NURSING CARE RELATED TO THE SENSORY AND
NEUROLOGICAL SYSTEMS
1-14
1-14. IRRIGATING THE EYE
a. Wash your hands and assemble the necessary equipment.
(1) Towel.
(2) Chux pads.
(3) Sterile gauze pads.
(4) Tissues.
(5) Irrigation solution (at room temperature).
(6) Emesis basin.
b. Approach and identify the patient.
c. Explain the procedure to the patient.
d. Assist the patient into the supine position, with the head turned toward the affected side.
e. Place a chux pad under the patient's head to protect the bed linen. Place an emesis basin against the affected side, next to the cheek, to catch the solution as it runs off.
f. Using the thumb and index finger of your non-dominant hand, separate the patient's eyelids.
g. Perform a moderate irrigation:
(1) Direct a constant flow of irrigation solution toward the inner canthus of the eye. Administer about one-half of the solution in the bottle. (Bottles of sterile ophthalmic irrigation solution are available for moderate irrigations.)
(2) Inspect the eye for foreign particles.
(3) Attempt to remove particles by touching them gently with a piece of sterile gauze that has been moistened with the solution. The particle should adhere to the gauze.
(4) Continue irrigation until the eye is clean or the prescribed amount of solution has been used.
h. Perform a copious irrigation:
(1) Attach IV tubing to a 1000cc container of sterile normal saline solution.
(2) Open the flow clamp, and direct a stream of fluid toward the inner canthus of the eye. Do not allow the end of the IV tubing to touch the eye.
(3) Periodically stop the flow of solution and inspect for foreign particles. If particles are seen, attempt to remove them in the same manner as described in g.(3) above.
(4) Continue the irrigation until the eye is clean or the prescribed amount of solution has been used.
i. Dry the eyelids by blotting gently from inner to outer corner with gauze squares.
j. Provide for the patient's comfort.
k. Remove supplies from the bedside and store or discard as appropriate.
l. Wash your hands.
m. Record the procedure in the patient's clinical record.
