MEASURES IN MEETING THE NEEDS OF CLIENTS WITH ALTERATION IN VISUAL

AND AUDITORY
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills, 3rd Edition
Adapted from Berman et al (2009) Skills in Clinical Nursing 6th Edition

I. DEFINITION

A. Eyes and Ears Medications

Refers to drops, ointment, and disks. These drugs are used for diagnostic and therapeutic
purposes- to lubricate the eye or socket for a prosthetic eye and to prevent or treat eye
conditions such as glaucoma (elevated pressure within the eye) and infection.

Safety Measures to prevent cross-contamination

1. Each client should have his or her own bottle of eye drops.
2. Discard any solution remaining in the dropper after instillation.
3. Discard the dropper if the tip is accidentally contaminated, as by touching the bottle or any
part of the client’s eye.

B. Ear Medications
Solutions ordered to treat the ear are often referred to as otic (pertaining to the ear) drops or
irrigation. External auditory canal irrigations are usually performed for cleaning purposes and
less frequently for applying heat and antiseptic solutions.

II. RATIONALE

EYE MEDICATION
1. Diagnostically, eye drops can be used to anesthetize the eye
2. Dilate the pupil, and stain the cornea to identify abrasions and scars.

EAR MEDICATION
1. To soften ear wax
2. To produce anesthesia
3. To treat infection or inflammation
4. To facilitate removal of a foreign body such as insect

III. EQUIPMENT

Eye Medication
Medication Administration Record (MAR)
Eye medication
Tissue or cotton ball
Nonsterile latex-free gloves (if needed)

Ear Medication
Medication Administration Record (MAR)
Otic Medication
Cotton-tipped applicator
 Tissue
Nonsterile latex-free gloves (if needed)

IV. IMPLEMENTATION

Special Considerations
a. When administering eye medication, make sure the client is not wearing contact lenses. In
addition, wearing contact lenses may be prohibited within 30 minutes after the eye
medication has been administered as medication may damage the contact lenses.
b. Some eye medications cause pupil dilation and make the client’s eyes sensitive to light and,
therefore, require protective measures such as sunglasses. Most often after the pupils are
dilated, it is difficult for the client to read for several hours. Proper client education should
be addressed to promote client comfort and safety.

ACTION RATIONALE

Eye Medication
1. Check with the client and the chart for any
known allergies or medical conditions that
would contraindicate use of the drug. To prevent occurrence of adverse reactions.

2. Gather the necessary equipment

3. Follow the 10 Rights of Drug To promote efficiency.

Administration
To promote safety.
4. Take the medication to the client’s room
and place on a clean surface.
To decrease risk of contamination of bottle
5. Check client’s identification armband. cap.

6. Explain the procedure to the client; inquire

if the client wants to instill medication. If
so, assess the client’s ability to do so.
7. Wash hands, don nonsterile latex-free
gloves, if needed
To accurately identifies client.
To reduce client’s anxiety and enhances
collaboration; some clients are used to
instilling their own medication.

8. Place client in a supine position with the To decrease contact with bodily fluids.
head slightly hyperextended.

Instilling Eye Drops To minimize drainage of medication through

9. Remove cap from eye bottle and place cap a tear duct.
 on its side.

10. Squeeze the prescribed amount of To prevent contamination of the bottle cap.
medication into the eyedropper.

11. Place a tissue below the lower lid. To ensure correct dose.

12. With dominant hand, hold eyedropper To absorb the medication that flows from the
one-half to one-third inch (1/2 - 1/3 inch) eye.
above the eyeball; rest hand on client’s
forehead to stabilize.

13. Place hand on cheekbone and expose To reduce risk of dropper touching eye
lower conjuctival sac by pulling down on structure, and prevents injury to the eye.
cheek.

14. Instruct the client to look up and drop

prescribed number of drops into center of To stabilize hand and prevents systemic
conjunctival sac. absorption of eye medication.

15. Instruct client to gently close eyes and

move eyes. Briefly place fingers on either
side of the client’s nose to close the tear
ducts and prevent the medication from
draining out of the eye.
16. Remove gloves; wash hands.
To reduce stimulation of the blink reflex;
prevents injury to the cornea.
To distribute solution over conjunctival
surface and anterior eyeball.

17. Record on the Medication Administration

Record (MAR) the route, site (which eye),
and time administered.
To reduce the transmission of microorganism.
18. Repeat Action 1 to 8.

19. Lower lid: To provide documentation that the

a. With nondominant hand, gently separate medication was given.
client’s eyelids with thumb and finger
and grasp lower lid near margin
immediately below the lashes; exert
pressure downward over the bony To provide access to the lower lid.
prominence of the cheek.

b. Instruct the client to look up.

c. Apply eye ointment along inside edge of

the entire lower eyelid, from inner to
outer canthus. To reduce stimulation of the blink reflex and
 keeps cornea out of the way of the
20. Upper lid: medication.
a. Instruct client to look down. To ensure drug is applied to entire lid.

b. With nondominant hand, gently grasp

client’s lashes near center of the upper
lid with thumb and index finger, and
draw lid up and away from eyeball. a. To keep cornea out of the way of
medication.
c. Squeeze ointment along upper lid b. To ensure medication is applied to entire
starting at inner canthus. length of lid.

21. Repeat Actions 16 and 17.

Medication Disk

22. Repeat Actions 1 to 8.

23. Open sterile package and press dominant, See Rationales 16 and 17.
sterile gloved finger against the oval disk so
that it lies lengthwise across fingertip.
24. Instruct the client to look up. See Rationale 1 to 8.

25. With nondominant hand, gently pull the To promote sticking of disk to fingertip.
client’s lower eyelid down and place the
disk horizontally in the conjunctival sac.
a. Then pull the lower eyelid out, up and To reduce stimulation of the blink reflex and
over the disk. keeps cornea out of the way of the
medication.
b. Instruct the client to blink several times.
To secure the disk in the conjuctival sac.
c. If disk is still visible, repeat steps.
To allow the disk to settle into place.
d. Once the disk is in place, instruct the
client to gently press the fingers against
the closed lids; do not rub eyes or move Ensures correct placement of the disk.
the disk across the cornea.
To secure disk placement of the disk.
e. If disk falls out, pick it up, rinse under
cool water, and reinsert To preserve medication. This is not a sterile
procedure. Health care provider must wear
26. If the disk is prescribed for both eyes (IU), gloves to pick up disk.
repeat Actions 23 to 25.
To ensure both eyes are treated at the sane
27. Repeat action 15 to 17. time.
See rationale 15 to 17.
Removing an eye Medication Disk
28. Repeat action 3 and 5 to 8.
See rationale 3 and 5 to 8.
29. Remove the disk:
a. With nondominant hand, invert the
lower eyelid and identify the disk. To expose the disk for removal.

b. If the disk is located in the upper eye, To safely move the disk to the lower
instruct the client to close eye, and place conjunctival sac.
your finger on the closed eyelid. Apply
gentle, long, circular strokes; instruct
client to open eye. Disk should be
located in corner of eye. With your To safely remove the disk without scratching
fingertip slide the disk to the lower lid, the cornea.
and then proceed.

c. With dominant hand, use the forefinger

to slide the disk onto the lid and out of
the client’s eye.

30. Remove gloves; wash hands. To reduce transmission of microorganism.

31. Record the removal of the disk on the To provide documentation that the disk was
MAR. removed.

Ear Medication
To prevent the occurrence of
1. Check with client and chart for any known hypersensitivity.
allergies.

2. Check the MAR against the health care To ensure accuracy in identification of the
provider’s written orders. medication.

3. Wash your hands. To reduce the transfer of microorganisms.

4. Calculate the dose. To ensure the administration of the correct

dose.
5. Use the identification armband to properly To ensure correct client.
identify the client

6. Explain the procedure to the client. To enhance cooperation.

7. Place the client in a side-lying position with To facilitate the administration of medication.
the affected ear facing up.

8. Straighten the ear canal by pulling the pinna To open the canal and facilitates introduction
down and back for children less than 3 years of the medication.
of age or upward and outward in adults and
 older children.

9. Instill the drops into the ear canal by holding To prevent injury to the ear canal.
the dropper at least ½ inch above the ear
canal.

10. Ask the client to maintain the position for 2 To Allow for distribution of medication.
to 3 minutes

11. Place a cotton ball on the outermost part of To prevent the medication from escaping
the canal. when the client changes to a sitting or
standing position.
12. Wash hands. To reduce the transmission of
microorganisms.
Document the drug, number of drops, time
administered and ear medicated. To document the actions of the nurse will
reduce the number of medication errors.

I. EVALUATION AND DOCUMENTATION

1. The right client received the right dose of the right medication via the right route at the right
time.
2. The procedure was performed with minimum trauma and/or discomfort to the client.
3. The client received maximum benefit from the medication.
4. All the prescribed medication went into the eye or ear and none was spilled.

Documentation
Medication Administration Record (MAR)
1. Record the date, time, location, and dosage of medication administered
2. If an ordered medication was not given, note this, usually by circling the time of the missed
medication.

Nurses’ Notes
1.If an ordered medication was not given, record the reason.
2.If an as-needed medication was given, note the reason for giving medication and the client’s
response.
3.Document on appropriate flow sheet or electronic medical record (EMR).
 Ear Drops

INSTILLING NASAL DROPS

I. DEFINITION

Administering a prescribed medication via the nasal route

Instillation- is the insertion of a medication into a body cavity.
II. RATIONALE

1. To shrink swollen mucous membranes.

2. To loosen secretions and facilitate drainage.
3. To treat infections of the nasal cavity or sinuses.

III. EQUIPMENT

Medication Tissue
Dropper Emesis Basin
Gloves (optional)

IV. PLANNING AND IMPLEMENTATION

ACTION RATONALE

1. Obtain client’s medication record. It may be To determine the drug to be given at a particular
a drug card, medication sheet or drug Kardex time to a particular client.
depending on the method of dispensing
medications in the facility.

2. Compare the medication record with the To ensure accuracy.

most recent physician’s order.

3. Wash your hands. To prevent the spread of microorganism.

4. Gather the necessary equipment. To save time and effort.

5. Remove the medication from the drug box To promote ease in drug preparation.
or tray on the medication cart.

6. Compare the label on the medication bottle To prevent medication error.

or tube with the medication record.

7. Check the drug information if it is To ensure client’s safety.

appropriate for nasal instillation.

8. Place the medication bottle or tube in a To prevent medication from contamination.

medication tray.

9. Take the medication to the client’s room, To ensure accuracy.

check the room number against the
medication card or sheet.

10. Check the client’s ID band and ask the To ensure that the right client is given the right
client to state his/her name. medication.
 11. Explain the procedure to the client and To reduce client’s anxiety and to gain his/her
provide privacy. cooperation.

12. Don a pair of gloves. To prevent contamination.

13. Provide tissue wipes to the client and To clear the nasal passages of mucus and
instruct him/her to blow the nose. secretions.

14. Position the client properly and To facilitate instillation of the drug.
comfortably; Sitting position with the head
tilted back or back-lying position with the
neck hyperextended over a pillow.

15. Fill the dropper with the prescribed To ensure accurate dosage.
amount of medication.

16. Elevate the nares by pressing the thumb To facilitates instillation of the drug.
against the tip of the nose, the dropper is
held just above the nostril, and the drops
are directed toward the midline of the
superior concha of the ethmoid bones as
the client breathes through the mouth.

17. Instruct the client not to sneeze and to To let the solution come in contact with the
remain in this position for 1 minute. entire nasal surface.

18. Discard any unused medication remaining To prevent contamination.

in the dropper before returning the
dropper to its container.

19. Place client in a comfortable position. To promote comfort.

Provide emesis basin and tissue wipes.

20. Do after-care of supplies and equipment To prevent the spread of microorganisms.

properly and wash your hands.

II. EVALUATION AND DOCUMENTATION

1. Document the name of drug, dosage, method of administration, time administered, and the
site where the drug was instilled (left, right or both nostrils).
2. Status of the mucous membrane, patient’s tolerance to the medication and effects of the
medication.
 APPLICATION OF EYE PATCH, EYE SHIELD, PRESSURE DRESSING
Adapted from Altman (2010), Fundamentals & Advanced Nursing Skills, 3rd Edition
Adapted from Berman et al (2009) Skills in Clinical Nursing 6th Edition

I. RATIOANALE

One or both eyes may need shielding for the following reasons:
1. To keep an eye at rest, thereby promoting healing
2. To prevent the patient from touching the eye
3. To absorb secretions.
4. To protect the eye
5. To control or lessen edema

II. EQUIPMENT

Eye covering to be used (shield, oval patches) Tape

Scissors Skin Protectant (optional)

III. IMPLEMENTATION

ACTION RATIONALE

Preparatory Phase
1. Wash hands To prevent contamination

2. Explain procedure to patient. To allay fear and ensure cooperation.

3. Verify patient and eye to be patched. To prevent error.

4. Instill ointment, if directed, prior to To protect the cornea from abrasion or

patching. prevent infection.

5. Shave the male face and apply skin To enhance ability to stick and protect the skin
protectant as indicated. from tape.

Performance Phase
1. For eye patch:
 a. Instruct patient to close both eyes To immobilized both eyes
b. Place patch over affected eye.
c. Secure the patch with two or more
strips of tape applied downward and
diagonally from midforehead to cheek.

2. For eye shield

a. Apply over dressing or directly over the To protect the eye.
undressed eye, fastening with two or
more strips of tape.
b. Be sure there are no rough edges To prevent abrasion. Use skin protectant as
against the skin. indicated.

3. For pressure dressing

a. Have the patient close both eyes tightly.

To prevent eye from opening before dressing

b. Fold patch in half (short end to short is secured.
end) and place over closed eyelid (with To provide pressure dressing bulk.
fold line at eyebrow). Cover with
additional unfolded patches.
c. Apply strips of tape firmly from check to
forehead, overlapping each strip. To secure dressing and apply pressure.

IV. EVALUATION AND DOCUMENTATION

1. Trim tape and monitor for security of patch or shield.

2. Advised patient that because depth perception will be impaired, he should perform
activities carefully and report any foreign body sensation.

Evidence Base:
American Ophthalmic Association of Registered Nurses. (2007). Ophthalmic Procedures for the
Office or Clinic.