Nursing assessment of eye part 3


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Nursing assessment of eye part 3

  1. 1. Nursing Assessment part III Gauri S. Shrestha, M.Optom, FIACLE
  2. 2. SYRINGING AND PROBING <ul><li>Syringing is performed to assess the epiphora as a result of a lacrimal pump failure. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To assess if lacrimal drainage system is patent. </li></ul></ul><ul><ul><li>To irrigate lacrimal drainage system to remove debris collected in to it. </li></ul></ul><ul><ul><li>To open partial occlusion of lacrimal drainage system. </li></ul></ul><ul><ul><li>To assess the area of obstruction. </li></ul></ul>
  3. 3. <ul><li>Assessment of patient </li></ul><ul><ul><li>Notice patient history of epiphora. </li></ul></ul><ul><ul><li>Notice distension/ swelling of lacrimal sac. </li></ul></ul><ul><ul><li>Assess regurgitation of fluid or discharge from the lacrimal sac upon pressing it. </li></ul></ul><ul><ul><li>Examine the eyeball and adnexa with a penlight to rule out any associated anomalies like redness, pain, discharge, and photophoia. </li></ul></ul><ul><li>Required instruments </li></ul><ul><ul><li>5ml syringe </li></ul></ul><ul><ul><li>Lacrimal cannula </li></ul></ul><ul><ul><li>Lacrimal probe or dilator </li></ul></ul><ul><ul><li>Sterile saline solution </li></ul></ul><ul><ul><li>topical anesthetic drop eg, proparacaine HCL </li></ul></ul><ul><ul><li>Sterile cotton balls. </li></ul></ul><ul><ul><li>Gloves if indicated </li></ul></ul>
  4. 4. <ul><li>Preparation of patient </li></ul><ul><ul><li>Explain the procedure to patient to gain the confidence of patient. </li></ul></ul><ul><ul><li>Place the patient in supine with the head slightly hyper extended </li></ul></ul><ul><ul><li>If the patient is child or uncooperative, restrain his or her movements to prevent any interference with the procedure. </li></ul></ul><ul><ul><li>Place a linen protector under the patient's head and shoulders to prevent wetting of bedding. </li></ul></ul><ul><ul><li>Occlude the ear with cotton ball to prevent saline to flow/drip into it during the procedure. </li></ul></ul>
  5. 6. Implementation <ul><li>Review the prescription for syringing </li></ul><ul><li>Wash hands and arrange supplies at bedside, and apply gloves. </li></ul><ul><li>Instill a drop of anesthetic on the inferior fornix </li></ul><ul><li>Use sterilized lacrimal dilator and probe. </li></ul><ul><li>Insert the dilator into the puncta vertically downwards up to 2mm whilst gently rotating clockwise and anticlockwise. </li></ul><ul><li>Pull the lower lid temporally . </li></ul><ul><li>Rotate the dilator horizontally and insert the dilator as required </li></ul>
  6. 7. Implementation <ul><li>Open the sterile packets of disposable syringe and cannula; connect them together. Remove the plunger and fill the syringe with sterile saline. </li></ul><ul><li>Re-insert the plunger, and with the syringe pointing upward, squeeze out any remaining air together with some saline. </li></ul><ul><li>Insert the cannula into the vertical canaliculus. </li></ul><ul><li>Pull the lower lid temporally </li></ul><ul><li>Rotate the syringe horizontally whilst inserting until a 'hard' or 'soft' stop is felt, then pull back about 2mm. </li></ul><ul><li>Press slowly and gently on the plunger. </li></ul><ul><li>Ask the patient to report when they taste saline or feel it in their nose </li></ul>
  7. 9. Implementation <ul><li>Saline refluxes from the inferior canaliculus. </li></ul><ul><li>Saline refluxes from the superior canaliculus. </li></ul><ul><li>Saline passes into the nose. </li></ul><ul><li>The saline may be purulent. </li></ul><ul><li>Make an attempt to close the superior punctum with a dilator and press plunger again. </li></ul><ul><li>Insert the probe into the canaliculus rotating it gently until hard or soft stop is felt. Mark the probe at the point of punctum. Release the probe and measure in measuring tape. </li></ul><ul><li>Remove and dispose of soiled materials. Remove gloves and perform hand hygiene. Sterilize lacrimal dilator and probe. </li></ul>
  8. 11. Findings <ul><li>Notice if patient feels pain during the procedure. </li></ul><ul><li>Notice type of discharge from the lacrimal sac. </li></ul><ul><li>Record and report the finding in patient's record form with detailed description about patency, obstruction, type of regurgitation, and area of obstruction. </li></ul>
  9. 12. SCHIRMER TEST <ul><li>Schirmer test is the test for the amount of tear film secretion. the patient with suspected dry eye or decreased tear secretion undergoes schirmer test. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To measure basal and reflex tear production. </li></ul></ul><ul><ul><li>To measure tear volume. </li></ul></ul><ul><li>Assessment of patient </li></ul><ul><ul><li>history of dryness, foreign body sensation, gritty sensation </li></ul></ul><ul><ul><li>unusual redness, photophobia, pain, lid swelling. </li></ul></ul><ul><ul><li>Unusual redness and ocular pain on prolong exposure to wind and heat. </li></ul></ul><ul><ul><li>Notice discharge and watering </li></ul></ul>
  10. 13. <ul><li>Instrumentation </li></ul><ul><ul><li>Anesthetic eye drop </li></ul></ul><ul><ul><li>Whatman no. 41 filter paper strip (5mm wide and 45mm long). </li></ul></ul><ul><ul><li>Cotton swab </li></ul></ul><ul><li>Preparation of patient </li></ul><ul><ul><li>Explain the procedure to patient to gain the confidence of patient. </li></ul></ul><ul><ul><li>A patient is sited in dimly lit room . </li></ul></ul>
  11. 14. Implementation <ul><li>Review the prescription for Schirmer test. </li></ul><ul><li>Wash hands arrange supplies at bedside, </li></ul><ul><li>Wipe out tears and discharge from the cul-de-sac with cotton swab. Switch off fans in room. </li></ul><ul><li>Filter paper strip is folded 5mm from the end. This fold is inserted gently over the lower palpebral conjunctiva at its lateral one third </li></ul><ul><li>The patient keeps eyes open, looks upward. Blink is permissible. </li></ul>
  12. 16. <ul><li>After 5 minutes the strips are removed and amount of wetting is measured from the folded end </li></ul><ul><li>The amount of wetting in the strip is read from the scale imprinted on it or from the measuring tape </li></ul><ul><li>If the strip is wetted before 5 minute, it is removed prematurely </li></ul><ul><li>For schirmer test II, Put one drop of praparacaine 0.5% eye drop under inferior conjunctival sac wait for 2 minutes. Repeat procedure 3 to 7. </li></ul><ul><li>Record and report the finding. </li></ul>
  13. 17. Findings <ul><li>Some patient may find difficult and irritating to keep filter paper strips. Reflex tear secretion could be intense, and larger volume of tear may secrete immediately. This finding results in false and high tear secretion. </li></ul><ul><li>Wetting of more than 10mm in the strip is considered tear secretion is adequate. Values less than 5mm on repeated testing indicates hyposecretion of basic tearing and considered dry eye. </li></ul>
  14. 18. ADMINISTERING TOPICAL EYE DROP AND EYE OINTMENT <ul><li>In ophthalmic practice majority of the patient receives eye drops and eye ointments. </li></ul><ul><li>The conjunctival sac is more appropriate site for medication instillation </li></ul><ul><li>Purpose </li></ul><ul><ul><li>Treat the eye conditions such as glaucoma, infection and inflammation, and post cataract surgery. </li></ul></ul><ul><ul><li>To prepare for eye surgery. </li></ul></ul><ul><ul><li>to anesthetize cornea for various reasons such as foreign body removal, surgery, etc, </li></ul></ul>
  15. 19. <ul><li>Assessment of Patient </li></ul><ul><ul><li>Assess condition of external eye structures such as redness, discharge, ulcer, edema </li></ul></ul><ul><ul><li>Assess patient's complaint of pain, irritation, blurring of vision, photophobia, etc </li></ul></ul><ul><ul><li>Assess patient's level of consciousness and ability to follow directions. This includes the patient's knowledge regarding drug therapy, desire to self-administer medication, and ability to manipulate and hold dropper </li></ul></ul><ul><li>Instrumentation </li></ul><ul><ul><li>Medication bottle with sterile eye dropper or ointment tube </li></ul></ul><ul><ul><li>Medical administration record </li></ul></ul><ul><ul><li>Cotton ball or tissue </li></ul></ul><ul><ul><li>Washbasin filled with warm water and wash cloth </li></ul></ul><ul><ul><li>Disposable gloves (optional) </li></ul></ul>
  16. 20. <ul><li>Patient's preparation </li></ul><ul><ul><li>Explain the procedure to patient. </li></ul></ul><ul><ul><li>Place the patient in supine or sit patient back in chair with the head slightly hyper extended and a pillow under the shoulders. </li></ul></ul><ul><ul><li>Place a linen protector over the patient's shoulders to prevent wetting of clothing and linen. </li></ul></ul>
  17. 21. Implementation <ul><li>Review the physician's medication order including patient's name, drug name, concentration, number of drops, time, and eye. </li></ul><ul><li>Review the information pertinent to medication including action, purpose, side effects, nursing implications. </li></ul><ul><li>Determine whether the patient has any known allergies to eye medications and any symptoms of visual alteration. </li></ul><ul><li>Wash hands and arrange supplies at bedside, and apply gloves. </li></ul>
  18. 22. <ul><li>Assess condition of external eye structures. If crusts or debris are present along with eyelid margins or inner canthus, gently wash away. Soak any crusts that are dried and difficult to remove by applying damp washcloth or cotton ball over eye for few minutes. Always wipe clean from inner to outer canthus. </li></ul><ul><li>Hold cotton ball or clean tissue on non-dominant hand on patient's cheekbone just below lower eyelid </li></ul><ul><li>With tissue or cotton resting below lower lid, gently press downward with thumb or forefinger against bony orbit </li></ul><ul><li>Ask patient to look up. </li></ul>
  19. 23. <ul><li>Instill eye drops while explaining steps to patient: </li></ul><ul><ul><li>With dominant hand resting on patient's forehead, hold filled medication eye dropper approximately 1 to 2cm above conjunctival sac. </li></ul></ul><ul><ul><li>Drop prescribed number of medication drops into conjunctival sac. </li></ul></ul><ul><ul><li>If patient blinks or closes eye or if drops land on outer margins, repeat the procedure. </li></ul></ul><ul><ul><li>When administering drugs apply gently pressure to patient's nasolacrimal duct for 30 to 60 seconds to prevent rapid drainage from the duct. </li></ul></ul><ul><li>After instilling drops, ask patient to close eye gently. </li></ul>
  20. 25. <ul><li>Instilling eye ointment: </li></ul><ul><ul><li>Hold ointment applicator above lid margin, apply thin stream of ointment evenly along inside edge of lower eyelid on conjunctiva from the centre outward. </li></ul></ul><ul><li>Ask patient to look down, close eye, and rub lid lightly in circular motion with cotton ball, if rubbing is not contraindicated. </li></ul>
  21. 26. <ul><li>If excessive medication is on eye lid, gently wipe it from inner to outer canthus </li></ul><ul><li>If patient had eye patch, apply clean one by placing it over affected eye so entire eye is covered. </li></ul><ul><li>Remove gloves, dispose of soiled supplies in proper receptacle and wash hands </li></ul>
  22. 27. Evaluation <ul><li>Note patient's response to instillation. </li></ul><ul><li>Ask any discomfort was felt. Ask patient to discuss drug's purpose, action, side effects, and techniques of administration. </li></ul><ul><li>Note if patient demonstrate self-administration of next dose. </li></ul><ul><li>At last, record drug, concentration, number of drops, and time of administration, and eye that received medication in medication record. </li></ul><ul><li>Report and record any undesirable side effects in eye. </li></ul>
  23. 28. Some notes <ul><li>Patient may notice burning, pain, irritation of eye. Some systemic medication causes alteration in heart rate and blood pressure, CNS depression and hallucination, acute attach of asthma, nausea and vomiting etc., </li></ul><ul><li>If eye drops are stored in refrigerator, medicine should be kept outside until rewarm to room temperature before administering. </li></ul><ul><li>Under nurse supervision, patient should be allowed to instill eye drop or ointment. </li></ul><ul><li>Patient who receives mydriatics or cycloplegic eye drops should not drive temporarily and should wear sunglasses to reduce photophobia. </li></ul>
  24. 29. ADMINISTERING AN EYE IRRIGATION <ul><li>Irrigation of eye refers to washing of the conjunctiva, cornea, and adnexa. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To remove foreign objects in the surface of eye. </li></ul></ul><ul><ul><li>To remove chemical substances such as acids, solvents, detergents, irritants (e.g., mace) and alkali (e.g., lye, cements, plasters) causing injury to the eye. </li></ul></ul><ul><ul><li>To clean eye in the inflammatory process conjunctiva and cornea. </li></ul></ul><ul><ul><li>To prepare for eye surgery. </li></ul></ul>
  25. 30. <ul><li>Assessment of patient </li></ul><ul><ul><li>Check patient’s name, bed number, and identification. </li></ul></ul><ul><ul><li>Check the physician’s instructions regarding type of solution and the temperature at which it is to be used. </li></ul></ul><ul><ul><li>Check the diagnosis and purpose of eye irrigation. </li></ul></ul><ul><ul><li>Assess patient’s ability and mental state to follow instructions. </li></ul></ul><ul><ul><li>Assess the need for any restraints. </li></ul></ul><ul><li>Required Instruments </li></ul><ul><li>Water proof pad Towel </li></ul><ul><li>Irrigation solution (0.9% sodium chloride) </li></ul><ul><li>Receiver Anesthetic drops </li></ul><ul><li>Gauze swabs Sterile dressing pack </li></ul><ul><li>pH check strips Nursing records </li></ul>
  26. 31. <ul><li>Patient preparation </li></ul><ul><ul><li>Explain the importance and sequences of procedure to patient to seek his confidence and co-operation. </li></ul></ul><ul><ul><li>Have patient sit or lie with head tilted toward the side of the affected eye. </li></ul></ul><ul><ul><li>Protect patient and bed with a waterproof pad. Head should be comfortably supported with chin almost horizontal. </li></ul></ul><ul><ul><li>If the patient is child or uncooperative, restrain his or her movements to prevent any interference with the procedure. </li></ul></ul>
  27. 33. Implementation <ul><li>Assemble equipment at patient’s bedside </li></ul><ul><li>Check the prescription for irrigating solution </li></ul><ul><li>Wash hand thoroughly </li></ul><ul><li>Wear sterile gloves in hand </li></ul><ul><li>Remove patient’s contact lenses immediately if present </li></ul><ul><li>Place water proof pad under face </li></ul><ul><li>Clean lids and lashes with cotton ball moistened with normal saline or solution ordered for irrigation. Wipe from inner canthus to outer canthus. </li></ul>
  28. 34. <ul><li>Do not press on the eye ball </li></ul><ul><li>Place curved basin at the cheek on the side of affected eye. If patient is sitting up, ask him or her to support basin. </li></ul><ul><li>Expose lower conjunctival sac and hold upper lid open with your nondominant hand. It is helpful to place an eyelid speculum and topical anesthetics in the eye before irrigation </li></ul><ul><li>Hold irrigator about 2.5 cm (1 inch) from eye. Direct flow solution from the inner (nasal corner) to the outer canthus along the conjunctival sac. </li></ul>
  29. 35. <ul><li>Irrigate the eye until solution is clear. This irrigation procedure should last at least for 30 minutes. Manual use of intravenous tubing connected to an irrigation solution facilitates the irrigation process. </li></ul><ul><li>Use only sufficient force to gently remove secretions from conjunctiva. </li></ul><ul><li>Have patient close eye periodically, particularly if burning or excessive blinking occurs </li></ul><ul><li>Litmus paper should be touched to the inferior cul-de-sac in case of chemical burn. The pH should be checked prior to irrigation and 20 minutes after irrigation </li></ul>
  30. 36. <ul><li>The conjunctival fornices should be swept with a moistened cotton-tipped applicator or glass rod for crystallized particles </li></ul><ul><li>Dry area with cotton balls or gauze sponge. Offer towel to patient if face and neck are wet </li></ul><ul><li>Examine the eye by instillation of Fluorescein. </li></ul><ul><li>Remove and dispose of soiled materials. Remove gloves and perform hand hygiene. </li></ul><ul><li>Document all the actions and observations in nursing record. </li></ul>
  31. 38. Note <ul><li>The volume of irrigation fluid required to reach neutral pH varies with the chemical and duration of the chemical exposure. </li></ul><ul><li>Work up should be done on time of injury, type of chemical patient exposed to. </li></ul><ul><li>The eyelids should be everted to search for foreign bodies. </li></ul><ul><li>Patient with corneal damage and patients whose symptoms do not resolve rapidly should be referred for urgent ophthalmologic assessment. </li></ul>
  32. 39. OCULAR PRESSURE PATCHING <ul><li>Pressure patching involves the use of sterile eye pads, therapeutic ophthalmic ointments, and adhesive tape to hold the superior lid in apposition to the globe and prevent blinking of the patched eye. </li></ul><ul><li>Purpose </li></ul><ul><ul><li>To facilitate normal healing of epithelial loss following foreign body removal. </li></ul></ul><ul><ul><li>Decrease patient discomfort due to blinking over wound. </li></ul></ul><ul><ul><li>To prevent secondary infection, ocular inflammation and recurrent erosion over the site of injury. </li></ul></ul>
  33. 40. <ul><li>Patient assessment </li></ul><ul><ul><li>Obtain a careful history of the incident of injury. </li></ul></ul><ul><ul><li>Measure best corrected visual acuity. </li></ul></ul><ul><ul><li>Perform biomicroscopic examination to rule out associated ocular abnormalities. </li></ul></ul><ul><ul><li>Assess patient's discomfort, watering, photophobia, and pain. </li></ul></ul><ul><li>Instrumentation </li></ul><ul><ul><li>Broad spectrum antibiotic ointment </li></ul></ul><ul><ul><li>Mydriatic/cycloplegic eye drop </li></ul></ul><ul><ul><li>Sterile cotton pads </li></ul></ul><ul><ul><li>Alcohol swabs </li></ul></ul><ul><ul><li>Hypoallergenic 1-in. wide adhesive tape </li></ul></ul>
  34. 41. <ul><li>Patient preparation </li></ul><ul><ul><li>Explain the procedure to patient to gain the confidence of patient. </li></ul></ul><ul><ul><li>Place the patient in supine or sit patient back in chair with the head relaxed. </li></ul></ul><ul><ul><li>If the patient is child or uncooperative, restrain his or her movements to prevent any interference with the procedure. </li></ul></ul>
  35. 43. Implementation <ul><li>Review the prescription for eye patching. </li></ul><ul><li>Wash hands and arrange supplies at bedside, and apply gloves. </li></ul><ul><li>Clean and remove oil from the patient's forehead and cheek area with cotton swab. </li></ul><ul><li>Instill a drop of mydriatic/cycloplegic eye drop according to physician recommendation. </li></ul><ul><li>Place a strip of antibiotic ophthalmic ointment in to the inferior cul-de-sac. </li></ul><ul><li>Instruct patient to close both eyes and relax. Place a single sterile eye pad over the closed eyelid. Instruct the patient to hold the patch in place over the lid. </li></ul>
  36. 44. <ul><li>Tear the six to eight 1-in. strips of adhesive tape. </li></ul><ul><li>Place a second sterile cotton eye pad over the first one. </li></ul><ul><li>Place a single piece of adhesive tape over both pads with one end stuck to the middle of the patient's forehead and the other to the cheek. </li></ul><ul><li>Apply additional strips of adhesive tape from the middle of the forehead, across the eye pads, and then firmly attached to the mandible or jaw. </li></ul><ul><li>After having successful placed the adhesive tape strips over the patch, ask the patient to blink. There should not be movement of lids under the patch. </li></ul><ul><li>Discharge patient with appropriate instruction. </li></ul>
  37. 45. Evaluation <ul><li>The pressure patch must prevent the superior lid from moving across the surface of the corneal epithelium. </li></ul><ul><li>If the patch doesn't perform this function, healing may be delayed. </li></ul>
  38. 46. Thank you