly by pressing the bulb of the Asepto syringe. 19.Let patient tilt his head to the other side to Drain the fluid. 20.Repeat the instillation and draining of the

RATIONALE - to verify order - to open patients cooperation - reduce the spread of microorganism - to gather baseline data To conserve time and energy To protect patient from discharge For aseptic purposes To observe aseptic technique, touching the lid might contaminate the preparation To catch the spill

For better access Protect ear from discharge

Materials lodged in the ear and meatus may be wasted away

To straighten the ear canal

Prevent injury

To drain the ear from the fluid and foreign bodies

fluid until return flow is clear. 21.Dry the outside of the ear with cotton ball And place a dry cotton in the auditory meatus. 22.Return all the materials, do after care. 23.Give health teachings about ear care, etc. 24.Document procedure.

For recording purposes

EAR INSTILLATION Materials: A lined tray with: Medication bottle with dropper Cotton-tipped applicator Clean gloves. Cotton ball RATIONALE - check 5Rsof medications - to prevent medication errors - to promote cooperation To gather baseline data To conserve time and energy To prevent irritation

PROCEDURE 1. Check the doctors order. 2. Compare the medicine ticket with the order. 3. Go to patients room. Explain the procedure and its purpose. 4. Take patients vital signs. 5. Go back to the station and gather the materials needed. 6. Compare ophthaimic medicine with medication ticket before taking the medicine from the cubicle. Then warm medication by running warm water over the bottle. 7. Wash hands and arrange supplies at bedside. Wear clean gloves. 8. Check the patients identification by his ID Bracelet and by asking his name. 9. Have the client assume side-lying position with ear to be treated facing up, or client may sit on chair at the bedside. The nurse should stabilize the patients head with his or her hand . Place the patients towel on the shoulder of his affected side. 10.For adults, gently pull the pinna up and back; in children age 3 or less, pull the pinna down and back. 11.If cerumen or drainage occludes outermost portion of ear canal, wipe out gently with cotton tipped applicator. Do not insert the applicator into the ear canal. 12.Instill prescribed drops holding dropper 1cm

To prevent contamination To prevent medication errors To expose ear to be treated

To expose ear canal properly

Prevent further impaction

Avoid

contaminating

the

(1/2 inch) above ear canal. 13.Ask client if any discomfort is felt during Instillation. 14.At time, the physician may order insertion of portion of cotton ball into the outermost part of the canal. Do not press cotton into the canal. 15.Ask client to remain in position for 5-10 minutes. Apply pressure to tragus of ear with finger. 16.Remove cotton after 15 minutes. 17.Assist client in a comfortable position after drops are absorbed. Remove gloves, dispose of soiled supplies and wash hands. 18.Evaluate condition of external ear before and after each during instillation. 19.Evaluate hearing acuity of patient. 20.Impart health teachings about the side effects of the medication, ear care, etc. 21.Document the following: A. drug/medication B. frequency C. amount D. patients response NASAL INSTILLATION

container

To prevent impaction

To spread the medication

To promote cleanliness

To assess improvements To note any changes baseline data For evaluation purposes

in

Materials:

A line tray with the following: Line kidney basin Drape Tissue wipes Nasal drops or spray Dry cotton balls Cotton applicators Waste receptacle

1. 2. 3. 4. 5. 6.

PROCEDURE Check and read the patients chart for doctors order. Compare the medication ticket with the doctors order Explain the procedure to the patient. Gather the necessary materials Compare the medication ticket with the medication before getting it from the cubicle Do medical hand washing.

RATIONALE - to verify the 5Rs of correct medication - to avoid medication errors To gain cooperation To save time and energy To avoid medication errors To prevent spread microorganisms of

7. Bring the equipment to the bedside table To save time and energy 8. Provide the patient with tissue wipes and ask To clean area first patient to blow his or her nose. If unable to do so, use the cotton applicators to clean the nose. 9. Inspect discharges for color and thickness For further assessment findings 10. Position the patient comfortably according So that the medication on go to the sinus/es to be treated: directly to desired area a) Proetz postion ethmold and sphenoid sinuses b) Parkinsons position maxillary and frontal sinuses 11. Instruct the patient to breathe through the To prevent difficulty in mouth during the procedure. breathing 12.Hold up the top of the nose and place the To prevent contamination dropper or the medication nozzle just inside the nares about one-third of an inch. 13.Instill the prescribed number of drops in one To maintain sterility naris. Avoid touching the nares with the dropper/ Nozzle 14. Do the same to the other nostril if indicated. 15. Observe and note for the patients reaction. For further assessment findings 16. Have the patient remain in position with head To allow the medication to Tilted back for five to ten minutes. spread 17.Provide the patient with a clean tissue paper To maintain good hygiene to wipe the excess solution or dry the area around the nose. 18. Place the patient in a comfortable position To promote comfort 18. Do after care. Promote cleanliness 17.Do documentation. For evaluation purposes

ASSISTING IN MOUTHCARE / OFFERING MOUTHWASH Materials: A lined tray with the following: Clean Kidney basin, lined with tissue wipe mouthwash solution glass with drinking water 3 medicine cups tissue wipes 5 padded tongue depressors waste receptacle PROCEDURE 1. Read the doctors order. RATIONALE - To verify the 5Rs of correct medication

2. Explain the procedure to the patient. 3. Do medical hand washing and gather all the needed materials. 4. Bring all the materials to the patients bedside. 5. Do oral care. a. Conscious patient: - Assist patient to a sitting position or on one side with his/her head over the edge of the pillow. - Place towel on the patients chest and place the kidney basin under the patients chin. - Pour the prescribed amount of mouthwash solution into the medicine cup. Dilute if indicated. - Offer the solution to the patient. Let the patient gargle. - Do not let patient hyperextend his neck when gargling especially if he has poor mouth control b. Unconscious patient: - Position patient supine with head tilted at one side. - Place towel on the patients chest and place the kidney basin under the patients chin. - Pour the mouthwash solution into the medicine cup. Dilute if indicated. - Dip a tongue depressor into the solution. Use the padded tongue depressors to clean the patients mouth (2 for the mouthwash solution, 2 for rinsing and 1 for the tongue). 6. Observe and note the patients reaction. 7. Wipe the mouth of the patient with tissue to dry he patients mouth area. 8. Remove the towel and return the use materials.

- To gain cooperation - Prevent spread microorganisms - Save time and energy

of

- For support

- To avoid spoiling the linens

- To provide oral care

- To promote independence - To prevent aspiration

- To drain secretions to the other side - To avoid soiling the linens

- To provide oral care

- To provide oral care, provide gentle means of giving mouthwash

- For further assessment findings - To prevent skin irritation - To promote cleanliness

9. Place the patient in a comfortable position. 10. Do after care. 11. Do documentation.

- To promote comfort - To promote cleanliness - For evaluation purposes