Administering an Eye Irrigation

Skill 5-16

Administering an Eye Irrigation

Eye irrigation is performed to remove secretions or foreign bodies or to cleanse and soothe the eye. In an emergency, eye irrigation can be used to remove chemicals or other substances that may burn or injure the eye. When irrigating one eye, take care that the overflowing irrigation fluid does not contaminate the other eye. Eye flush stations may be available in emergency departments to aid in irrigation of the eye; many work environments, such as a lab where chemicals are used, in which there is risk for accidental exposure also have eye flush stations as well.

Delegation Considerations

The administration of an eye irrigation is not delegated to nursing assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, the administration of an eye irrigation may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile irrigation solution as prescribed at room temperature (sterile water, normal saline solution, Ringer's lactate, clean water) (Gwenhure, 2020; Stevens, 2016)
Local anesthetic eye drops
Sterile irrigation set (sterile container and irrigating or bulb syringe) or intravenous infusion administration tubing, depending on circumstances and prescribed irrigant
Emesis basin or irrigation basin
Washcloth
Waterproof pad
Towel
Gloves
Face shield and splash guard
Additional PPE, as indicated

Assessment

Assess the appropriateness of the irrigation solution for the patient. Review the medical history and allergy, assessment, and laboratory data that may influence drug administration. Check the expiration date of the irrigant. Assess the patient's eyes for redness, erythema, edema, drainage, or tenderness. Assess the patient's knowledge of the procedure. If the patient has a knowledge deficit about the procedure, this may be an appropriate time to begin patient education. Assess the patient's ability to participate in the procedure. Verify patient name, dose, route, and time of administration.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Knowledge deficiency
Infection risk
Acute pain

Outcome Identification and Planning

The expected outcome to achieve is that the eye is cleansed successfully. Other outcomes that may be appropriate include the following: the patient verbalizes an understanding of the procedure and is able to participate, the patient's pain and discomfort are reduced/relieved, and the patient's eye remains free from additional injury.

Implementation

Action	Rationale
1. Gather equipment. Check each irrigation intervention prescribed against the original in the health record, depending on facility policy and the medication order system in place. Clarify any inconsistencies. Check the patient's health record for allergies.	The prescription is the legal record of prescribed medication interventions. This comparison helps to identify errors that may have occurred when orders were transcribed. Computer provider order-entry (CPOE) systems allow prescribers to send electronic medication prescriptions directly to the pharmacy located in a health care facility and to outpatient pharmacies.
2. Know the actions, special nursing considerations, purpose of administration, and potential adverse effects of the medications to be administered. Consider the appropriateness of the medication for this patient.	This knowledge aids the nurse in evaluating the therapeutic effect of the medication in relation to the patient's health status and can also be used to educate the patient about the medication.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Move the medication supply system to the outside of the patient's room or prepare for administration at the medication supply system in the medication area. Alternatively, access the medication administration supply system at or inside the patient's room.	Organization facilitates error-free administration and saves time.
5. Unlock the medication supply system or drawer. Enter the passcode into the computer and scan employee identification, if required.	Locking the medication supply system or drawer safeguards each patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use. Entering the passcode and scanning ID allows only authorized users into the computer system and identifies the user for documentation by the computer.
6. Prepare medications for one patient at a time.	This prevents errors in administration.
7. Read the eMAR/MAR and read the label when selecting the proper irrigation solution from the medication supply system or patient's medication drawer.	This is the first check of the medication label.
8. Read the label and compare the medication label with the eMAR/MAR. Check expiration dates and perform calculations, if necessary. Scan the bar code on the package, if required.	This is the second check of the label. Verify calculations with another nurse to ensure safety, if necessary.
9. Depending on facility policy, the third check of the label may occur at this point. If so, when all medications for one patient have been prepared, read the label and recheck the labels with the eMAR/MAR before taking the medications to the patient. However, many facilities require the third check to occur at the bedside, after identifying the patient.	This third check ensures accuracy and helps to prevent errors. Note: Many facilities require the third check to occur at the bedside, after identifying the patient and before administration.
10. Log out of and/or lock the medication supply system before leaving it.	Locking the medication supply system or drawer safeguards the patient's medication supply. Facility accrediting organizations require medication supply systems to be locked when not in use.
11. Transport medications to the patient's bedside carefully and keep the medications in sight at all times.	Careful handling and close observation prevent accidental or deliberate disarrangement of medications.
12. Ensure that the patient receives the medications at the correct time.	Check facility policy, which may allow for administration within a period of 30 minutes before or 30 minutes after the designated time.
13. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
14. Identify the patient. Compare the information with the eMAR/MAR. The patient should be identified using at least two of the following methods (The Joint Commission, 2021):	Identifying the patient ensures the right patient receives the medications and helps prevent errors. The patient's room number or physical location is not used as an identifier (The Joint Commission, 2021). Replace the identification band if it is missing or inaccurate in any way.
a. Check the name on the patient's identification band.	This requires a response from the patient, but illness and strange surroundings often cause patients to be confused.
b. Check the identification number on the patient's identification band.
c. Check the birth date on the patient's identification band.
d. Ask the patient to state their name and birth date, based on facility policy.
15. Close the door to the room or pull the bedside curtain.	This provides patient privacy.
16. Complete necessary assessments before administering medications. Check the patient's allergy bracelet, if present, or ask the patient about allergies. Explain the purpose and action of each medication to the patient.	Assessment is a prerequisite to administration of medications. Explanation provides rationale, increases knowledge, promotes patient engagement, and reduces anxiety.
17. Scan the patient's bar code on the identification band, if required (The Joint Commission, 2021).	This provides an additional check to ensure that the medication is given to the right patient.
18. Assemble equipment at the patient's bedside.	This provides for an organized approach to the task.
19. Based on facility policy, the third check of the medication label may occur at this point. If so, read the label and recheck the label with the eMAR/MAR before administering the medications to the patient.	Many facilities require the third check to occur at the bedside, after identifying the patient and before administration. If facility policy directs the third check at this time, this third check ensures accuracy and helps prevent errors.
20. Administer the local anesthetic eye drops to the affected eye(s) (Stevens, 2016).	Anesthetic eye drops can make the procedure less painful and uncomfortable (Gwenhure, 2020).
21. Have the patient sit or lie with their head tilted toward the side of the affected eye (Figure 1). Protect the patient and bed with a waterproof pad.	Gravity aids the flow of the solution away from the unaffected eye and from the inner canthus of the affected eye toward the outer canthus.
22. Put on gloves. Clean lids and lashes with a washcloth moistened with water or normal saline or the solution ordered for the irrigation, as indicated by the patient's condition. Wipe from the inner canthus toward outer canthus (Figure 2). Use a different corner of the washcloth with each wipe.	Gloves protect the nurse from contact with mucous membranes, body fluids, and contaminants. Materials lodged on lids or in lashes may be washed into the eye. Wiping from the inner to outer canthus protects the nasolacrimal duct and the other eye. Use of a different part of the washcloth prevents transmission of bacteria.
23. Put on a face shield/splash guard. Place the curved basin at the patient's cheek on the side of the affected eye to receive the irrigating solution (Figure 3). If the patient is able, ask them to support the basin.	The face shield/splash guard protects the nurse from contact with splashed body fluids and contaminants. Gravity aids the flow of the solution.
24. Fill the irrigation syringe with the prescribed fluid. Place your thumb near the margin of the lower eyelid immediately below eyelashes and two fingers above the eye. Apply pressure downward over the bony cheek prominence to expose the lower conjunctival sac as the lower lid is pulled down. Hold the upper lid open with your fingers (Figure 4).	The solution is directed only into the lower conjunctival sac because the cornea is sensitive and easily injured. This also prevents reflex blinking.
25. Hold the irrigation syringe (Figure 5) or tip of the IV tubing 3 to 4 cm but no more than 5 cm from the eye (Stevens, 2016). Tell the patient the irrigation is going to start. Direct the flow of the solution from the inner to outer canthus along the conjunctival sac.	This minimizes the risk for injury to the cornea. Directing the solution toward the outer canthus helps prevent the spread of contamination from the eye to the lacrimal sac, the lacrimal duct, and the nose. A distance of 3 to 4 cm and no more than 5 cm prevents damage to the eye from the force of fluid (Gwenhure, 2020; Stevens, 2016).
26. Ask the patient to move the eye in all directions, if possible, while the irrigation is maintained (Stevens, 2016). Irrigate until the solution is clear or all the solution has been used. Use only enough force to remove secretions gently from the conjunctiva. Avoid touching any part of the eye with the irrigating tip.	Directing solutions with force may cause injury to the tissues of the eye as well as to the conjunctiva. Touching the eye is uncomfortable for the patient and may cause damage to the cornea.
27. Pause the irrigation and have the patient close their eye periodically during the procedure.	Movement of the eye when the lids are closed helps to move secretions from the upper to the lower conjunctival sac.
28. Dry the periorbital area after irrigation with a gauze sponge. Offer a towel to the patient if their face and/or neck is wet.	Leaving the skin moist after irrigation is uncomfortable for the patient.
29. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position.	Removing gloves and performing hand hygiene prevents the spread of microorganisms. Assisting the patient to a position of comfort promotes patient comfort.
30. Remove the face shield and splash guard and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk of infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
31. Evaluate the patient's response to the medication within an appropriate time frame.	The patient needs to be evaluated for therapeutic and adverse effects from the medication.

Evaluation

The expected outcomes have been met when the eye was irrigated successfully, the patient has verbalized an understanding of the procedure and was able to participate, the patient's pain and discomfort were reduced/relieved, and the patient's eye has remained free from additional injury.

Documentation

Guidelines

Document the procedure, site, the type of solution and volume used, length of time irrigation performed, pre- and post-procedure assessments, characteristics of any drainage, and the patient's response to the treatment on the eMAR/MAR or record using the required format. If using a bar-code system, medication administration is automatically recorded when the bar code is scanned. PRN medications require documentation of the reason for administration. Prompt recording avoids the possibility of accidentally repeating the administration of the drug. If the drug was refused or omitted, record this in the appropriate area on the medication record and notify the health care team. This verifies the reason medication was omitted and ensures that that health care personnel providing care for the patient are aware of the occurrence.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient reports significant pain during the procedure: Stop the procedure and notify the health care team. Consult with the health care team regarding the need for an ophthalmology consult to check for any foreign objects, such as glass, before proceeding with irrigation.
Patient cannot keep the eye open during the procedure: You may need assistance to help the patient keep the eye open.

Special Considerations

For foreign body removal, a minute or so of irrigation should be sufficient to remove any foreign bodies (Stevens, 2016).
For severe acid or alkali burns, emergency irrigation should continue for at least 15 minutes, and 30 minutes is better (Stevens, 2016).
Ongoing assessment is an important part of nursing care to evaluate patient response to administered treatments and early detection of adverse drug reactions. If an adverse effect is suspected, notify the health care team. Provide additional intervention based on type of reaction and patient assessment.
In some instances where chemical contamination is suspected, the pH of the eye may need to be checked to facilitate treatment. When only one eye is contaminated, both eyes should be checked to use the noncontaminated eye as a control (Gwenhure, 2020).

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Skill 5-16