EYE DISORDER

TREATMENT AND MODALITIES; PROCEDURES

GUIDELINES ON:

INSTILLATION OF MEDICATION; EYE IRRIGATION,

APPLICATION OF EYE PATCH, EYE SHIELD AND
PRESSURE DRESSING TO THE EYE; REMOVING
PARTICLE FROM THE EYE;

NCM 116 RLE

BATARIO, YSSA MARIELLE L.

JUNE 26, 2021 / GROUP 2
PROF. ZOLETA
 Instillation of Eye Medications

Nursing Action Rationale

Preparatory Phase

1. Inform the patient of the need and reason 1. Allays fear and enlists cooperation.
for instilling drops or ointment.
2. Provides a position of comfort and safety
2. Allow the patient to sit with head tilted for the patient and accessibility for the
backward or to lie in a supine position. nurse.

3. Verify the patient’s identification. 3. Prevents error.

4. Check written prescription and bottle, vial, 4. Avoids medication error.

or tube for correct medication.
5. Order may be written with abbreviation.
5. Check prescription, designating eye
requiring drops. 6. OD (oculus dexter)—right eye OS (oculus
sinister)—left eye OU (oculus uterque)—
6. Wash hands before instilling medication. both eyes

7. Prevents transfer of microorganisms to

patient.
Performance Phase
1. Remove cap from container and place on 1. Prevents contamination of lid.
clean surface.
2. Eye droppers are used less frequently than
2. If eyedropper is used, fill eyedropper with dropper bottles.
medication by squeezing bulb.
3. Exposes inner surface of lid and cul-de-
3. Using forefinger, pull on skin below lower sac.
lid
4. Prevents medication from hitting sensitive
4. Instruct patient to look upward. cornea and prevents blephorospasm.

5. Drop medication amount prescribed into 5. Prevents medication from hitting sensitive
center of lower lid (cul-de-sac) (see Figure cornea.
A).
 6. If ointment is to be instilled, squeeze out 8 6. Prevents contamination of the tube.
– -inch ribbon of medication (size of grain Avoids dispensing excessive ointment;
of rice) from the tube into the lower lid clouds vision.
without touching the eye with the end of
the tube (see Figure B). 7. Squeezing or rubbing would express
medication from eye and increase lacrimal
7. Instruct patient to close eyes slowly but drainage from the eye; closing allows
not to squeeze or rub them. Open eye. medication to be distributed evenly over
eye.
8. Clear any excess medication with gauze or
tissues. 8. Prevents possible skin irritation.

9. If additional eye drops are ordered, wait 9. Allows time for absorption of medication.
30 seconds between each drop.
Nursing Alert: Parietal occlusion (place finger over lacrimal duct for 1 minute) may be necessary
after instilling drops if systemic absorption is to be avoided, prolonged corneal contact is desired,
or taste or smell of medication is distressing.
Follow-up Phase
1. Wash hands after instilling medication. 1. Prevents transfer of microorganisms to self
or other patients.
2. Record time, type, strength, and amount of
medication and the eye into which 2. Provides documentation in the medication
medication was instilled. record.
IRRIGATION OF THE EYE
Ocular irrigation is often necessary for the following:
1. To irrigate chemicals or foreign bodies from the eyes.
2. To remove secretions from the conjunctival sac.
3. To treat infections
4. To relieve itching.
5. To provide moisture on the surface of the eyes of an unconscious patient.
APPLICATION OF EYE PATCH, EYE SHIELD AND PRESSURE DRESSING TO THE
EYE
EQUIPMENT PICTURE
Eye covering to be used (shield,
oval patches)

Tape

Scissors

Tincture of benzoin or skin protect-

ant (optional)

PROCEDURE
NURSING ACTION RATIONALE
PREPARATORY PHASE
1. Wash hands. 1. Prevents contamination.
2. Explain procedure to patient. 2. Allays fear and ensures cooperation.
3. Verify patient and eye to be patched. 3. Prevents error.
4. Instill ointment, if directed, prior to 4. May be ordered to protect cornea from
patching. abrasion or prevent infection.
5. Shave the male face and apply tincture of 5. Enhances ability for tape to stick and
benzoin, as indicated. protect the skin from tape.
PERFORMANCE PHASE
1. For eye patch:
a. Instruct patient to close both eyes. a. It may be difficult to close only the
b. Place patch over affected eye. affected eye.
c. Secure the patch with two or more b. May need two or more patches, depending
strips of tape applied downward and on the depth of the eye compared with the
diagonally from midforehead to cheek. surrounding bones.
c. Although transparent tape is easy to
remove and adhesive tape is most secure,
hypoallergenic tape should be used if
patient has had reaction to tape in past.
2. For eye shield:
a. Apply over dressings or directly over a. Used primarily to protect the eye. Some
the undressed eye, fastening with two shields may be bent to rest over bony
or more strips of tape. prominences. Tape placed around edges
b. Be sure there are no rough edges of the shield will not obstruct vision
against the skin. through holes in the shield.
a. c. Secures dressing and applies b. Prevents abrasion. Use skin protectant, as
pressure. indicated.

3. For pressure dressing:

a. Have the patient close both eyes a. Prevents eye from opening before
tightly. dressing is secured.
b. Fold patch in half (short end to short b. Provides pressure dressing bulk.
end) and place over closed eyelid a. c. Secures dressing and applies pressure.
(with fold line at eyebrow). Cover
with additional unfolded patches.
c. Apply strips of tape firmly from check
to forehead, overlapping each strip.

FOLLOW UP PHASE
1. Trim tape and monitor for security of patch 1. For patient’s safety and comfort.
or shield.

2. Advise patient that because depth 2. Prevent accidents or corneal abrasion if

perception will be impaired, he or she should eyelid opens and patch rubs against cornea.
perform activities carefully and report any
foreign body sensation.
Removing a Particle from the Eye and Fluorescein Staining:
EQUIPMENT

 Local Anesthesia
 Hand Lens
 Sterile Fluorescein strips and
illumination source

 Cotton Applicator
 Normal Saline
 Antibiotic Solution
Procedure:
Nursing Action Rationale

Preparatory phase:

NURSING ALERT It is important to take a

patient history to determine the nature of the
foreign body. If the particle is metal or
entered the eye with projectile force, trauma
to the eye could result. It may be necessary
for the ophthalmologist to remove the foreign
body immediately without attempting this
method to prevent further injury.
1. Perform hand hygiene 1. Prevents contamination
2. Explain procedure to patient. 2. Allays fear and ensures cooperation.
3. Instill anesthetic eye drops, as directed 3. Facilitates comfort

PERFORMANCE PHASE:
Removal of Particle:
As patient looks upward, place your finger Particles are often washed downward by the
below the lower lid and pull downward to upper lid
expose the conjunctival sac. Inspect for
particles using a hand lens.
With small cotton applicator dipped in saline, Prevents trauma. Saline promotes adherence
remove particle by gently wiping across of a particle
conjunctival surface
If offending particle is not found, proceed to
examine upper lid. a. Moves sensitive cornea down and
away from area of activity.
a. Have the patient look downward. b. . Relaxation prevents squeezing the
b. Encourage the patient to relax; move lids shut, a maneuver that contracts the
slowly and reassure patient that orbicularis muscle, making eversion of
procedure will not be painful. lid impossible.
. Because the upper tarsal plate extends
c. Place cotton applicator stick 0.4−0.5 inch (10−12 mm) above the lid
horizontally on outer surface of upper margin, pressure must be applied at least
lid. Apply pressure about 1 cm above ½ inch (1 cm) above the lid margin for
lid margin (see Figure A) easy eversion of lid.
d. Grasp upper eyelashes with forefinger
and thumb and pull the upper lid d. Because particles may be washed
outward and upward over cotton under the lid, visual exposure assists
 applicator (see Figure B). Remove in detection. Eyelid will remain
particle if present. everted by itself during inspection and
removal.
e. Ask the patient to look up and blink. e. Returns eyelid to neutral position.

Fluorescein Staining
1. Use fluorescein strip to detect corneal Green stain will indicate if abrasion is
abrasion. present.
2. Apply a drop of saline to the strip; pull the 2. Moistening the strip enhances release of the
lower eyelid down and gently touch the tip of dye.
the strip to the inner aspect of the eyelid.
3. Ask the patient to blink several times to 3. Dye will be dispersed over the conjunctive
distribute the dye. and cornea
4. Cornea is viewed through a slit lamp, 4. Breaks in the epithelium will cause
Wood’s lamp, or other blue filter light to best aqueous humor to color the fluorescein dye
illuminate area of abrasion and ulceration. green under blue light.
FOLLOW UP PHASE:
1. Apply antibiotic ointment, as directed. 1. Prevents potential serious infection from
break in cornea.
2. Apply patch, if indicated 2. Rest eye and protect cornea for healing.