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Students Orientation Document Ward 25 Ophthalmology Ninewells Hospital Student Nurse: _______________________ Mentor 1: ____________________________ Mentor 2: ___________________________ Half way assessment date ___/___/___ Final assessment date ___/___/___ Photocopy when completed and file in SCN office 2015 Review Jun 2017 Welcome to ward 25. The following information is a guide and any information or education can be added during your placement. You should be allocated a mentor, if not see either the SCN or CN during your first week. If your mentor is absent see SCN or CN immediately. You should discuss with your mentor particular skills and learning activities you wish to achieve. Set dates and times of achievement. Also, write down comments and any problems, which arise affecting your objective setting. If you have any particular problems or concerns with your placement please see me personally, your personal tutor or our ward PEF (contact details on ward poster or in CPPSU mentor folder), thank you. SCN S.McGilvray Ward Information Student information is on student notice board and information folder, along with general NHS policies, NHS Tayside policies and guidelines. Books and other learning materials are available but please do not remove from the ward. Your orientation of the ward and objectives should be discussed by the end of your first week. You are responsible for arranging with your mentor a date for your halfway assessment and final assessment. It is your responsibility to keep your competency books safe and up to date. General responsibilities to discuss with mentor (date and sign when achieved) Dress code Responsibilities if you are sick or absent from duty CPR and resuscitation trolley Manual handling equipment and competencies Fire safety procedure and equipment Infection control policies, Standard Infection Control Practices, Food Hygiene and hand washing practice Student’s experience and previous learning. Discussion notes Statement of Values Relating to the Education of Students Ward 25 Ninewells Hospital Dundee We encourage students to ask questions and will always try to answer them. However, we will expect students to assist with their own learning by developing a questioning approach. We look forward to hearing your views and suggestions about how we can improve the learning experience for our students; this opportunity is available through the university questionnaire, our PEF (Practice Education facilitator), or ward team members. We Will: Treat students as individuals acknowledging their needs and encouraging their participation in formulating care management. Encourage students to feel part of the care team by involving them in assisting and directing healthcare professionals in providing patient care. Recognise and value the contribution of all students in the process of planning and carrying out patient care and assist them to achieve/maintain knowledge and skills in order to provide safe and effective care. Mentors are responsible and accountable for: Organising and co-ordinating student learning activities in practice. Supervising students in learning situations and providing them with constructive feedback on their achievements. Setting and monitoring achievement of realistic objectives. Assessing total performance – including skills, attitudes and behaviours. Providing evidence as required by programme providers of student achievement or lack of achievement. Liaising with others (e.g. mentors, sign-off mentors, practice facilitators, practice teachers, personal tutors, programme leaders) to provide feedback, identify any concerns about the student’s performance and agree action as appropriate. Providing evidence for or acting as a sign–off mentor with regard to making decisions about achievement of proficiency at the end of a programme. Developed with the support of PEF (Practice education Facilitator) and NMC (Nursing & Midwifery Council) Standards to support learning and assessment in practice July 2008. Review Jun 2017 Clinical experience (date and sign when achieved) Guiding the visually impaired Safety of the visually impaired in hospital setting Admission and discharge process for routine in-patient and emergency admission Admission and discharge process for day case surgery Bathing the eye Instillation of pre-operative dilating drops (in accordance with NHS Tayside drug administration policy) Instillation of other topical treatments Application of eye shield/dressing Diabetic management and care, diet, drug regimes, protocols Observation opportunities within ophthalmology (record details of learning for each opportunity achieved) To be arranged with your mentor Eye theatre Learning outcomes Area 6A/ orthoptist / IV fluoresceine angiography / treatment room/ nurse led glaucoma clinic Learning outcomes Pre-assessment clinic Learning outcomes LASER clinic Learning outcomes Macular degeneration- Intravitreal treatment clinic Learning objectives Ophthalmic education sessions with mentor (date and sign when achieved) Basic anatomy and physiology of the eye Measuring visual acuity Cataracts Glaucoma Retinal disorders Squint Red eye Learning outcomes As a student you will be able to achieve competent, safe, planned care for patients with a visual impairment under the supervision of Registered Nurses in ward 25. You will achieve any planned outcomes relevant to the stage of your training and education. The student will gain awareness of special needs of the visually impaired person. Communicate effectively with colleagues, patients and relatives Demonstrate safe effective practice using initiative, judgement and showing awareness of areas of learning development asking advice when necessary to maintain patient safety Demonstrate understanding of common ophthalmic conditions, nursing interventions and treatments Student’s learning objectives should be documented in their personal books Mentor’s comments Glossary of terms commonly used Amblyopia Angiography Anisometropia Anterior chamber Aphakia Aqueous Astigmatism Axis Band keratopathy EDTA Blepharitis Cataract Canal of Schlemm Canthus Cataract extraction Chalazion Conjunctiva Reduced visual acuity, vision in one eye does not develop fully during early childhood. In most cases, however, glasses do not help Diagnostic test in which vascular system is examined Fluoresceine angiography is an eye test that uses a special dye and camera to look at blood flow in the retina and choroid, the two layers in the back of the eye. two eyes have unequal refractive power The anterior chamber is filled with a watery fluid known as the aqueous humour, or aqueous. Produced by a structure alongside the lens called the ciliary body, the aqueous passes first into the posterior chamber (between the lens and iris) and then flows forward through the pupil into the anterior chamber of the eye Absence of crystalline lens Clear, watery fluid that fills anterior and posterior chambers Astigmatism is usually the result of an irregular-shaped cornea or lens. The cornea is the transparent layer of tissue at the front of the eye. The cornea should be regularly curved like the surface of a football, but in cases of astigmatism it has an irregular curve, more like the shape of a rugby ball. This means that light rays entering the eye aren't focused properly, creating a blurred image Line through the centre Calcium deposits on cornea – debridement used to remove calcium deposits Apply 0.05 mol, 1.5% neutral disodium ethylenediaminetetra-acetic acid (EDTA) to the corneal surface, then scrape off calcium deposits Inflammation of the eyelids Opacity of crystalline lens Drains aqueous humour Angle formed by junction of upper and lower eyelids Removal of cataract either by intracapsular - the entire natural lens of the eye, including the capsule that holds it in place, is removed. or by extracapsular- involves removing the eye's natural lens while leaving in place the back of the capsule that holds the lens in place Small swollen sebaceous gland in eyelid Mucous membrane covering front of eyeball and lining of eyelids Convergence Cornea Cyclodiode laser Cycloplegic Dacryocystorhinostomy DASEK – decemet’s automated stripping endothelial keratoplasty Process of directing visual axis of eyes to a near point Transparent portion of anterior surface of eyeball For painful blind glaucoma – use a G-probe contact surface to indent the conjunctiva and sclera, thus improving energy delivery to the ciliary body Drug to paralyze ciliary muscle Procedure to create opening between lacrimal sac and nasal cavity Only the back layer of the cornea is removed, consisting of the endothelial cells and the Descemet's membrane that holds the cells. A partial thickness of the donor cornea, containing new endothelial cells, then is implanted to replace the dysfunctional cells. Unit used in measuring lenses for spectacles Seeing one object as two A way of testing visual acuity for someone who cannot understand the alphabet Turning out of eyelid Ectropion Turning inward of eyelid Entropion Overflow of tears Epiphora Entire area which can be seen without shifting gaze Fields of vision Opacities in vitreous humour that move about and Floaters appear as spots before eyes Raised intra-ocular pressure Glaucoma Long-sightedness Hypermetropia Blood in anterior chamber Hyphaema Cone shaped deformity of cornea Keratoconus Instrument for measuring curvature of cornea Keratometer Dilated area at junction of nasolacrimal duct and Lacrimal sac cannaliculi visual acuity is scored with reference to the Logarithm Log MAR chart of the Minimum Angle of Resolution, as the chart's name suggests designed to enable a more accurate estimate of acuity A drug to constrict pupil Miotic MOH’s (developed by Dr Frederick Technique for removing Basal Cell Carcinoma and Squamous Cell Carcinoma (BCCs and SCCs), the two Mohs most common skin cancers The procedure entails removing one thin layer of tissue at a time; as each layer is removed, its margins are studied under a microscope for the presence of cancer cells. If the margins are cancer-free, the surgery is ended. If not, more tissue is removed from the margin where the cancer cells were found, and the procedure is repeated until all the margins of the final tissue sample examined are clear of cancer A drug to dilate pupil Mydriatic shortsightedness Myopia Dioptre Diplopia “E” test OCT Optical coherence tomography - non-invasive imaging test that uses light waves to take cross-section pictures of your retina, the light-sensitive tissue lining the back of the eye. Ophthalmoscope Orthoptist Phacoemulsification of lens Instrument for viewing inner eye particularly retina and associated structures Diagnose and manage disorders of binocular vision and mainly work in the NHS. The phaco probe is an ultrasonic handpiece with a titanium or steel needle. The tip of the needle vibrates at ultrasonic frequency to sculpt and emulsify the cataract while the pump aspirates particles through the tip. In some techniques, a second fine steel instrument called a "chopper" is used from a side port to help with chopping the nucleus into smaller pieces. The cataract is usually broken into two or four pieces and each piece is emulsified and aspirated out with suction. The nucleus emulsification makes it easier to aspirate the particles. After removing all hard central lens nucleus with phacoemulsification, the softer outer lens cortex is removed with suction only. An irrigation-aspiration probe or a bimanual system is used to aspirate out the remaining peripheral cortical matter, while leaving the posterior capsule intact. The foldable IOL, made of silicone or acrylic of appropriate power is folded either using a holder/folder, or a proprietary insertion device provided along with the IOL. It is then inserted and placed in the posterior chamber in the capsular bag. Photophobia Pinguecula Sensitive to light Posterior chamber Part of aqueous chamber that lies behind the iris, but in front of lens Impairment of vision occurring in old age Presence of artificial intraocular lens implant A growth that develops across the clear cornea of the eye that can affect people who spend a lot of time outside in the sun. Presbyopia Pseudphakia Pterygium Yellowish patch or bump on the conjunctiva near the cornea. The conjunctiva is the thin, moist membrane on the surface of the eye. Ptosis Punctum Pupil Refraction Refractive error Retina Retinal detachment Retinopexy Pneumatic Retinopexy Sclera Sheridan Gardner test Slit lamp Snellen chart Strabismus Tarsorraphy Tonometer Trabeculectomy Uveitis Visual acuity Vitreous Drooping of eyelid Opening of lacrimal ducts at inner canthus of eye Small hole in centre of iris through which light passes into eye Bending or deviation of rays of light, the test to ascertain amount of refractive error Optical defect which prevent light rays from focusing on retina Light-sensitive layer at the back of the eye that covers about 65 percent of its interior surface. Photosensitive cells called rods and cones in the retina convert incident light energy into signals that are carried to the brain by the optic nerve. In the middle of the retina is a small dimple called the fovea or fovea centralis. It is the centre of the eye's sharpest vision and the location of most colour perception. occurs when the thin lining at the back of your eye called the retina begins to pull away from the blood vessels that supply it with oxygen and nutrients Laser retinopexy uses a powerful light beam around the hole to seal or “spot weld” the retina to the underlying tissues, stopping the retina from detaching Pneumatic retinopexy, inject a gas bubble into the middle of the eyeball then use a freezing probe (cryopexy) or laser beam (photocoagulation) to seal the tear in the retina. It forms the supporting wall of the eyeball, and is continuous with the clear cornea, the episclera, loose connective tissue, immediately beneath the conjunctiva; sclera proper, the dense white tissue that give the area its color; and the lumina fusca, the innermost zone made up of elastic fibers Consists of set of cards, each marked with a single letter of specific size, cards shown one at a time, at 6 meters (usually for children) Combination of light and microscope for examining eye For testing visual acuity, lines of letters in graded sizes Squint, It is a condition where the eyes do not look in the same direction Surgical joining of upper and lower eyelids Instrument for measuring intra-ocular pressure Surgical procedure to create a drainage channel in treatment of glaucoma Inflammation of one or part of uveal tract (iris, ciliary body, choroid) Measurement of acuteness of vision Transparent, jelly-like substance filing posterior space of the eye COMMONLY USED EYE TREATMENT ACETAZOLAMIDE CAPSULES BENOXINATE Reduce intra-ocular pressure Corneal anaesthesia, to allow tonometry, fitting contact lens, removal of corneal foreign body Broad spectrum antibiotic CHLORAMPHENICOL Dilate pupil and paralyses ciliary muscle lasts 24 hours CYCLOPENTOLATE 1% Non steroidal anti-inflammatory and inhibits intraFLUBRIPROFEN SODIUM operative miosis (does not have mydriatic properties) (OCUFEN) Tear deficiency HYPROMELLOSE Ocular lubricant LACRI-LUBE LIGNOCAINE&FLUORESCEINE Corneal anesthesia and stain NEPAFEN Dilate pupil lasts 5-7 hours PHENYLEPHRINE 10% Miotic, constricts pupil, treat POAG and angle closure PILOCARPINE glaucoma PREDNISOLONE ACETATE Beta blocker, reduces intraocular pressure by reducing TIMOPTOL production of aqueous humour Short acting midriatic lasts 4-6 hours TROPICAMIDE Ocular lubricant VISCOTEARS Instillation of Eye Drops Learning Resource Pack Author – Doreen Laing Registered Nurse, Area 6A Ophthalmology OPD Ninewells Hospital Reviewed Feb 2016 Introduction Welcome, this Learning Resource Pack (LRP) has been complied for the use of students whilst on placement within Ninewells Hospital Ophthalmology Department; it can also be a resource for Newly Qualified Practitioners or new Registered Nurses to ophthalmology. The department incorporates outpatient services in Area6A; ward 25 provides inpatient services, day case surgery and additional specialist clinics. For ophthalmic examination, surgery or specialist treatment clinics the administration of eye drops is required, to examine/treat the structures within the eye; administer short-term treatments; support and educate patient with long-term or lifelong eye medication administration. Supplementary material and answers to the activities can be found at the end of the resource pack. The practical element of the pack involves a skills analysis checklist to complete with your mentor while observing you carrying out the procedure. An evaluation questionnaire is also provided. Your feedback and comments are welcomed. Aim The aim of this LRP is to assists your learning and understanding of safe and correct administration of eye drops, enabling you to apply this knowledge and skills within ophthalmology department and other clinical areas. Learning Outcomes 1. Demonstrate patient identification procedure in out-patient setting, in-patient ward, day case area 2. Demonstrate/describe required hand decontamination prior to procedure 3. Demonstrate safe and correct instillation of eye drops or ointment/gel 4. Discuss with patient / family / carer eye drop instillation procedure 5. Discuss the importance of eye treatment compliance to patient/family/carer 6. Discuss common side effects and action if they occur with patient /family /carer 7. Discuss commonly used eye treatments Topic Analysis The learner should be able to answer questions on the following: 1. How patient identification is conducted in the out-patient setting, in-patient setting, day case area and the rationale 2. The learner must demonstrate good hand washing technique and explain rationale 3. The learner will demonstrate the correct technique of instillation of eye drops/ointment /gel 4. The learner will demonstrate sound knowledge of the importance of patient compliance and the Registered Nurses role supporting patients to achieve this 5. The learner will gain knowledge and understanding of the most commonly used eye treatments Skills Analysis 1. Introduce yourself and your role 2. Explain to patient/family/carer the procedure you are about to undertake and obtain verbal consent (NHST consent policy, NMC ) 3. Patient seated comfortably in appropriate chair/room/area to have treatment 4. Check patients identity (NHST Correct Patient Identity Policy) In outpatient setting, orally with patient, full name, DOB CHI address with patient case notes In-patient ward / day case patient – orally as above and check ID band 5. Check if patient has any allergies 6. Demonstrate hand washing decontamination (NHST Infection Control Policy) 7. Check doctor/Nonmedical Prescriber has prescribed eye medication in case notes/as per clinic protocol printed label/ ward patients have medication prescribed on TPAR chart/day case prescription/laser consent form/clinic printed label NHST Medicines Management Policy) 8. Check medication is correct dose, expiry date 9. Assist patient into correct position to ensure safe and correct instillation of eye treatment 10. Instil mediation safely and correctly 11. Deliver a clear explanation of the importance of eye drop compliance 12. Supply patients with relevant written information to supplement oral instructions ( medicines for continued use over a specified period should be labelled (NHST Medicines Management Policy, NHST TTO policy) 13. Demonstrate correct disposal of containers 14. Demonstrate hand washing decontamination post treatment (NHST Infect ion Control Policy) The activities contained within this LRP are in place to facilitate your learning. The time is purely a guide. Activity 1 45 mins Please read: Shaw M (2014) How to administer eye drops and ointments. Nursing Times; 110: 40, 16-18 Activity 2 1 hour Please read: NMC Code of Professional standards of practice and behaviour for nurses and midwives 2015 NMC Standards for medicine management 2008, 2009 Staffnet : our websites : pharmacy: - you will find access to NHST Safe and Secure Handling of Medicines – see section 18 prescribing system, section 20 administration of medicines and use of recording sheet, section 27 non medical prescribing, appendices 1 using patient own medicines Activity 3 1 hour Your mentor will demonstrate during the course of your placement the safe and correct instillation of eye medication. Please observe closely and feel free to ask questions regarding the actions of the eye treatments, side effects and reasons for administration. BNF online is a good resource and is up to date. You will be given the opportunity to instil eye treatments to patients when you have demonstrated your knowledge and understanding of the process and completed the activities. Activity 4 30 mins Please complete the following: 1. What is the most common treatment used for ophthalmic conditions? a. Oral medication b. Topical medication c. IV medication 2. Is eye mediation (eye drops/ointment) governed by the same guidelines as administration of medicines? a. No b. Yes c. IV medications 3. Practitioners should possess sound knowledge of the therapeutic use of medications (normal does, side effects, precautions and contraindications) they administer? a. No b. Yes c. Don’t’ know 4. Which of the following resources could you access to gain know ledge regarding the contraindications and use of medicines? a. b. c. d. e. BNF (British national Formulary) Drug information leaflet Pharmacist All of the above None of the above 5. A registered nurse should always be present and supervise student nurses undertaking administration if medicines? a. Yes b. No c. Don’t know 6. You are asked to undertake the instillation of eye drops without first observing the procedure with any previous oral or written instructions given. What would you do? a. Attempt the procedure regardless b. Ask for a demonstration first with clear oral and written instructions for future reference c. Don’t know 7. A patient informs you that they have discontinued their medication because they have developed an allergy. What t would you? a. Ignore it b. Inform medical staff c. Don’t know (Your mentor will have correct answers to check with you) When you have completed activity 1- 4 and 100% with test questions then go to activity 5. Activity 5 Instillation of eye medications; 1. Check and understand prescribes medication with Registered Nurse 2. Introduce yourself 3. Check the patient name, DOB CHI, address with case notes/referral notes (outpatient), check ID band with patient and case notes (IP and DC) 4. Check if patients has any known allergies 5. Collect and check prescribed medication with registered nurse following NHST Safe and Secure Handling of Medicines 6. Explain procedure to patient, gain consent, explain any effects they may feel such as stinging/blurring of vision etc. 7. Use correct disinfection of hands 8. Ensure patient is seated comfortably 9. Ask patience to tilt their head back and look up to the ceiling 10. Gently pull down lower eye lid to form a small pocket 11. Hold the eye dropper/bottle in the other hand just above the lower eye lid and allow one drop to fall inside the lower fornix, thus avoiding touching the patients eye lid with the tip of the bottle /dropper 12. Gently ask the patients to close their eye gently and blot gently with a tissue 13. Dispose of dropper /tissue in an appropriate receptacle 14. Ensure patient understands rationale/compliance of the eye drops and leave patient comfortable 15. Adhere to hand decontamination post procedure Mentor Checklist for assessing student competency. Does student:1. Show knowledge that the prescribed eye medication must be checked by a Registered Nurse? YES/NO 2. Introduces themselves to patient and explain what they are about to do and why, gain patient consent? YES/NO 3. Check and clarify patient name, DOB CHI, address (which is applicable to clinical area) check allergy status? YES/NO 4. Collect and check the medication with the registered Nurse in accordance with NHST medicines policy? YES/NO 5. Use good hand washing/cleansing technique? YES/NO 6. Ensure the patients seated comfortably? YES/NO 7. Ask the patient to achieve optimum position by tilting head back? YES/NO 8. Gently pull down eye lid? YES/NO 9. Instil eye drop allowing drop to fall inside fornix without touching the eye lid? YES/NO 10. Continue by gently closing and blotting the patient’s eye with a tissue? YES/NO 11. Dispose of used items appropriately? YES/NO 12. Ensure adequate information was given leaving the patient comfortable? YES/NO reading eye medication before 13. Wash their hands effectively afar completion and record medication on relevant document (appropriate to clinical area)? YES/NO Students name ____________________________________ Mentor signature _________________________________ Date competency achieved ___/___/___ If not achieved, then repeat competency and record outcome. Student evaluation 1. The LRP was simple to follow? YES/NO if no please comment 2. Were learning outcomes achievable? YES/NO if no please comment 3. Was the time taken to complete the LRP appropriate to your learning needs? YES/NO if no please comment 4. Were the references contained informative and relevant? YES/NO if no please comment 5. The skills assessment questions, were hey helpful focussing learning? YES/NO if no please comment 6. Did you find this resource a good method of learning? YES/NO if no please comment 7. What did you enjoy the most in the LRP? 8. What was not useful in the LRP? 9. Any further comments or reflection please record below. PLEASE HAND YOUR EVALUATION TO YOUR MENTOR, (Mentors please return to SCN McGilvray ward 25 to review evaluations) References NMC Code of Professional standards of practice and behaviour for nurses and midwives (2015) NMC Standards for medicine management (2008, 2009) Shaw M (2014) How to administer eye drops and ointments. Nursing Times; 110: 40, 16-18 www.bnf.org Locate these policies on NHS Tayside (NHST) Staff Net: NHST Medicines Management Policy NHST TTO (To Take Out) labelled medicines policy NHST Infection Control Policy