to the manufacturer’s instructions, which in some cases will be in the refrigerator.
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As with all drugs, advise the patient that medications should be stored in a place out of reach of children and animals.Special considerations for instilling eye medication in children Instilling any drops in children can be traumatic for the healthcare profes- sional, the child and parents. Be truthful if a child asks if the drops will sting.
Show the drops to the child and, if appropriate, allow the child to handle the drops. If instilling fluorescein drops, it is helpful to place a drop on the child’s hand to demonstrate the colour. Involve the child in the instillation of the drops by giving them some tissues to hold and instruct them to dab the eye after the instillation. If a child refuses to open her/his eyes, instil the drops in the inner canthus of the closed lid and when the child opens his/her eyes, hopefully some of the drops will slide in.
Post-operative eye care
The majority of post-operative ophthalmic patients attend for surgery as a day case and, as a result, may be taught to perform their own first dressing at home since some of these patients may not necessarily be reviewed the next day.
General principles
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The eye should be cleaned only if necessary, e.g. when discharge is present.r
Staff should instruct the patient about the importance of hand washing before and after carrying out any procedure to the eye.r
Cartella shields should be washed with soap and water if necessary. The shield should be stored dry.Nursing Action Pre-procedure
1 Wash hands with soap and water.
2 Gather the drops, boxed tissues and alcohol gel.
3 Check patient identification against request card/patient’s notes us- ing patient name band/verbal confirmation from patient.
4 Confirm which eye the drops have been prescribed for.
5 Check drops/ointment against the prescription/PGD.
6 Check the correct strength (%) of the drops against prescription.
7 Check drops/ointment have not expired. Check clarity of drops, i.e.
the fluid in the bottle/minim must be clear and not discoloured.
8 Check packaging/bottle seal is intact when first used.
9 Explain the procedure, including any effects and side-effects 10 Identify any allergy to the topical medications.
11 Assess the patient’s medical and physical needs and level of under- standing, and take into account any cultural needs.
12 Obtain patient’s verbal consent and co-operation.
13 Examine the eye to be treated for the following:
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Redness not attributed to surgery or other known causes;r
Not sticky or painful;r
No deterioration of vision.14 Check no contact lens in-situ unless advised to the contrary by doctor.
15 The patient should be sitting comfortably, ideally in a private area.
Procedure 1 Wash hands.
2 Prepare the eye drops. NB: Before using any bottle of eye drops, shake the bottle first.
3 Gently hold down lower lid with clean tissues, using one hand.
4 Position hand holding the bottle/minims either gently on patient’s forehead or just at the lower fornix of the eye. The tip of the bottle/minim must not be in contact with the patient’s eyes or any- where else as this is the key part.
5 Instil only one drop into the lower fornix towards outer cantus or squeeze 5 mm of ointment along lower fornix towards outer cantus.
NB: Ointment must only be applied after prescribed eye drops.
6 Ask patient to gently close his eyes, counting slowly to 60. This helps to minimise systemic absorption.
7 Wipe away any excess drops/ointment, taking care not to wick away drops from the eye.
8 If further drops are prescribed, wait an interval of 3 minutes before carrying out the procedure. Apply alcogel to hands before instilling the next eye drop.
9 Make the patient comfortable; patients usually appreciate being given a tissue to dab their cheeks.
10 Dispose of clinical waste, cleanse hands and then clean the tray.
11 Document the procedure in the case notes and/or drop chart.
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PROCEDURE GUIDELINE
Post-operative eye-drop and eye-ointment instillation
This post-procedural pathway is applicable to inpatient day cases, certain outpatient departments and acute ophthalmic patients.
Equipment
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Plastic tray;r
Sterile eye pack;r
Alcowipes;r
Relevant eye drops/ointment;r
Prescription chart/PGD;r
Access to sink and soap dispenser to wash hands;r
Access to alcohol gel;r
Tissues;r
Sterile cotton wool (it is appropriate to clean the eye with this as, with most ocular surgery, the wound is on the globe and so linting should not interfere with wound healing, if there is a lid wound, use non-woven swabs);r
Two sets of non-sterile gloves;r
Apron.Nursing Action
1 Wash hands and prepare trolley and equipment in accordance with ANTT principles.
2 Check patient identification band against eye-drop medication chart.
3 Prepare patient for the procedure and obtain consent, giving an explanation of procedure including any side-effects of the medi- cation.
4 Assess the patient as before, including ensuring that the drops are not contra-indicated.
5 The patient should be seated.
6 Wash hands or use alcogel.
7 Prepare equipment and place in tray, identifying key parts to be protected during the procedure; in this case, the tips of bottles.
8 Check drops/ointment against the prescription.
9 Check the correct strength (%) of the drops against prescription.
10 Check drops/ointment have not expired. Check clarity of drops, i.e.
the fluid in the bottle/minim must be clear and not discoloured.
11 Check packaging/bottle seal is intact when first used.
12 Identify any current allergy to the topical medications.
13 Ensure that the drops are instilled into the correct eye.
14 Examine the eye to be treated for the following:
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Redness not attributed to surgery or other known causes;r
Not sticky or painful;r
No deterioration of vision;r
Allergies to the prescribed eye drops.... ...
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15 Check no contact lens in situ unless advised to the contrary by doctor.
16 Remove gloves, clean hands with alcohol gel and reapply non-sterile gloves.
17 Open packaging, ensuring key parts remain protected.NB: You may need to open additional packaging if the eye needs cleaning prior to drop instillation, in which case you should proceed to eye cleaning first.
18 Instruct patient to slightly tilt the head back and ask the patient to look up.NB: Before using any bottle of eye drops, shake the bottle first.
19 Instil only one drop into the lower fornix towards the outer cantus or squeeze 5 mm of ointment along the lower fornix towards the outer cantus.NB: Ointment must only be applied after prescribed eye drops.
20 Ask the patient to gently close his eyes, counting slowly to 60. This helps to minimise systemic absorption.
21 Wipe away any excess drops/ointment, taking care not to wick away drops from the eye
22 If further drops are prescribed, wait an interval of 3 minutes before carrying out the procedure. Apply alcogel to hands before instilling the next eye drop.
23 Make the patient comfortable; patients usually appreciate being given a tissue to dab their cheeks.
24 Dispose of clinical waste, cleanse hands and then clean the tray.
25 Cleanse hands and document the procedure in the case notes and/or drop chart.
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PROCEDURE GUIDELINE
Taking a conjunctival swab Equipment
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Plastic tray or trolley;r
Appropriate sterile culture medium and swab stick – different ones are required for bacteria, viruses andChlamydia;r
Completed request form (paper or electronic);r
Non-sterile gloves.Nursing Action
1 Identify patient, utilising local procedure for correct identification of patient.
2 Check request for the type of swab that is required e.g. bacterial or viral.
3 Wash hands.
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4 Clean aseptic surface for carrying out the procedure, i.e. tray or dressing trolley.
5 While tray or trolley is drying, gather equipment for procedure.
6 Wash or apply alcogel to hands, assemble equipment and put it in the tray.
7 If both eyes are to be swabbed, label the swabs ‘right’ and ‘left’.
8 Take assembled tray to patient.
9 Explain to the patient the procedure and obtain verbal consent.
10 Wash or apply alcogel to hands and wait for hands to dry before putting on gloves.
11 Remove the sterile swab from the container and ask patient to look up.
12 Swab firmly along lower fornix from nasal side outwards.
13 Place the stick in culture medium, remove gloves and wash your hands.
14 Ensure the swab is accurately and clearly labelled with patient’s name, hospital number, the correct eye, date of birth, date of re- quest of specimen.
15 Dispose of all waste appropriately.
16 Wash or apply alcogel to hands.
17 Clean tray and store dry.
18 Wash hands then document the procedure in the patient’s notes.
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PROCEDURE GUIDELINE
Epilation of lashes
Ingrowing eyelashes (trichiasis) may be removed by epilation to give temporary relief from symptoms caused by their constant irritation of the cornea and conjunctiva.
Equipment
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Plastic tray or trolley;r
Sterile epilation forceps;r
Tissues;r
Fluorescein minims;r
Slit lamp or good light magnification unit.Nursing Action
1 Wash hands and prepare trolley and gather equipment in accordance with ANTT principles.
2 Prepare equipment and place in tray, identifying key parts to be protected during procedure.
3 Check patient identification against request card/notes with patient.
4 Obtain patient’s consent and co-operation including explanation of procedure including any side-effects.
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5 Identify any current allergy to the topical medications.
6 Ensure the patient’s head is supported during the procedure.
7 Evert lid slightly – for lower lid ask the patient to look up; for upper lid ask the patient to look down.
8 Remove each of the offending lashes by gripping the lash at the lid margin with epilation forceps and pulling firmly in the direction of the hair growth.
9 Make the patient comfortable; patients usually appreciate being given a tissue to dab their cheeks.
10 Dispose of clinical waste, cleanse hands and then clean the tray.
11 Document the procedure in the case notes and/or drop chart.
The treatment must be repeated as often as required by the patient, e.g.
weekly, monthly or as necessary. Patients or carers with good vision may be able to perform epilation themselves at home.
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Electrolysis
Electrolysis is used to remove ingrowing lashes by means of a needle elec- trode applied to the lash follicle. It is a painful procedure, and the lid is first anaesthetised with a local anaesthetic injection.
PROCEDURE GUIDELINE
Cryotherapy
Cryotherapy can be used to remove lashes by applying liquid nitrogen to the offending lash follicle. This is performed by the doctor, but the nurse needs to prepare the patient.
Equipment
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Plastic tray or trolley;r
Local anaesthetic drops, e.g. proxymetacaine hydrochloride 0.5%(Ophthaine);
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Local anaesthetic injection, e.g. lignocaine hydrochloride 2%;r
2-ml syringe;r
Green and orange needles;r
Paraffin gauze;r
‘Shoe horn’;r
Lubricant (K-Y) jelly;r
Sterile cotton wool buds;r
Dressing towel;r
Tissues;r
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Sterile gloves;r
Liquid nitrogen (cryo) container.Nursing Action
1 Wash hands and prepare trolley and equipment in accordance with ANTT principles.
2 Check patient identification against request card/notes with patient.
3 Prepare patient for the procedure.
4 Assess the patient as before.
5 The patient should be lying in a recumbent position.
6 Prepare equipment and place in tray, identifying key parts to be protected during procedure.
7 Obtain patient’s consent and co-operation giving explanation of pro- cedure including any side-effects.
8 Check patient name-band against the case notes.
9 Identify any current allergy to the topical medications.
10 Instil prescribed local anaesthetic drops.
11 Prepare and administer local anaesthetic injection.
12 Insert ‘shoe horn’, well lubricated with jelly, into appropriate fornix.
13 Cover the patient’s head with sterile drape leaving appropriate eye exposed.
14 Fill cryo container with liquid nitrogen.
15 Put cotton wool buds into liquid nitrogen and pass to doctor or spe- cialist nurse when ready to assist with procedure.
16 The patient may open or close his eyes during the procedure.
17 Make the patient comfortable.
18 Dispose of clinical waste and clean hands then the trolley.
19 Wash hands and then complete documentation.
The patient should be warned that the lid(s) may become inflamed.
Cryotherapy is not used on patients with symblepharon.
Taping the lower lid to relieve entropion
As a temporary measure, the lower lid can be taped to relieve an en- tropion. A piece of hypoallergenic tape about 1.3–2.5 cm (0.25–1 inch) in length is applied just below the lower lid margin and secured on the cheek in such a way as to bring the lower lid into its normal position. Prior to using hypoallergenic tape for this procedure, it is important to ascertain from patient that they are not allergic to hypoallergenics. When the tape is in position on the lower cheek, ask the patient to close his eyes to ensure that the lower conjunctiva is not inadvertently exposed. If the lower conjunctiva is exposed, re-position the tape.
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PROCEDURE GUIDELINE
Testing for dry eyes using tear strips
The tear strip test is performed to discern if the eyes are dry. It is a test of the quantity not quality of the tear film.
Equipment
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Tear test strips;r
Timer or watch;r
Local anaesthetic;r
Patient case notes with request.Nursing Action
1 Wash hands and prepare trolley and equipment.
2 Confirm patient identification against request card/notes with the patient.
3 Prepare patient for the procedure obtaining consent.
4 The patient should be seated with the head well supported.
5 Prepare equipment and place in tray, identifying key parts and sites to be protected during the procedure.
6 Instil local anaesthetic drops if prescribed or as per PGD.
7 When performed without anaesthesia, this test measures the func- tion of the main lacrimal gland. The irritation from the Schrimer strips stimulates the secretory activity of the main lacrimal gland.
When this test is used in conjunction with a topical anaesthetic, it measures the function of the accessory lacrimal glands. Less than 5 mm in 5 minutes is considered abnormal.
8 Prepare strips in accordance with instructions on the packet.
9 Ask the patient to look up and insert the strip in accordance with the manufacturer’s instructions. It is helpful to mark the strip R and L as appropriate. The patient may open or close his eyes during the procedure.
10 Make the patient comfortable.
11 Dispose of clinical waste and clean hands then the trolley.
12 Wash hands and then complete documentation.
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PROCEDURE GUIDELINE
Syringing the naso-lacrimal ducts
This is performed to determine whether the lacrimal drainage apparatus is blocked or patent.
Equipment
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Plastic tray or trolley;r
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Tray or trolley with:r
One sterile 2-ml syringer
One disposable sterile lacrimal cannular
One sterile Nettleship dilatorr
One ampule of normal saliner
Local anaesthetic drops, e.g. pyroxymetacaine hydrochloride 0.5%(Ophthaine);
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Box of tissues;r
Bag for soiled tissues;r
Good light magnification unit;r
Patient’s case notes.Nursing Action
1 Wash hands and prepare trolley and equipment.
2 Check patient identification against request card/notes with patient.
3 Prepare the patient for the procedure, obtaining consent.
4 The patient should be seated with the head well supported.
5 Prepare equipment and place in tray, identifying key parts to be protected during procedure. Fill syringe with saline, attach cannula securely and ensure patency.
6 Stand behind or beside the patient, for ease of performance of this procedure.
7 Ask the patient to look upwards/outwards.
8 With the right hand, insert the Nettleship dilator into the punctum vertically 1–2 mm. Then gently turn it horizontally towards the nose and carefully rotate it a few times between the finger and thumb to dilate the first part of the lower canaliculus.
9 Remove the dilator and carefully insert the cannula following the direction of the canaliculus to a maximum of 4–5 mm (when fine disposable cannulas are used, it is not always necessary to dilate the punctum).
10 Inject the fluid slowly. Undue pressure must not be used.
11 Note whether the patient can taste the saline in the back of the throat or if there is any resistance and or regurgitation through the upper or lower punctum.
12 Make the patient comfortable.
13 Dispose of clinical waste and clean hands then the trolley.
14 Wash hands and then complete documentation.
Result of the procedure
The result will be one of several outcomes and should be recorded in the patient’s case notes:
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The saline may pass easily into the sac, through the nasolacrimal duct and trickle into the nasopharynx. The patient will taste the saline on the back of his tongue and can be told to swallow it. The result is reported as freely patent.... ...
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There may be partial patency with some regurgitation around the cannula.r
The saline may return through the lower punctum around the cannula.This shows an obstruction near the nasal end of the lower canaliculus.
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The saline may return through the upper punctum showing an obstruction in the sac or nasolacrimal duct.r
Mucopurulent discharge may return with the saline if the sac is infected. This should be reported.Occluding the upper punctum with a second Nettleship dilator is some- times performed if the saline has returned via the upper punctum. Syring- ing is repeated to try to remove the obstruction. In this case, an assistant is needed to hold the dilator in place. Syringing must not be performed by a nurse if there is an obvious swelling over the nasolacrimal sac, as in- fection renders the structures more prone to damage. The medical staff may use a set of lacrimal probes. These are used on infants in theatre, when the saline may be coloured with fluorescein to aid the detection of patency.
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PROCEDURE GUIDELINE
Subconjunctival injections
Small amounts of fluid (1.5–2 ml) can be injected under the bulbar con- junctiva. This form of treatment is not used as frequently as it used to be for eye infections. Here are some examples of drugs given by this method:
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Mydricaine no. 2 (Moorfields). This contains a cocktail of drugs, all having a mydriatic effect, in a 0.5-ml dose. It is used in uveitis to dilate the pupil when other methods have failed:r
Atropine sulphate 1.00 mgr
Procaine hydrochloride 6.00 mgr
Adrenaline 216 gr
Antibiotics. These are given subconjunctivally to treat or prevent intra-ocular infection:r
Cefuroxime 100 mg in 0.5 ml waterr
Gentamicin 10–20 mgr
Steroids. Given to suppress the inflammatory process in cases of uveitis. Steroids used include:r
Betamethasone 4 mg (quick-acting)r
Methylprednisolone 40 mg (long-acting)r
Local anaesthetics may be given in this manner.Equipment
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Tray or trolley;... ...
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Dressing pack;r
Receiver with:r
1-ml and/or 2-ml syringe(s)r
Dark green needler
Subconjunctival needler
Drugs for injectionr
Topical anaesthetic drops;r
Gauze squares;r
Pad;r
Bandage;r
Tape;r
Sachet of normal saline and alcohol wipe to clean the surface before opening;r
A good light source;r
Prescribed drops or ointment (if applicable);r
Prescription/case notes;r
Tissues.Nursing Action
1 Wash hands and prepare trolley and equipment.
2 Check patient identification against request card/notes with patient.
3 Prepare patient for the procedure and obtain consent.
4 Assess the patient as before.
5 Position the patient lying down or sitting in a chair with the head well supported.
6 Cleanse hands and prepare equipment and place in tray, identifying key parts to be protected during procedure.
7 Give prescribed analgesia (if required).
8 Commence instilling local anaesthetic drops as per prescription or PGD, e.g. G. amethocaine hydrochloride 2% or G. cocaine hydrochlo- ride 5%, one drop every 5 minutes over 25 minutes.
9 Apply alcogel to hands and put on non-sterile gloves.
10 Prepare drugs to be injected, identifying key parts to be protected during procedure. Check drugs with second nurse to ensure cor- rect drug(s) are administered. Put subconjunctival needle on syringe firmly and check patency.
11 Once the eye is anaesthetised, commence the procedure.
12 Open dressing pack in usual way.
13 Clean eye if necessary.
14 Hold lower lid down and ask patient to look up (an assistant may be required for this).
15 Hold the syringe horizontally, with the needle bevel uppermost and the fingers in the correct position to inject the drug, to ensure pro- cedure is carried out correctly.