Download PROCEDURES FOR EYE CARE - Wirral Community NHS Trust

PROCEDURES FOR EYE CARE
CLEANSING OF THE EYE
INSTILLATION OF EYE DROPS / OINTMENTS
CARE OF AN EYE PROSTHESIS
EYE IRRIGATION FOR ADULTS AND CHILDREN ( WALK IN CENTRES ONLY)
Issue
History
Issue
Version
One
Purpose of Issue/Description of Change
To promote safe and effective patient care for
patients requiring eye care.
Planned Review
Date
2013
Named Responsible Officer:-
Approved by
Date
Quality and Governance Service
Clinical Policy and Procedures
Group
May 2010
Impact Assessment Screening
Complete
Date: May 2010
Full Impact
Assessment
Required Y/N
Section :- Ears, Nose, Throat and Eyes
ENT No 02
UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM THE TRUST WEB
SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION
EYE CARE PROCEDURES
INDEX
Introduction
Contents
Page Number
3
Indications
3
Target Group
3
Clinical Incidents
3
Procedure for the cleansing of the eye
4
Procedure for the Instillation of eye
drops / eye ointments
6
Procedure for the care of an eye
prosthesis
10
Procedure for eye irrigation
12
C ONS UL T AT ION
•
•
•
•
Infection Prevention and Control Team
Clinical Policies and Procedures Group
Quality and Governance Service
Medicines Management
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
2/14
EYE CARE PROCEDURES
INT R ODUC T ION
Eye care is the practice of assessing, cleaning or irrigating the eye and /or the instillation
of prescribed ocular preparations.
INDICATIONS
Eye care may be necessary under the following circumstances:
• Prevent or treat infection
• Prevent or treat injury to the eye
• Prevent damage to the cornea in sedated or unconscious patients
• Care for false eye prostheses
• Following surgery
T AR G E T G R OUP
These procedures can be performed by Registered Nurses, Assistant Practitioners and
Nursing Auxiliaries working under the instruction of a Registered Nurse. Care delegated
requires ongoing supervision, at least monthly.
NB the procedure for eye irrigation should only be carried out by employed registered
nurses trained in the procedure working in Walk in Centres,
RELATED TRUST POLICIES AND PROCEDURES
Please refer to related policies and procedures, including Standard Operating Procedure
for Administration of Medicines on the Trust web site
CLINICAL INCIDENTS
Any related incidents which may involve a clinical error or near miss in relation to these
procedures must be reported following the Trust Incident Reporting Policy.
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
3/14
PROCEDURE FOR THE CLEANSING OF THE EYE
E QUIP ME NT
If cleansing both eyes, each eye should be treated as a separate procedure. Use a
separate dressing pack for each eye to prevent cross contamination. Always treat the
uninfected or uninflammed eye FIRST
•
•
•
•
Sterile dressing pack
Gallipot
Normal saline
Patients Health Record
PROCEDURE
RATIONALE
Confirm patients identity by asking for full name
and date of birth or confirm identity with
family/carer
Ensure positive identification of the patient
Explain procedure and obtain valid consent
To allow the patient to make an informed
decision and gain co-operation
Collect and check all equipment
To prevent delays and enable full concentration
on the procedure
Patient to be encouraged to sit / lie with head well
supported in a position they find comfortable
To facilitate ease and accuracy of procedure
Ensure light source is adequate
To facilitate ease and accuracy of procedure
Decontaminate hands prior to procedure
To reduce the risk of transfer of transient
organisms on the healthcare workers hands.
Open sterile dressing pack onto a clean field and
place all sterile single use equipment required
within sterile field.
To maintain asepsis and prevent contamination
of sterile equipment.
Apply single use disposable apron
To protect clothing or uniform from
contamination and potential transfer of microorganisms
Apply single use disposable sterile gloves in a
manner which prevents the outer surface of the
sterile gloves being touched by a non-sterile item
To maintain asepsis, reduce the risk of
microbial contamination and prevent the spread
of infection
Use aseptic principle to ensure that only sterile
single use items are used to keep exposure of the
susceptible site to a minimum
To prevent contamination of a susceptible site
by organisms that could cause infection.
Always bathe the lids with the eyes closed first
Lower Lid
Using a sterile gauze swab moistened slightly with
normal saline, ask the patient to look up and gently
swab the lower lid from the nasal corner outwards
once only.
To reduce the risk of damaging the cornea
Reduces the risk of swabbing discharge into
the lachrymal ducts or into the other eye
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
4/14
PROCEDURE
RATIONALE
Ensure the edge of the swab is not above the lower
lid margin to avoid touching the cornea
Reduces the risk of damage to the cornea
Use a new swab for each wipe until all discharge
has been removed
Reduces the risk of cross infection
Upper Lid
Facilitates access to the upper eyelid
Using a sterile gauze swab moistened slightly with
normal saline, gently swab the upper lid by gently
lifting the eye lid margin and asking the patient to
look down from the nasal corner outwards once
only.
Reduces the risk of damage to the cornea
Avoid touching the corner
Reduces the risk of cross infection
Reduces the risk of swabbing discharge into
the lachrymal ducts or into the other eye
Use a new swab for each wipe until all
discharge has been removed
On completion of procedure remove and dispose of To prevent cross infection and environmental
contamination
Personal Protective Equipment (PPE) to comply
with waste management policy
Decontaminate hands following removal of PPE
To remove any accumulation of transient and
resident skin flora that may have built up under
the gloves and possible contamination
following removal of PPE.
If signs of infection or inflammation are noted,
inform General Practitioner
Medical treatment may be required
Ensure patient / client is comfortable following
procedure
Maintain privacy and dignity
Document all actions and observations in nursing
records
To monitor trends and fluctuations. Ensure
compliance with Trust record keeping policies
ADVICE
Staff can contact the Eye Unit at Wirral University Teaching Hospital for further information
and advice if needed 0151 678 5111
BIBLIOGRAPHY
Dougherty, L. and Lister, S.E. (2008) The Royal Marsden Manual of Clinical Nursing
Procedures – Seventh Edition. Blackwell Publishing, Oxford.
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
5/14
PROCEDURE FOR THE INSTILLATION OF EYE DROPS / EYE OINTMENTS
This is a clean procedure. Where both eyes may require treatment, each eye must be
treated separately. If infection is present, there should ideally be two containers of
medication one for each eye labelled L and R to prevent cross contamination. If there is
only one, the least affected eye should be treated first to minimise the likelihood of transfer
of infection from one eye to the other. If more than one eye preparation is to be inserted
into the eye there needs to be an interval of at least 5 minutes between the two
preparations (BNF March 2010)
E quipment
• Prescribed eye drops / ointment
• Sterile dressing pack
• Normal saline (if required)
• Patient Medication Administration Chart (PMAC)
• Record of administration of prescribed eye treatments (a form will be required for
each prescribed medication)
• Patients health record
PROCEDURE
RATIONALE
Confirm patients identity by asking for full name and date
of birth or confirm identity with family / carer
Ensure positive identification of the
patient
Explain procedure and obtain informed consent
To allow the patient to make an
informed decision and gain cooperation
Check patient is not allergic to any of the ingredients in the
prescribed eye products
Reduce risk of allergic reactions
Explain the benefits and potential side effects of the
medication to inform patient that some eye medication
may cause side effects such as blurred vision and difficulty
in focussing
Gain informed and understood
consent and reduce the risk of
accidents / falls
Check that patient has not already received eye
drops/ointment by asking patient and check in patient’s
health record.
To prevent patient receiving eye
preparation twice and prevent
potential harm
Collect and check all equipment
To prevent delays and enable full
concentration on the procedure
Check the Patients Medication Administration Chart
(PMAC) for the following:
 all the details on the pharmacy label match the PMAC,
including:
 correct, medicine name, form and strength
correct patient name
 date ,time and frequency of administration.
 which eye the medication is prescribed for (Left , right or
both)
 PMAC must be re written at least six monthly
 Clearly written PMAC, unambiguous directions and
To minimise the potential for drug
errors
Clear instruction for the administration
of medication is essential – report any
detected errors to the line manager
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
6/14
PROCEDURE
RATIONALE
signature of prescriber is present
and complete an incident from
Check
• Manufacturer’s expiry date of the medication.
• Once opened, eye products usually must be
discarded after 28 days.
• Refer to manufacturers instructions for details or
pharmacy label
• Document on label the date of opening
• Discard expired medication
Medication outside its expiry date is
no longer pharmacologically
efficacious and may cause harm if
administered.
Once opened there is a potential for
contamination
Close doors / curtains where appropriate
Maintain privacy and dignity
If the eyelid needs to be cleansed prior to administration of
the drops, follow Nursing Procedure for cleansing of the
eye
Follow Trust procedure
Patient to be encouraged to sit / lie with head tilted
backwards and well supported
For ease and accuracy of
administration
Ensure light source is adequate
For ease and accuracy of
administration
Reduce the risk of transfer of transient
organisms on the healthcare workers
hands transferring to the patient
To maintain asepsis and prevent
contamination of sterile equipment.
Decontaminate hands prior to procedure
Open sterile dressing pack onto a clean field and place all
single use equipment required within sterile field
Apply single use disposable apron
To protect clothing or uniform from
contamination and potential transfer of
micro-organisms
Apply single use disposable sterile gloves in a manner
which prevents the outer surface of the sterile gloves
being touched by a non sterile item
To maintain asepsis, reduce the risk of
microbial contamination and prevent
the spread of infection
Use aseptic principle to ensure that only sterile single use
items are used to keep exposure of the susceptible site to
a minimum
To prevent contamination of a
susceptible site by organisms that
could cause infection.
Eye Drops
Gently pull down the lower eyelid and ask the patient to
look upwards
Instil the prescribed number of drops into the lower fornix
Ask patient to keep eye closed for as long as possible,
preferably 1-2 minutes
Dab away excess medication with gauze
To ensure the lower fornix is exposed
to allow for administration of the drop
Administration in the lower fornix
minimises the risk of corneal abrasion
To ensure adequate drug absorption
Prevent excess medication irritating
surrounding skin
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
7/14
PROCEDURE
Eye Ointment
Hold the nozzle of the tube approximately 2.5cm above
the eye
RATIONALE
Reduce the risk of cross infection,
contamination of the tube and trauma
to the eye
Apply approximately 2.5 cm line of ointment to the inner
edge of the lower lid from the nasal corner outwards
Encourage patient to close eye immediately after
administration of medication
To ensure adequate drug absorption
Dab away excess medication with gauze
Prevent excess medication irritating
surrounding skin
Ensure patient / client is comfortable following procedure
Maintain privacy and dignity
On completion of procedure remove and dispose of
Personal Protective Equipment (PPE) to comply with
waste management policy
To prevent cross infection and
environmental contamination
Decontaminate hands following removal of PPE
To remove any accumulation of
transient and resident skin flora that
may have built up under the gloves
and possible contamination following
removal of PPE
If signs of infection or inflammation are noted, inform
General Practitioner
Medical treatment may be required
Document all actions in nursing records including the
following:
• Consent
• Date
• Time
• Dose
• Medication
• Administration site
• Expiry date
• Batch number
• Patient / client perceptions following care
Ensure compliance with Trust health
records policy and procedures
Print, sign and note designation of staff member for all
entries made
To comply with Trust Health Records
Policy
If medication NOT given – document and explain
reasoning
If medication is not given the rationale
must be recorded for effective
communication of the patients care
with the community nursing team/s
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
8/14
DE L E G AT ION OF C AR E
Registered nurses are accountable for the supervision of delegated health care tasks
CARE PLANS
Delegated care must be documented on a care plan outlining role and responsibilities
BIBLIOGRAPHY
Dougherty, L. and Lister, S.E. (2008) The Royal Marsden Manual of Clinical Nursing
Procedures – Seventh Edition. Blackwell Publishing, Oxford.
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
9/14
PROCEDURE FOR THE CARE OF AN EYE PROSTHESIS
E QUIP ME NT
•
•
•
•
•
Sterile dressing pack
Gallipot
Normal saline
Mirror (for promoting self-care)
Patients Health Record
PROCEDURE
RATIONALE
Confirm patients identity by asking for full name
and date of birth or confirm identity with
family/carer
Ensure positive identification of the patient
Explain procedure and obtain valid consent
To allow the patient / client to make an
informed decision and gain co-operation
Collect and check all equipment
To prevent delays and enable full
concentration on the procedure
Patient to be encouraged to sit / lie with head well
supported in a position they find comfortable
To facilitate ease and accuracy of
procedure. To promote privacy and dignity.
Ensure light source is adequate
To facilitate ease and accuracy of
procedure
Decontaminate hands prior to procedure
To reduce the risk of transient microorganisms on the healthcare workers
hands.
To maintain asepsis and prevent
contamination of sterile equipment
Open sterile dressing pack onto a clean field and
place all sterile single use equipment required
within sterile field
Apply single use disposable apron
Apply single use disposable sterile gloves in a
manner which prevents the outer surface of the
sterile glove being touched by a non sterile item
Use aseptic principle to ensure that only sterile
single use items are used to keep exposure of the
susceptible site to a minimum
Removal of Prosthesis
Wearing gloves and with the dominant hand,
gently pull the eyelid downwards and exert slight
pressure below the eyelid to overcome the suction
Cleanse the shell in normal saline
To protect clothing or uniform from
contamination and potential transfer of
micro organisms
To maintain asepsis, reduce the risk of
microbial contamination and prevent the
spread of infection
To prevent contamination of a susceptible
site by organisms that could cause infection
Enabling the safe removal of the prosthesis
Reduce risk of infection
If mucous discharge is present, follow nursing Patient comfort
procedure for cleansing the eye
Reduce risk of infection
If signs of infection or inflammation are noted, Medical treatment may be required
inform General Practitioner
Follow up referral to determine outcome if
required
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
10/14
PROCEDURE
RATIONALE
Insertion of Prosthesis
Hold the prosthesis between the thumb and index
finger the correct way round with the pointed side
towards the nose
To ensure correct insertion and reduce the
risk of trauma
With the other hand, lift the upper eyelid
To improve access to the eye socket
Insert the upper part of the prosthesis gently under
the upper eyelid and into the socket
To ensure correct insertion
Gently lower the finger holding the eyelid down
onto the prosthesis and hold in place
To prevent the prosthesis falling out of the
socket
Pull down the lower eyelid to allow the inferior
aspect of the prosthesis to slide behind the lower
lid
To ensure correct insertion
On completion of procedure remove and dispose
of PPE to comply with waste management policy
Decontaminate hands following removal of PPE
Ensure patient / client is comfortable following
procedure
Document in nursing records : all actions and observations
 including consent
 include patient perceptions of
intervention given
Plan in partnership with patient / carers any follow
up care / visits
To prevent cross infection and
environmental contamination
To remove any accumulation of transient
and resident skin flora that may have built
up under gloves and possible
contamination following removal of PPE
Maintain privacy and dignity
To monitor trends and fluctuations. Ensure
compliance with Trust record keeping
policies
ADV IC E
Staff can contact the Eye Unit at Wirral University Teaching Hospital for further information
and advice if needed 0151 678 5111
BIBLIOGRAPHY
Dougherty, L. and Lister, S.E. (2008) The Royal Marsden Manual of Clinical Nursing
Procedures – Seventh Edition. Blackwell Publishing, Oxford.
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
11/14
P R OC E DUR E F OR E Y E IR R IG AT ION
This procedure should only be undertaken by Trust employed registered nurses trained in
the procedure working in Minor Injuries Units or Walk-in-Centres.
Note:
This procedure should NOT be used for eyes contaminated with C/S gas
( 2-Chlorobenzalmalononitrile )
Equipment Required
• Waterproof cape
• Towel
• Irrigation solution – Sodium chloride 0.9%
• Receiver
• Administration set (if required)
• Anaesthetic drops
• Gauze swabs
• Single use disposable non-sterile gloves
• Single use disposable apron
• Sterile dressing pack
• pH check strips (specific eye testing strips)
• Nursing records
• Relevant Patient Group Direction
PROCEDURE
RATIONALE
Verbally check the identity of the patient by asking for
the patients full name and date of birth
To ensure positive identification of the
patient
If a Child: Two nurses required
One nurse to hold child, with parental /carer consent
and one nurse to hold the child’s eyelids apart using
the first and second finger held against the orbital
ridge. One nurse to administer wash out.
Patient will be unable to hold the eyelids
themselves once irrigation commences
Explain the procedure, including risks and benefits
So the patient understands the procedure
and to gain patient’s informed consent and
co-operation
When patient gives history of exposure to agents
containing alkali or acid immediate irrigation should
precede full examination
Establish patient has no known allergies
To reduce damage to anterior segment; the
amount of damage is related to the duration
of the exposure
To reduce risk of allergic reaction
Decontaminate hands prior to procedure
To reduce the risk of transfer of transient
micro-organisms on the healthcare workers
hands
Apply towel and cape
To protect the patient’s clothing
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
12/14
PROCEDURE
RATIONALE
Apply single use disposable non-sterile gloves and
single use disposable apron to
remove contact lenses immediately if present
To protect hands from contamination with
organic matter and transfer of microorganisms
To facilitate irrigation and prevent corneal
damage
Check pH (a measure of the hydrogen ion
concentration) of the eye prior to treatment using
specific eye testing strips for chemical injury – pH
testing should not delay commencement of irrigation
To determine if an acidic or alkaline
corrosive substance is present A pH above
8.0 or below 7.5 may indicate that an acidic
or corrosive substance is still present in the
eye
Remove and dispose of PPE to comply with waste
management policy
Decontaminate hands following removal of PPE and
prior to commencement of irrigation if required
To prevent cross infection and
environmental contamination
To remove any accumulation of transient
and resident skin flora that may have built
up under gloves and possible
contamination following removal of PPE
Prepare the sodium chloride 0.9% irrigation solution, To reduce discomfort
check that it is at room temperature
Open sterile dressing pack onto a clean field and To
maintain
asepsis
and
prevent
place all sterile single use equipment required within contamination of sterile equipment
sterile field
Apply single use disposable apron
To protect clothing or uniform from
contamination and potential transfer of
micro-organisms
Apply single use disposable sterile gloves in a manner To maintain asepsis, reduce the risk of
which prevents the outer surface of the sterile glove
microbial contamination and prevent the
being touched by a non sterile item
spread of infection
Instil anaesthetic drop (if required) as per Patient To reduce discomfort and aid assessment
Group Direction
Assist the patient into an appropriate position:
To reduce discomfort
• Head comfortably supported with chin almost
horizontal
• Head inclined to the side of the eye to be treated
Remove any discharge from the eye by cleansing the
eye socket
To prevent discharge from running across
cheek
Ask the patient to hold the receiver against the cheek,
below the eye being treated
To collect fluid running from the eye
Do not press on the eyeball
To avoid causing unnecessary discomfort
Inform the patient that irrigation is about to start and
pour a little of the fluid onto the cheek
To prepare the patient and to make them
aware of the sensation and temperature of
the irrigation fluid
Direct the flow of irrigation fluid from the nasal corner
To wash away any secretions
Ask the patient to look up, down and to either side
whilst irrigating
To ensure the whole eye is irrigated
Evert the eyelids when irrigating and ensure there is a
constant flow of irrigation fluid
To ensure complete removal of any foreign
body
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
13/14
PROCEDURE
Check pH after 20 minutes of irrigation using specific
eye testing strips for chemical injury,
Irrigation should be continued until the conjunctival
sac pH is normal (7.5-8.0).
Retest after 20 minutes and use further irrigation if
necessary
identify chemical and discuss with
‘Toxbase’ a national poisons data base
0870 600 6266
RATIONALE
A pH above 8.0 or below 7.5 may indicate
that an acidic or corrosive substance is still
present in the eye
To assess level of chemical risk
www.spib.axl.co.uk hosts the Toxbase web
site
Patients with:
corneal damage
patients whose symptoms do not resolve rapidly
patients who have been exposed to strong acids or
alkalis
Should be referred for urgent ophthalmologic
assessment [same day]
To ensure emergency Opthalmic
assessment of severe eye injury
Ask the patient to close the eye and dry lid with a
gauze swab
To promote patient’s comfort
Remove receiver and dry patient’s cheek
To promote patient’s comfort
Examine eye for corneal damage by installation of
Fluorescein as per Patient Group Direction
To detect corneal damage
On completion of procedure remove and dispose of
PPE to comply with waste management policy
Decontaminate hands following removal of PPE
Document all actions and observations (including
consent and patient perceptions) in nursing records
To prevent cross infection and
environmental contamination
To remove any accumulation of transient
and resident skin flora that may have built
up under gloves and possible
contamination following removal of PPE
Ensure compliance with Trust Health
Records Policy
Advice
Staff can contact the Eye Unit at Wirral University Teaching Hospital for further information
and advice if needed 0151 678 5111
REFERENCES AND BIBLIOGRAPHY
Dougherty, L. and Lister, S.E. (2008) The Royal Marsden Manual of Clinical Nursing
Procedures – Seventh Edition. Blackwell Publishing, Oxford.
St. Paul’s Primary Care Eye Centre – Guidelines for eye irrigation – Royal Liverpool
University Hospital
NPIS (2007) Chemicals splashed or sprayed into the eyes. TOXBASE. National Poisons
Information Service. www.spib.axl.co.uk [Accessed: 12/03/2009].
Clinical Knowledge Summaries- Corneal Superficial injury – Management
http://cks.library.nhs.uk [Accessed 12/03/2009
EYE CARE PROCEDURES
ADOPTED BY WIRRAL COMMUNITY TRUST APRIL 2011
14/14