Xavier University – Ateneo De

Cagayan College of Nursing

PERFORMANCE RATING
SCALE ACTIVE RANGE OF
MOTION EXERCISE
NAME: Ira Velle J. Vios DATE: _March 02, 2022 _
BLOCK: NL SCORE:

PERFORMANCE EVALUATION
CRITERIA

Scor Description Indicato

e rs
4 Very Good
3 Good
2 Fair
1 Needs
Improvement
Student performs behaviors/tasks reflecting the highest level of
performance:
consistent, independent, effective.
Student performs behaviors/tasks reflecting mastery of
performance with
minimal supervision.
Student performs behaviors/tasks reflecting development and
movement toward mastery of performance: with help or direct
supervision in some aspects.
Student performs behaviors/tasks reflecting beginning level of
performance tasks not done properly majority of the time but
demonstrate understanding of concepts involved with tasks.

EYE CARE
Definition:

It is an essential aspect of daily hygiene among patients in hospital or home care and to those who are
dependent on health care givers to maintain this aspect of care.

Eye care is carried out for a number or reasons:

1. To clean the eye of discharge and crusts
2. To clean prior to eyedrop installation
3. To soothe eye irritation
4. To prevent corneal damage/abrasion in the unconscious/sedated patient.

Assessment of the client’s eyes;

Nursing History
▪ Client’s eyeglasses or contact lenses
▪ Recent examination by an ophthalmologist
▪ History of eye problems and related treatments.

Physical Assessment
▪ Signs of inflammation
▪ Excessive drainage
▪ Encrustations

Principles of Eye Care (Cleansing)

▪ The eye should be carefully assessed before eye care is provided.
▪ Patients should be encouraged to carry out their own eye care if they are assessed and found able
to do so
 ▪ Each eye should be treated as a separate procedure
▪ Infected eyes should be treated last to reduce the risk of cross infection
▪ A clean technique can be used for eye cleansing unless there are specific concerns about infection
risk such as in post-operative
▪ Ensure good lighting during the procedure

Materials needed:
o Washcloth
o Warm water
o Basin
o Clean gloves
o Saline solution
o Cotton balls
o Clean towel
o Eye pads
o Artificial tears
o Eye ointment (lubricant

BASIC EYE CARE

PROCEDURE
1. Explain the procedure to the patient
2. Make sure the bed area is clear of any
obstructions and needed materials
and equipment are complete
RATIONALE 4 3 2 1 Remarks
Explaining the procedure
helps gain the trust and
participation of the patient.
Making the bed area clean
enables one to move
around the bed freely.

Ensuring the completeness

of equipment or materials
means that the patient will
not be left unnecessarily
during the procedure.
3. Make sure that the patient is in a A comfortable position gives
comfortable position and that there is patient comfort during the
a good light source. procedure, and a good
light source helps or allows
an easy access to the eyes.
4. Ensure patients privacy. Promotes effective
communication and
prevents embarrassment
or discrimination for
patients.
5. Make an assessment of the patient’s For the doctors to have an
eyes effective medical
diagnosis. Also, to identify
their real needs.
6. Wash hands and wearing clean gloves Proper cleaning and
wearing of gloves
minimize transfer of
microorganisms.
7. Place towel under client’s head and To promote comfort.
neck
8. Ask the patient to close their eyelids,
to avoid damage to the cornea
9. Cleaning the eyes involves simply
washing with a clean washcloth
moistened in water
10. Fold washcloth around fingers of your
hand to form a mitt. Immerse mitt in
water and wring thoroughly
11. Wash the patient’s eyes with plain
warm water. Use different section of
mitt for each eye
12. Move mitt from inner to outer canthus
13. Dried secretions that have
accumulated on the lashes need to be
softened and wiped away
14. Soften dried secretions by placing a
sterile cotton ball moistened with
sterile water or normal saline over the
lid margins for 2 to 3 minutes before
attempting removal.
15. Wipe the loosened secretions from the
inner canthus of the eye to the outer
canthus
16. Never apply direct pressure over the
eyeball.
17. Dry eyes with dry clean wash cloth
Assessment:
▪ Position and general appearance
▪ Patency of the nostrils
▪ Presence of tenderness, dryness, edema, bleeding or discharges
Materials needed:
o Soft tissue
o Clean Cloves
If cornea is damaged this
may cause blindness.
A dirty washcloth may
introduce debris, dirt, or
other harmful bacteria into
the eyes.
Very wet washcloth may
be uncomfortable to the
patient, and it can also
increase the risk of
contamination.
Hot washcloth may
damage the eye.
Using different section of
mitt for each eye
decreases risk of infection.
To not introduce debris or
dirt into the lacrimal ducts.
Immediately wiping the
dried secretions without
softening it may hurt the
patient’s eyelashes/eyes.
Using dirty or used water
to moisten the cotton ball
might introduce
microorganisms when it is
placed on the eyes.
To not introduce debris or
dirt into the lacrimal ducts.
Applying direct pressure
might hurt the patient.
Drying the eyes with dry
dirty washcloth increases
risk of contamination and
infection to the eye.
NOSE CARE
 o Wash Cloth/Cotton tipped applicator
o Water or Saline solution
o Medical Tape
o Suction (if needed)

PROCEDURE RATIONALE 4 3 2 1 Remarks

1. Have the patient blow gently the
secretions from the nose into a
disposable soft tissue.
*Bleeding is a sign of harsh blowing.
2. If the patient is not able to remove
nasal secretions, wear clean gloves
and help the patient using
moistened washcloth or cotton
tipped applicator with water or
saline.
If patient blows harshly
then this causes pressure
capable of enduring the
eardrum, nasal mucosa,
and sensitive eye structure.
A moistened washcloth or
cotton-tipped applicator
with water or saline softens
and removes the crust
inside the nose.

3. Do not insert the applicator beyond Inserting applicator beyond

the length of the cotton tip. the length of the cotton tip
causes injury to the patient.
CARE OF THE NOSE IN PATIENTS WITH NGT
1. When patient has Cleaning the tape at least
nasogastric/feeding tube, change once a day helps avoid
the tape anchoring the tube at least complications that are due
once a day to the friction from the tube.
2. After carefully removing the tape of Cleaning the tube carefully
the NGT, maintain hold of the tubing and thoroughly is important
and thoroughly clean and dry the because secretions are
nasal surface likely to collect and
become dry around the
tube.
PATIENT RECEIVING OXYGEN PER NASAL CANNULA
1. When patients receive oxygen per Cleaning the nares at least
nasal cannula, you should cleanse every 8 hours helps
the nares every 8 hours. Use a prevents complications,
cotton tipped applicator moistened such as skin irritation.
with saline.

2. Gentle suctioning may be necessary Gentle suctioning cleans

if the secretions are excessive. mucus out and helps the
oxygen move easily
through the tubing.

EAR CARE
▪ Basic ear care involves cleaning the ear with the end of a moistened washcloth rotated gently into
the ear canal

▪ It involves paying particular attention on the buildup of wax in the ear canal (cerumen), foreign
body, dryness, crusting and presence of any discharge as well as the general appearance

Materials needed:
o Washcloths
o Warm water
 o Washbasin
o Clean gloves
o Sterile Saline solution
o Clean towel
o Water faucet
PROCEDURE
1. Cleanse the pinna with soft
towel or moist wash cloth. Do
not force towel into the ear for
drying to prevent formation of
wax plugs.
2. Loosen and remove visible
cerumen by retracting the
auricle downward, and back.
3. Do not use bobby pins,
toothpicks or cotton-tipped
applicators to remove cerumen.
4. This can rupture the tympanic
membrane or traumatize the
ear canal. Cotton-tipped
applicators can push wax into
the ear canal, which can cause
blockage.
5. If the cerumen is not loosened,
per doctor's order,
cerumenolytic (wax-softening
agent is used to soften the
cerumen) and make it easier for
it to be removed from the ear
6. If wax softener is ineffective,
irrigation may be necessary per
doctor's order
Overall Score: 120
CI Name:
RATIONALE 4 3` 2 1 Remarks
Cleansing the pinna will
wipe away excess cerumen
that’s visible in the outer
ear.
This will also keep the ear
fresh and this will also
remove any odors.
Doing so will help the easy
removal of cerumen.
Using bobby pins,
toothpick, or cotton-tipped
applicators to remove
cerumen might damage or
injure the ear canal, and the
cotton-tipped applicator
might drive the cerumen all
the way to the eardrum
resulting in ear infections or
burst eardrum.
Cotton-tipped applicators
should not be used as this
can cause blockage and
blocked ears reduces the
capacity of the patient to
hear their surroundings.
This could also be
uncomfortable and may
cause ear pain, itchiness or
dizziness.
Cerumenolytic makes it
easier for the removal of the
cerumen and helps ease
discomfort to the patient.
Irrigation will help the
hardened cerumen be
easily removed and the
client will then have clean
ears. Also, ear irrigation is
one of the safest ways to
minimize the risk of damage
to the ear.