PROCEDURES FOR EYE CARE

Transcription

1 m PROCEDURES FOR EYE CARE 1. CLEANSING OF THE EYE 2. INSTILLATION OF EYE DROPS/OINTMENTS 3. CARE OF AN EYE PROSTHESIS 4. EYE IRRIGATION FOR ADULTS AND CHILDREN (WALK-IN CENTRES ONLY) Issue History Issue Version One Purpose of Issue/Description of Change Planned Review Date To promote safe and effective care for patients requiring eye care 2016 Named Responsible Officer:- Approved by Date Quality & Governance Service Section :- Ears, Nose, Throat and Eyes CP48 Quality, Patient Experience and Risk Group Target Audience Community Nursing Walk-in Centres Leasowe Primary Care Centre All Day Health Centre September 2013 UNLESS THIS VERSION HAS BEEN TAKEN DIRECTLY FROM TRUST WEB SITE THERE IS NO ASSURANCE THIS IS THE CORRECT VERSION 1

2 CONTROL RECORD Title Purpose Author PROCEDURE FOR EYE CARE To promote safe and effective care for patients requiring eye care Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Document Librarian Groups consulted with:- Mary Lyden Rodgers/Judith Roberts QGS Clinical Policies and Procedures Group Infection Control Approved 26 th September 2013 Date approved by Quality, Patient Experience and Risk Group 25 th September 2013 Method of Distribution Intranet:- Staff Zone Archived Date Location:- Datix Librarian Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments One Quality & Governance Service N Status New / Revised / Trust Change 2

3 PROCEDURES EYE CARE INTRODUCTION Eye care is the practice of assessing, cleaning or irrigating the eye and /or the instillation of prescribed ocular preparations. TARGET GROUP These procedures will be performed by Registered Nurses, Assistant Practitioners and Nursing Auxiliaries working under the instruction of a Registered Nurse. Care delegated requires monthly supervision as agreed with line manager. TRAINING All staff in the Trust are required to comply with mandatory training as specified in the Trusts Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures. CONTRAINDICATIONS Special care is required in prescribing eye preparations for contact lens users. Some medications and preservatives in eye preparations can accumulate in hydrogel lenses and may induce toxic reactions. Therefore, unless medically indicated, the lenses should be removed before instillation of the eye preparation and not worn during the period of treatment. Alternatively, unpreserved drops can be used. Eye drops may, however, be instilled while patients are wearing rigid corneal contact lenses. Ointment preparations should never be used in conjunction with contact lens wear; oily eye drops should also be avoided. (BNF 2013) CONSENT Valid consent must be given voluntarily by an appropriately informed person prior to any procedure or intervention. No one can give consent on behalf of another adult which is deemed to lack capacity regardless of whether the impairment is temporary or permanent. However such patients can be treated if it is deemed to be within their best interest. This must be recorded within the patient s health records with a clear rationale stated at all times. Refer to Trust Patient Information and Consent Policy for further information and guidance or the Clinical Protocol for Assessing Mental Capacity and Best Interests. 3

4 1. PROCEDURE FOR THE CLEANSING OF THE EYE EQUIPMENT If cleansing both eyes, each eye should be treated as a separate procedure. Always treat the uninfected or inflamed eye FIRST to reduce the risk of cross infection. Single use lint-free sterile gauze Single use sterile saline Clean tray (POUDS tray can be used) Trust Approved cleaning wipe Single use gallipot Single use disposable apron Single use disposable non sterile gloves Patients Health Record Trust Approved cleaning wipe ACTION Verbally confirm the identity of the patient by asking for full name and date of birth. If client unable to confirm, check identity with family/carer Introduce yourself as a staff member and any colleagues involved at the contact. Wear identity badge which includes name and status and designation Ensure verbal consent for the presence of any other third party is obtained Explain procedure to patient including risks and benefits and gain valid consent. Obtain verbal consent. If patient is a child, a legal guardian/parent with parental responsibility should be present to consent. If patient lacks capacity to consent refer to Trust policy for gaining patient consent /best interests Collect and check all equipment; check expiry dates. Patient to be encouraged to sit / lie with head well supported in a position they find comfortable Ensure light source is adequate Clean tray using Trust approved cleaning wipe and place all equipment onto tray Decontaminate hands prior to the procedure RATIONALE To avoid mistaken identity To promote mutual respect and put patient at their ease For patients to know who they are seeing and to promote mutual respect Students for example, as the client has the choice to refuse To ensure patient understands procedure and relevant risks. The patient should be able to make an informed choice about their care through shared decision making. In order to obtain informed valid consent/treat in best interests To prevent delays, reduce risk and enable full concentration on the procedure To facilitate ease and accuracy of procedure To facilitate ease and accuracy of procedure To create clean work area, promote asepsis and prevent contamination of key parts To reduce the risk of transfer of transient microorganisms on the healthcare workers hands 4

5 ACTION Apply single use disposable apron Apply single use disposable non sterile gloves Always bathe the lids with the eyes closed first Lower Lid Using a sterile gauze swab moistened slightly with sterile saline ask the patient to look up and gently swab the lower lid from the nasal corner outwards once only. Ensure the edge of the swab is not above the lower lid margin to avoid touching the cornea Use a new single use swab for each wipe until all discharge has been removed Upper Lid Using a sterile gauze swab moistened slightly with saline, gently swab the upper lid by gently lifting the eye lid margin and asking the patient to look down from the nasal corner outwards once only. Avoid touching the corner Use a new single use swab for each wipe until all discharge has been removed On completion of procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy Decontaminate hands following removal of PPE If signs of infection or inflammation are noted, inform General Practitioner Ensure patient / client is comfortable following procedure Document all actions and observations in nursing records RATIONALE To protect clothing or uniform from contamination and potential transfer of microorganisms To protect hands from contamination with organic matter and transfer of micro-organisms To reduce the risk of damaging the cornea Reduces the risk of swabbing discharge into the lachrymal ducts or into the other eye To reduce the risk of damaging the cornea Reduces the risk of swabbing discharge into the lachrymal ducts or into the other eye Reduces the risk of damage to the cornea Reduces the risk of cross infection To reduce the risk of damaging the cornea Facilitates access to the upper eyelid Reduces the risk of swabbing discharge into the lachrymal ducts or into the other eye Reduces the risk of damage to the cornea Reduces the risk of cross infection To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under the gloves and possible contamination following removal of PPE. Medical treatment may be required Maintain privacy and dignity To monitor trends and fluctuations. Ensure compliance with Wirral Community Trust record keeping policies 5

6 2. PROCEDURE FOR THE INSTILLATION OF EYE DROPS / EYE OINTMENTS Where both eyes may require treatment, each eye must be treated separately. If infection is present, there should ideally be two containers of medication one for each eye labelled L (left) and R (right) to prevent cross contamination. If there is only one, the least affected eye should be treated first to minimise the likelihood of transfer of infection from one eye to the other. If more than one eye preparation is to be inserted into the eye there needs to be an interval of at least 5 minutes between the two preparations (BNF, March 2013) EQUIPMENT Single patient use only, prescribed eye drops / ointment Clean tray (POUDS tray can be used) Trust Approved cleaning wipe Single use only gallipot Single use disposable apron Single use disposable non sterile gloves Patients Health Record Patient Medication Administration Chart (PMAC) if applicable Record of administration of prescribed eye treatments if applicable Patients health record and community nursing care plan for Administration of Eye Drops ACTION Verbally confirm the identity of the patient by asking for full name and date of birth. If client unable to confirm, check identity with family/carer. Introduce yourself as a staff member and any colleagues involved at the contact. RATIONALE Ensure positive identification of the patient To promote mutual respect and put patient at their ease Wear identity badge which includes name and status and designation Ensure verbal consent for the presence of any other third party is obtained. Explain procedure to patient including risks and benefits and gain informed consent Obtain verbal consent. If patient is a child, a legal guardian/parent with parental responsibility should be present to consent. If patient lacks capacity to consent refer to Trust policy for gaining patient consent /best interests For patients to know who they are seeing and to promote mutual respect Students for example; as the client has the choice to refuse. To ensure patient understand procedure and relevant risks. The patient should be able to make an informed choice about their care through shared decision making. In order to obtain informed valid consent/treat in best interests Check patient is not allergic to any of the ingredients in the prescribed eye products Reduce risk of allergic reactions 6

7 Explain the benefits and potential side effects of the medication to inform patient that some eye medication may cause side effects such as blurred vision and difficulty in focussing. Check that patient has not already received eye drops/ointment by asking patient and check in patient s health record. Collect and check all equipment and check and document expiry dates Check the Patients Medication Administration Chart (PMAC) for the following: all the details on the pharmacy label match the PMAC, including: correct medicine name, form and strength and batch number/expiry date Correct patient name, date, time and frequency of administration. which eye the medication is prescribed for (Left, right or both) PMAC must be re written at least six monthly Check: Clearly written PMAC, unambiguous Manufacturer s expiry date of the medication. Once opened, eye products usually must be discarded after 28 days. Refer to manufacturer s instructions for details or pharmacy label and storage instructions Document on label the date of opening Discard expired medication and document in notes Close doors / curtains where appropriate If the eyelid needs to be cleansed prior to administration of the drops, follow Nursing Procedure for cleansing of the eye. Patient to be encouraged to sit / lie with head tilted backwards and well supported Ensure light source is adequate Gain informed and understood consent to reduce the risk of accidents / falls To prevent patient receiving eye preparation twice and prevent potential harm To prevent delays, reduce risk and enable full concentration on the procedure To minimise the potential for drug errors and reduce risk Use relevant PGD as relevant to service Clear instruction for the administration of medication is essential report any detected errors to the line manager and complete a DATIX incident form To reduce risk and medication error. Medication outside its expiry date is no longer pharmacologically efficacious and may cause harm if administered. Some eye preparations require specific storage temperatures Once opened there is a potential for contamination Maintain privacy and dignity Follow Trust procedure For ease and accuracy of administration For ease and accuracy of administration 7

8 Clean tray using Trust approved cleaning wipe and place all equipment on to tray Decontaminate hands prior to procedure. Apply single use disposable apron Apply single use disposable non sterile gloves To create clean work area, promote asepsis and prevent contamination of key parts Reduce the risk of transfer of transient organisms on the healthcare workers hands transferring to the patient To protect clothing or uniform from contamination and potential transfer of microorganisms To protect hands from contamination with organic matter and transfer of micro-organisms Eye Drops Gently pull down the lower eyelid and ask the patient to look upwards Using ANTT instil the prescribed number of drops into the lower fornix Ask patient to keep eye closed for as long as possible, preferably 1-2 minutes Dab away excess medication with gauze Eye Ointment Hold the nozzle of the tube approximately 2.5cm above the eye To ensure the lower fornix is exposed to allow for administration of the drop Administration in the lower fornix minimises the risk of corneal abrasion. To ensure adequate drug absorption Prevent excess medication irritating surrounding skin Reduce the risk of cross infection, contamination of the tube and trauma to the eye Using ANTT apply approximately 2.5 cm line of ointment to the inner edge of the lower lid from the nasal corner outwards Encourage patient to close eye immediately after administration of medication Dab away excess medication with gauze Ensure patient / client is comfortable following procedure On completion of procedure remove and dispose of Personal Protective Equipment (PPE) to comply with waste management policy To ensure adequate drug absorption Prevent excess medication irritating surrounding skin Maintain privacy and dignity To prevent cross infection and environmental contamination Decontaminate hands following removal of PPE To remove any accumulation of transient and resident skin flora that may have built up under the gloves and possible contamination following removal of PPE If signs of infection or inflammation are noted, inform General Practitioner Medical treatment may be required 8

9 Document all actions in nursing records including the following: Consent Date Time Dose Medication Administration site Expiry date Batch number Print, sign and note designation of staff member for all entries made If medication NOT given document and explain reasoning Ensure compliance with Wirral Community Trust health records policy and procedures To comply with Wirral Community Trust policy If medication is not given the rationale must be recorded for effective communication of patients care within the community nursing team and/or multi-disciplinary team 3. PROCEDURE FOR THE CARE OF AN EYE PROSTHESIS EQUIPMENT Normal sterile saline Clean tray (POUDS tray can be used) Single use Lint-free swabs Single use gallipot (single use only) Single use disposable apron Single use disposable non sterile gloves Extractor (if available) Mirror (for promoting patient self-care) Patients Health Record and community nursing care plan ACTION Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer. Introduce yourself as a staff member and any colleagues involved at the contact RATIONALE To avoid mistaken identity. To promote mutual respect and put client at their ease Wear identity badge which includes name, status and designation Ensure verbal consent for the presence of any other third party is obtained For patients to know who they are seeing and to promote mutual respect Students for example, as the client has the choice to refuse 9

10 Explain procedure to patient including risks and benefits and gain valid consent. Obtain verbal consent. If patient is a child, a legal guardian/parent with parental responsibility should be present to consent. If patient lacks capacity to consent refer to Trust policy for gaining patient consent /best interests Collect and check all equipment including expiry dates Clean tray using Trust approved cleaning wipe and place all equipment onto tray Patient to be encouraged to sit / lie with head well supported in a position they find comfortable Ensure light source is adequate Decontaminate hands prior to procedure. Apply single use disposable apron Apply single use disposable non sterile gloves Removal of Prosthesis Using the dominant hand, gently pull the eyelid downwards and exert slight pressure below the eyelid to overcome the suction. If available an extractor may be used to gently lever prosthesis out of eye socket Cleanse the shell in sterile saline If mucous discharge is present, follow nursing procedure for cleansing the eye If signs of infection or inflammation are noted, inform General Practitioner Insertion of Prosthesis Hold the prosthesis between the thumb and index finger the correct way round with the pointed side towards the nose With the other hand, lift the upper eyelid Insert the upper part of the prosthesis gently under the upper eyelid and into the socket. Gently lower the finger holding the eyelid down onto the prosthesis and hold in place To ensure patient understand procedure and relevant risks. The patient should be able to make an informed choice about their care through shared decision making. In order to obtain informed valid consent/ treat in best interests To prevent delays, risks and enable full concentration on the procedure To create clean work area, promote asepsis and prevent contamination of key parts To facilitate ease and accuracy of procedure. To promote privacy and dignity. To facilitate ease and accuracy of procedure To reduce the risk of transient microorganisms on the healthcare workers hands. To protect clothing or uniform from contamination and potential transfer of micro organisms To protect hands from contamination with organic matter and transfer of microorganisms Enabling the safe removal of the prosthesis and reduce patient discomfort To ease removal of prosthesis Reduce risk of infection Patient comfort Reduce risk of infection Medical treatment may be required Follow up referral to determine outcome if required To ensure correct insertion and reduce the risk of trauma To improve access to the eye socket To ensure correct insertion To prevent the prosthesis falling out of the socket 10

11 Pull down the lower eyelid to allow the inferior aspect of the prosthesis to slide behind the lower lid On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE. Ensure patient / client is comfortable following procedure Document in nursing records :- all actions and observations consent To ensure correct insertion To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE Maintain privacy and dignity Ensure compliance with Wirral Community Trust record keeping policies 4. PROCEDURE FOR EYE IRRIGATION Eye irrigation should only be performed following assessment by a clinician. This procedure should NOT be used for eyes contaminated with C/S gas (tear gas) (2-Chlorobenzalmalononitrile) Equipment Required Waterproof cape and towel Normal sterile saline/ 0.9% sodium chloride (one litre plus) for irrigation Receiver Administration set (if required) Anaesthetic drops Single use Lint-free swabs Single use disposable non-sterile gloves Single use disposable apron Single use sterile dressing pack or POUDS tray PH check strips (specific eye testing strips) Nursing records Relevant Patient Group Direction Trust approved cleaning wipe ACTION Verbally confirm the identity of the patient by asking for their full name and date of birth. If client unable to confirm, check identity with family/carer. If the patient is a Child, a Legal Guardian/Parent should be present to consent and may assist by holding child during procedure. Two nurses may be required for eye irrigation. RATIONALE To ensure positive identification of the patient To allow the patient to make an informed choice about their care through shared decision making and to gain co-operation Patient will be unable to hold the eyelids themselves once irrigation commences 11

12 Introduce yourself as a staff member and any colleagues involved at the contact Wear identity badge which includes name status and designation Ensure verbal consent for the presence of any other third party is obtained To promote mutual respect and put client at their ease For patients to know who they are seeing and to promote mutual respect Students for example, as the client has the choice to refuse Explain the procedure to patient including risks and benefits and gain valid verbal consent, which needs to be documented in the patient records. Patient /Parental Guardian consent must be obtained prior to procedure. If patient lacks capacity to consent refer to Trust policy for gaining patient consent /best interests In order for the patient/parental guardian to understand the procedure and to gain patient s informed consent ensuring patient understands procedure and relevant risks In order to obtain informed valid consent/ treat in best interests Establish patient has no known allergies When patient gives history of exposure to agents containing alkali or acid immediate irrigation should precede full examination IF A CHEMICAL INJURY Identify chemical and consult with Toxbase a National Poisons database via NHS Direct or 111 Decontaminate hands. Apply towel and cape Clean tray using Trust approved cleaning wipe or if indicated open sterile dressing pack onto a clean area, place all sterile single use equipment required within aseptic field. Apply single use disposable apron. Apply single use disposable non-sterile gloves To reduce risk of allergic reaction To reduce damage to anterior segment; the amount of damage is related to the duration of the exposure To assess level of chemical risk The National Poisons Information Service (Public Health England) hosts the Toxbase website (available to UK National Health Service registered users) To reduce the risk of transfer of transient microorganisms on the healthcare workers hands To protect the patient s clothing To create clean work area, promote or ensure asepsis and prevent contamination of key parts. To protect hands from contamination with organic matter and transfer of microorganisms To facilitate irrigation and prevent corneal damage Remove contact lens (immediately if worn) To facilitate irrigation and prevent corneal damage Examine eye for corneal damage by installation of Fluorescein as per Patient Group Direction To detect corneal damage 12

13 Check ph (a measure of the hydrogen ion concentration) of the eye prior to treatment using specific eye testing strips for chemical injury ph testing should not delay commencement of irrigation (This is not required for foreign bodies) To determine if an acidic or alkaline corrosive substance is present. A ph above 8.0 or below 6 may indicate that an acidic or corrosive substance is still present in the eye. (An acceptable ph value of the eye is 6.5 8) (NSW DOH, 2009) Prepare the irrigation fluid, check that it is at room temperature/tepid Using ANTT instil anaesthetic drop (if required) as per Patient Group Direction Assist the patient into an appropriate position: Head comfortably supported with chin almost horizontal Head inclined to the side of the eye to be treated Remove any discharge from the eye by cleansing the eye socket Ask the patient to hold the receiver against the cheek, below the eye being treated Do not press on the eyeball Inform the patient that irrigation is about to start and pour a little of the fluid onto the cheek Direct the flow of irrigation fluid from the nasal corner Ask the patient to look up, down and to either side whilst irrigating Evert the eyelids when irrigating and ensure there is a constant flow of irrigation fluid Check ph after 20 minutes of irrigation using specific eye testing strips for chemical injury, Irrigation should be continued until the conjunctival sac ph is neutral (ph6.5 ph8) Retest after 20 minutes and use further irrigation if necessary Patients with: corneal damage patients whose symptoms do not resolve rapidly patients who have been exposed to strong acids or alkalis Should be referred for urgent ophthalmologic assessment [same day] if not available arrange immediate transfer to Accident and Emergency Department To reduce discomfort. Tepid fluid will be more comfortable for the patient To reduce discomfort and aid assessment To reduce discomfort To prevent discharge from running across cheek To collect fluid running from the eye To avoid causing unnecessary discomfort To prepare the patient and to make them aware of the sensation and temperature of the irrigation fluid To wash away any secretions To ensure the whole eye is irrigated To ensure complete removal of any foreign body A ph above 8.0 or below 7.4 may indicate that an acidic or corrosive substance is still present in the eye To ensure emergency Ophthalmic assessment of severe eye injury 13

14 Ask the patient to close the eye and dry lid with a gauze swab Remove receiver and dry patient s cheek On completion of procedure remove and dispose of PPE to comply with waste management policy Decontaminate hands following removal of PPE Document all actions and observations (including consent and patient perceptions) in nursing records To promote patient s comfort To promote patient s comfort To prevent cross infection and environmental contamination To remove any accumulation of transient and resident skin flora that may have built up under gloves and possible contamination following removal of PPE Ensure compliance with Wirral Community Trust Health Records Policy INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s Datix incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. REFERRALS Any referrals to health professionals, therapists or other specialist services must be followed up and all professional advice or guidance documented in the patient s health records. EQUALITY ASSESSMENT During the development of this procedure the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these names groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. ADVICE Staff can contact the Eye Unit at Wirral University Teaching Hospital for further information and advice if needed

15 REFERENCES BNF (2013) Contact lenses. Eye. British National Formulary 65, (March to September 2013) Chapter 11 p723 Pharmaceutical Press London Dougherty, L. and Lister, S.E. (2011) The Royal Marsden Manual of Clinical Nursing Procedures Eighth Edition. Blackwell Publishing, Oxford. NSW Department of Health (2009) Chemical Burns : Eye irrigation. Eye Emergency Manual : An Illustrated Guide 2 nd Edition. (Accessed 29/05/13) Available at BIBLIOGRAPHY HPA (2011) Compendium of Chemical Hazards. Health Protection Agency Available at (Accessed 10/06/13) Khodabukus R and Tallouzi M (2009) Chemical eye injuries 2: management and nursing care to promote visual rehabilitation. Nursing Times, Vol 105 No 23 NICE (2011) Eye Drugs Prescribing and Administering. Accessed 06/06/13 Available at RCN (2012) Ophthalmic nursing: an integrated career and competence framework. Royal College of Nursing. London. Accessed 06/06/13. Available at Watkinson S & Seewoodhary R (2007) Common conditions and practical considerations in eye care. Nursing Standard. Vol 21. No