NUR 113: SKILL 21-4 INSTILLING EYE & EAR MEDICATIONS

SKILL 21-4: INSTILLING EYE & EAR MEDICATIONS-INTRODUCTION Common eye (ophthalmic) medications are in the form of drops and ointments, including over-the counter preparations such as artificial tears and vasoconstrictors (e.g., Visine and Murine). However, many patients receive prescribed ophthalmic drugs for eye conditions such as glaucoma, infection, and following cataract extraction. In addition, there is a third type of delivery system, the intraocular disk. Medications delivered by disk resemble a contact lens; but the disk is placed in the conjunctival sac, not on the cornea, and it remains in place for up to 1 week. The eye is the most sensitive organ to which you apply medications. The cornea is richly supplied with sensitive nerve fibers. Care must be taken to prevent instilling medication directly onto the cornea. The conjunctival sac is much less sensitive and thus a more appropriate site for medication instillation. Any patient receiving topical eye medications should learn correct self- administration of the medication, especially patients with glaucoma, who must often undergo life long medication administration for control for the disease.

assessment 1. Check accuracy and completeness of each medication administration record (MAR) with health care provider’s medication order. Check patient’s name, drug name and dosage route (eye{s} or ear{s}) and time for administration. 2. Review pertinent information related to medication, including action, purpose, normal dose and route, side effects, time of onset and peak action, and nursing implications. 3.Assess condition of external eye or ear structures (see chapter 6). This may be done just before drug instillation (if drainage is present, apply clean gloves).

ASSESSMENT – CONT’D 4. Determine whether patient has any symptoms of eye or ear discomfort or visual or hearing impairment. 5. Assess patient’s medical history, history of allergies (including latex), and medication history. 6. Assess patient’s level of consciousness (LOC) and ability to follow directions. 7. Assess patient’s knowledge regarding drug therapy and desire to self-administer medication. 8. Assess patient’s ability to manipulate and hold dropper or ocular disk.

PLANNING 1. Expected outcomes following completion of procedure: Patient experiences desired effect of medication Patient denies discomfort Patient experiences no side effects, and symptoms (e.g., irritation) are relieved. Patient is able to discuss information about medication and technique correctly. Patient demonstrates self-instillation of eye-drops. 2. Explain procedure to the patient Demonstrates learning Relieves anxiety and promotes patient participation.

IMPLEMENTATION 1. Prepare medications for instillation. Check label of medication against MAR 2 times. Preparations usually involves taking eye- drops/eardrops out of refrigerator and rewarming to room temperature before administering to patient. Check expiration date on container. 2. Take medication(s) to patient at correct time (see agency policy). Medications that require exact timing include stat, first-time or loading doses, and one time doses. Give time-critical scheduled medications (e.g., antibiotics, anticoagulants, insulin, anticonvulsants, immunosuppressive agents) at exact time ordered (no later than 30 minutes before or after scheduled dose). Give non-time-critical scheduled medications within a range of 1 or 2 hours of scheduled dose. During administration, apply six rights of medication administration: 6 RIGHTS OF MEDICATION ADMINISTRATION

Implementation – cont’d 3. Perform hand hygiene 4. Identify patient using two identifiers. 5. At patient’s bedside again compare MAR or computer printout with names of medications on medication labels and patient name. Ask patient if they have any allergies. 6. Discuss purpose of each medication, action, and possible adverse effects. Allow patient to ask any questions about the drugs. Patients who self-instill medications may be allowed to give drops under nurse’s supervision (check agency policy). Tell patients receiving eye-drops (mydriatics) that vision will be blurred temporarily and sensitivity to light may occur.

IMPLEMENTATION – CONT’D 7. INSTILL EYE MEDICATIONS: A. Apply clean gloves. Ask patient to lie supine or sit back in chair with head slightly hyperextended, looking up. B. If drainage or crusting is present along eyelid margins or inner canthus, gently wash away. Soak any dried crusts with warm, damp washcloth or cotton ball over eye for several minutes. Always wipe clean from inner to outer canthus. Remove gloves and perform hand hygiene. C. Explain there might be a temporary burning sensation from the drops – the corneas are highly sensitive. D. INSTILL EYEDROPS: 1. Apply clean gloves. Hold cotton ball or clean tissue in non-dominant hand on patient’s cheekbone just below lower eyelid. 2. With tissue or cotton resting below lower lid, gently press downward with thumb or forefinger against bony orbit, exposing conjunctival sac. Never press directly against patient’s eyeball.

CONJUNCTIVAL SAC

IMPLEMENTATION – CONT’D Instill Eye-drops – cont’d 3. Ask patient to look at the ceiling. Rest dominant hand on patient’s forehead; hold filled medication eyedropper approximately 1 to 2 cm (1/2 to ¼ inch) above conjunctival sac. 4. Drop prescribed number of drops into conjunctival sac. 5. If patient blinks or closes eye, causing drops to land on outer lid margins, repeat procedure. 6. When administering drops that may cause systemic effects, apply gentle pressure to patient’s nasolacrimal duct with clean tissue for 30 to 60 seconds over each eye, one at a time. Avoid pressure directly against patient’s eyeball. 7. After instilling drops, ask patient to close eyes gently.

IMPLEMENTATION – CONT’D E. Instill Eye Ointment: 1. Holding applicator above lower lid margin, apply thin ribbon of ointment evenly along inner edge of lower eyelid on conjunctiva from inner to outer canthus. 2. Have patient close eye and rub lid lightly in circular motion with cotton ball if not contraindicated. Avoid placing pressure directly against patient’s eyeball. 3. If excess medication is on eyelid, gently wipe it from inner to outer canthus. 4. If patient needs an eye patch, apply clean one by placing it over affected eye so entire eye is covered. Tape securely without applying pressure to the eye A clean eye patch reduces the risk of infection.

IMPLEMENTATION – CONT’D F. Apply Intraocular Disk: 1. Open package containing disk. Gently press your fingertip against disk so it adheres to your finger. It may be necessary to moisten gloved finger with sterile saline. Position convex side of disk on your fingertip. 2. With your other hand gently pull patient’s lower eyelid away from eye. Ask patient to look up. 3. Place disk in conjunctival sac so it floats on sclera between iris and lower eyelid. 4. Pull patient’s lower eyelid out and over disk. You should not be able to see disk at this time. Repeat if you can see the disk.

IMPLEMENTATION – CONT’D 8. After administering eye medications remove and dispose of gloves and soiled supplies, perform hand hygiene. 9. Remove intraocular disk. A. Perform hand hygiene and apply clean gloves. Gently pull downward on lower eyelid using your non- dominant hand. B. Using forefinger and thumb of your dominant hand, pinch disk and lift it out of patient’s eye. C. Remove and dispose of gloves, perform hand hygiene.

IMPLEMENTATON – CONT’D 10. Instill Eardrops: A. Perform hand hygiene. Apply clean gloves (only if drainage is present). B. Warm medication to room temperature by running war water over bottle (make sure not to damage label or allow water to enter bottle). C. Position patient on side (if not contraindicated) with ear to be treated facing up, or patient may sit in chair or at bedside. Stabilize patient’s head with his or her own hand. D. Straighten ear can by pulling pina up and back to 10 o’clock position (adult or child older than age 3) or down and back to 6 to 9 o’clock position (child under 3).

IMPLEMENTATION – CONT’D E. If cerumen or drainage occludes outermost portion of ear canal, wipe out gently with cotton- tipped applicator. Take care not to force cerumen into canal. F. Instill prescribed drops holding dropper 1 cm (1/2 inch) above ear canal. G. Ask patient to remain in side-lying position for a few minutes. Apply gentle message or pressure to tragus of ear with finger. H. If ordered, gently insert portion of cotton ball into outermost part of canal. Do not press cotton into canal. I. Remove cotton after 15 minutes. Help patient to comfortable position after drops are absorbed. J. Dispose of soiled supplies in proper receptacle, remove and dispose of gloves, and perform hand hygiene.

EVALUATION 1. Observe response to medication by assessing visual or hearing changes, asking if symptoms are relieved, and noting any side effects or discomfort felt. 2. Ask patient to discuss purpose of drug, action, side effects, and technique of administration. 3. Have patient or family caregiver demonstrate self-administration of next dose.

Unexpected outcomes 1. Patient complains of burning or pain or experiences local side effects (e.g., headache, bloodshot eyes, local eye irritation). Drug concentration and patient’s sensitivity both influence chances of side effects developing. 2. Patient experiences systemic effects from drops (e.g., increased heart rate and blood pressure from epinephrine, decreased heart rate and blood pressure from timolol). 3. Ear canal remains inflamed, swollen, tender to palpation. Drainage is present. 4. Patient’s hearing acuity continues to be reduced. 5. Patient is unable to explain drug information or steps for taking eye-drops / eardrops and/or has trouble manipulating dropper

RECORDING & REPORTING Record drug, concentration, dose or strength, number of drops, site of application (left, right, or both eye/ear), and time of administration on MAR immediately after administration, not before. Include initials or signature. Record patient teaching and validation of understanding in nurse’s notes and EHR. Record objective data related to tissues involved (e.g., redness, drainage, irritation), any subjective data (e.g., pain, itching, altered vision or hearing), and patient’s response to medications. Note any side effects experienced in nurses’ notes and EHR. Report adverse effects/patient response and/or withheld drugs to nurse in charge or health care provider. Depending on medication, immediate health care provider notification may be required.

END OF SKILL FOR THE EAR-DROP VIDEO: FOR THE EYE-DROP VIDEO: The book has provided videos for you and the links are as follows: FOR THE EAR-DROP VIDEO: http://booksite.Elsevier.com/Perry-Potter/ClinicalSkills/video26.php Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques, 8e-21.5 Administering Ear Drops. FOR THE EYE-DROP VIDEO: http://booksite.Elsevier.com/Perry-Potter/ClinicalSkills/video25.php Elsevier: Perry-Potter: Clinical Nursing Skills and Techniques. 8e-21.4 Administering Eye Medications.