Nursing Procedure 5.2
Instills medications in mucous membranes of eye for various therapeutic effects, such as decreasing inflammatory and infectious processes and preventing drying of cornea, conjunctiva, and other delicate eye structures.
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
For older clients who have difficulty remembering, use a calendar to remind them when to administer eye medication.
Instilling eye medications involves touching the client's head, and in some cultures (e.g., Vietnamese), touching the head may be viewed as taking away the spirit. The nurse should consult the client, or parents if a child is involved, regarding what is culturally appropriate. Ask a family member to assist in positioning the client's head if necessary or desired.
As a basic standard, medication preparation, teaching, and administration are done by a licensed registered or vocational nurse. Some drugs may be given by registered nurses only. Policies vary by agency and state. A registered nurse should observe the client for untoward reactions if there are potential medication side effects. BE SURE TO NOTE SPECIFIC AGENCY POLICIES FOR A GIVEN ROUTE AND DRUG BEFORE DELEGATING ADMINISTRATION!
| Action | Rationale | |
|---|---|---|
| 1 | Perform hand hygiene and organize equipment. | Reduces microorganism transfer; promote efficiency |
| 2 | Prepare medication to be administered, adhering to the five rights of drug administration (see Nursing Procedure 5.1). Use barcode scanning, if available. | Promotes safe drug administration |
| 3 | Identify client by scanning or visually checking (if scanning unavailable) identification bracelet and by addressing client by name. | Verifies identity of client |
| 4 | Explain procedure and purpose of medication to client. | Reduces anxiety; promotes cooperation |
| 5 | Verify any client allergies. | Prevents allergic reactions and injury |
| 6 | Don gloves. | Prevents contamination of hands; reduces risk of infection transmission |
| 7 | Lower side rails, and position client in supine or sitting position, with forehead tilted back slightly. | Facilitates proper placement of medication |
| 8 | If drainage or excess tearing is noted around lower lashes and eyelids, wipe eye with cotton ball from the inner to outer aspect (if both eyes need to be wiped, use a separate cotton ball for each eye). | Removes excess secretions and debris to facilitate absorption of medication through mucous membranes; prevents cross-contamination |
| 9 | If using bottle with a dropper, squeeze top of medication dropper to aspirate solution into dropper tube. If using ointment, remove cap from container tube. | Prepares medication for administration |
| 10 | Holding dropper or ointment to be administered in dominant hand, place heel of dominant hand on client’s forehead (Fig. 5.2). | Stabilizes hand for administering eye medication; helps to prevent accidental injury to client’s eye |
| 11 | Using cotton ball, gently pull lower eyelid down. | Exposes lower conjunctival sac for placement of medication |
| 12 | Instruct client to look up toward forehead. | Eliminates corneal-reflex stimulation |
| 13 | Administer ordered number of drops (or quantity of ointment) into conjunctival sac of appropriate eye without letting dropper touch the client (Fig. 5.2); apply a thin line of ointment from inner to outer canthus without letting ointment tube tip touch the client, ending administration smoothly with a twisting motion. | Places medication in conjunctival sac for absorption without contaminating dropper or ointment tip |
| 14 | Remove hands and instruct client to close and roll eyes around, unless prohibited or unless client cannot do so. | Spreads medication evenly over eye |
| 15 | Remove excess medication and secretions from around eye with cotton balls. | Prevents local irritation and discomfort |
| 16 | Replace cap on medicine container. | Maintains medication sterility |
| 17 | Remove gloves and discard with soiled materials. | Reduces microorganism transfer |
| 18 | Perform hand hygiene. | Reduces microorganism transfer |
| 19 | If ointments or drops temporarily affect vision, instruct client not to move about until vision is clearer. | Prevents accidental injury |
| 20 | Raise side rails and place call light within reach. | Promotes safety; facilitates communication |
| 21 | Restore or discard all equipment appropriately. | Reduces microorganism transfer among clients; prepares equipment for future use |
| 22 | Document administration on medication record. | Provides legal record of medication administration; prevents accidental remedication |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
Transcultural