Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups and communities, sick or well and in all settings.
A person educated with the scientific knowledge to care for people with ophthalmic problems.
The ophthalmic patient may be of any age and from any background. Ophthalmic conditions affect all age groups – ranging from a few days to more than 100 years old. The ophthalmic patients may have other diseases such as diabetes mellitus (Type 1 or Type2), ankylosing spondylitis or arthritis, as these conditions have ocular manifestations. They may also suffer from unrelated diseases.
The taking and recording of visual acuity;
Examination of the eye
Instillation of drops and ointment;
Removal of conjunctival and superficial corneal foreign bodies;
Unnecessary interruptions such as telephone messages.
Entering consulting rooms without knocking.
Gaping curtains and theatre gowns.
Not closing the door of consultation rooms.
Talking with the patient in a crowded waiting room.
Recording visual acuity
Visual acuity is the measurement of acuteness of central vision only. Visual acuity is a test of the visual system from the occipital cortex to the cornea.
General considerations when performing visual acuity
Recording of contact lens wear
Good communication skills.
Good lighting for chart tests and near vision test.
Record if a patient uses contact lenses.
Avoid patient ‘cheating’.
Using the Sheridan Gardner test chart, Kay picture chart or the tumbling ‘E’ chart on patients with learning disabilities and language difficulties.
Using appropriate chart for illiterate patients.
Common charts used in the measurement of distance visual acuity
The most common chart for measuring distance visual acuity in a literate adult is the Snellen chart.
If the patient wears glasses constantly, vision may be recorded with and without glasses, but this must be noted on the record. Each eye is tested and recorded separately, the other being covered with a card held by the examiner.
Snellen’s test type
Heavy block letters, numbers or symbols printed in black on a white background, are arranged on a chart in nine rows of graded size, diminishing from the top downwards. The top letter can be read by the normal eye at a distance of 60 m, and the following rows should be read at 36, 24, 18, 12, 9, 6, 5 and 4 m, respectively.
Visual acuity is expressed as a fraction and abbreviated as VA. The numerator is the distance in metres at which a person can read a given line of letters. The denominator is the distance at which a person with normal average vision can read the same line, e.g. if the seventh line is read at a distance of 6 m, this is VA 6/6. If some letters in the line are read but not all, it is expressed as, for example, VA 6/6 −2, or VA 6/9 + 2.
For vision less than 6/60, the distance between the patient and the chart is reduced by a metre at a time and the vision is recorded accordingly as, for example, 5/60, 4/60, 3/60, 2/60, 1/60.
If the patient cannot read the top letter at a distance of 1 m, the examiner’s hand is held at 0.9 m, 0.6m or 0.3m away against a dark background and the patient is asked to count the number of fingers held up. If he answers correctly, record VA = CF (count fingers). For less vision, the hand is moved in front of the eye at 0.3 m, record VA = HM (hand movement).
Sheridan Gardner test chart
The Sheridan Gardner test chart can be used for children and patients who are illiterate. This test type has a single reversible letter on each line. For example, A, V, N. The child holds the card with these letters printed on and is asked to point to the letter on his card which corresponds to the letter on the test type.
This test can also be used for very young children as they do not have to name a letter.
Kay picture chart
The Kay picture chart is again used with patients who are illiterate or with children. Instead of letters, the book contains pictures, which are also of varying sizes. The patient is asked what the picture represents. In order to avoid any misunderstanding amongst patients with language difficulties, it is good practice to ask the hospital’s official interpreter to translate for patients.
Tumbling E chart
The tumbling E chart again is mainly used for patients who are illiterate. In the chart, the Es face in different directions. The patient is asked to hold a wooden E in his hand and to turn it the same way as the one the examiner is pointing to on the test chart. It is important to remember to identify in the patient’s notes which chart system has been used to test the patient’s visual acuity; for example, if the Kay picture chart is used, this must be indicated in the notes.
The LogMAR chart was designed by Bailie and Lovie and was originally used in the Early Treatment Diabetic Retinopathy Study. The LogMAR chart is expressed as the logarithm of the minimum angle of resolution. LogMAR scale converts the geometric sequence of a traditional chart to a linear scale.
It measures visual acuity loss so that positive values indicate vision loss, while negative values denote better or normal vision. It is therefore more accurate than the Snellen’s chart and it is gaining more popularity clinically. The chart is designed to be used at various distances such as 4, 3 or 2 metres.
Near vision is tested by cards consisting of different sizes of ordinary printer’s type, each card being numbered. The eyes are tested and recorded separately and, if the patient uses reading glasses, these should be worn during the test. The card is held at a comfortable distance (approximately 25 cm) and should be well illuminated by a light from behind the patient’s shoulder. The near vision is recorded as the card number of the smallest type size he can most easily read.
Principles of ANTT (Aseptic Non Touch Technique)
An ANTT procedure is achieved by preventing direct and indirect contamination of what are referred to as key parts (for example the tip of a syringe or the tip of a drop bottle) or key sites such as the eye or a wound, using a non-touch approach and taking other appropriate infection-control precautions.
The principles of ANTT are:
Wash hands effectively.
Never contaminate key parts or key sites.
Touch non key parts with confidence.
Take appropriate infection-control precautions.
Principles and protocol for ophthalmic medication instillation/application
Avoid risk of trauma and/or cross-infection.
The drops and ointment should be administered in the correct strength, to the correct patient, into the correct eye, at the correct time and at the appropriate interval.
Record all drops instilled and ointment applied in a hospital setting.
Teach patients about the action and the side-effects of the medications.
Unless directed by medical staff, ask the patient to remove his contact lenses prior to instilling drops and ointment.
Tell patients about that drops may sting or have unpleasant taste.
Additional drops may reduce the effectiveness as they increase tear-duct stimulation and outflow, increase the amount of systematic absorption, and overflow onto the cheek and cause skin irritation.
Teach patients to slow count to 60 as the period for effective therapeutic absorption of medication is from 1 to 1.5 minutes, keeping the lids gently closed without squeezing reduces lacrimal duct outflow and maximises medication contact with ocular structures.
Give 3 minutes interval between each drop in order to prevent dilution and overflow.
All medication should be delivered to the fornix but can include the cornea, lids, periocular wounds and the socket.
Special considerations for instilling eye medication in children
Be truthful if a child asks if the drops will sting.
Show the drops to the child and, if appropriate, allow the child to handle the drops.
If instilling fluorescein drops, it is helpful to place a drop on the child’s hand to demonstrate the colour.
Involve the child in the instillation of the drops by giving them some tissues to hold and instruct them to dab the eye after the instillation.
If a child refuses to open eyes, instill the drops in the inner canthus of the closed lid and when the child opens his/her eyes, some of the drops will slide in.
General principles of eye examination
Take a holistic approach to patient care.
Ensure comfortable and pain free procedure.
Ensure that the patient is not suffering from shock and has no other injuries.
Take history first to ascertain the nature and acuteness of the problem.
Chemical injury must be treated prior to examining the eye.
First look at the patient’s face as a whole to determine facial symmetry.
Start from the outside inwards.
If only one eye is affected, inspect the ‘good’ eye first for comparison. Ask the patient to open both eyes as this is easier than opening one.
Use a slit lamp or a good pen torch.
Ensure that the patient’s head is well supported.
Topical anaesthetic drops may be used for patients with ocular pain after assessing the pain.
Verbal pain scale is used for pain assessment.
Avoid ‘misuse’ of the topical anaesthetic for patient’s corneal pain since this can delay corneal epithelial healing.
If there is a history of glass or fibreglass in the eye or the history indicates possible penetrating injury or perforation, local anaesthetic should not be instilled to avoid the drug entering the eye.
The upper palpebral conjunctiva must also be examined by everting the upper lid. Look for:
_ Injection (redness);
_ Degree of injection;
_ Position of injection:
_ Limbal/ciliary; (برذؤلةيى)
_ Localised – with or without dilated episcleral vessels;
_ Subconjunctival haemorrhage;
_ Chemosis (swelling);
_ Foreign body;
_ Pinguecula (شحيمة);
_ Pterygium (ظفرة);
_ Follicles (جريبة);
_ Papillae( حليمة);
_ Corneal curvature, e.g. keratoconus;
_ Pannus (superficial vascularisation of the cornea);
_ Foreign body;
Using a slit lamp, examine the layers of the cornea and note any abnormalities such as sub-epithelial opacities, corneal oedema, descemets folds or breaks, fresh or old keratatic precipitate or pigment on the endothelium.
Assess depth (should be deep but compare with other eye). Look for:
_ Hyphaema; bleeding of the anterior chamber of the eye
_ Hypopyon; inflammatory cells in the anterior chamber of eye.
_ Flare and cells (using slit lamp).
Iris (القُزَحِيَّة، طليَنة)
_ Colour – compare with other eye;
_ Clarity and pattern.
_ Iridodialysis(افْتِكَاكُ القُزَحِيَّة);
_ Iris prolapsed (تَدَلِّي).
_ Shape (should be round – an irregular pupil could indicate synaechiae (the iris adheres to the lens or cornea); an oval pupil could indicate acute glaucoma);
_ Colour – usually black: the red reflex may be noted (a white or grey pupil suggests the presence of a cataract; a white pupil in a baby/child indicates a cataract or retinoblastoma or imperforate pupil membrane).
Everting the upper lid
The upper lid is everted to inspect the palpebral conjunctiva over the subtarsal area. Foreign bodies, conjunctival follicles, papillae or concretions may be present.
_ Cotton bud;
_ Slit lamp or illuminated magnification unit.
Use Aseptic Non Touch Technique (ANTT) principles.
Check patient identification.
Obtain patient’s consent and co-operation. Explain procedure, including any side-effects. Warn patient that there will be a strange sensation during the examination.
Ask the patient to look downwards.
Take hold of the lashes of the upper lid with one hand and gently pull forwards and downwards.
With the other hand, place cotton bud vertically over tarsal plate (mid lid area) Do not apply any pressure on the globe.
The majority of foreign bodies (such as metal) found either on the conjunctiva or especially on the cornea is usually well embedded. Removal by inexperienced staff or without the slit lamp can cause a great deal of damage to the cornea and may result in the creation of a larger corneal injury, infection and even perforation of the cornea.
1. Take and record the patient’s visual acuity.
2. Take and document the relevant patient history.
3. Examination of the anterior segment of the eye
4. Sit patient back from slit lamp and explain your findings to him.
_ Plastic tray or trolley;
_ Slit lamp;
_ Sterile green needle firmly mounted on a cotton bud;
_ Sterile wet (minims normal saline) cotton bud;
_ Local anaesthetic drops;
_ Minims of fluorescein drops;
_ Minims of lignocaine/fluorescein drops.
1. Wash hands.
2. Gather equipment in the tray.
3. Prepare patient for procedure.
4. Instill topical anaesthetic such as G. tetracaine hydrochloride (Amethocaine) or oxybuprocaine hydrochloride (G. benoxinate).
5. Bring patient back into the slit lamp.
6. Hold the patient’s upper lid with your hand away from the cornea.
7. Increase the magnification on the slit lamp to get a better view.
8. Using the sterile green needle firmly mounted on a cotton bud, gently dislocate the foreign body. It may be necessary to gently swab the foreign body off the conjunctiva/cornea with a sterile wet cotton bud.
9. Continue to examine the anterior segment of the eye for signs of infiltrate. Take appropriate action if any signs noted. Note extent of injury by using a topical fluorescein. If the foreign body is metal, a rust ring may be noted. If it is difficult to remove the rust ring at that visit, the patient must be given an appointment in two days to have the rust ring removed. Meanwhile, a broad-spectrum antibiotic is prescribed to prevent infection. The antibiotic ointment will also soften the rust and make it easier to remove.
10. Measure the patient’s intra-ocular pressure as part of the examination, to detect any abnormalities in intra-ocular measurement.
Applying pad and bandage
The corneal epithelium healing rate is significantly improved without a pad. Patients with large abrasions may find a pad, and perhaps a bandage. If a pad is to be applied, it is important that the eye is firmly closed under the pad to avoid corneal abrasion. In some instances, it is useful to apply a piece of paraffin gauze over the eyelids, then a pad or half a pad folded in two, and finally a pad applied flat over the eye. This method is useful in the casualty or outpatient departments but should not be used on post-operative patients as it will put too much pressure on the globe. Secure the pad with three pieces of tape. For the right eye, the first piece of tape should be placed over the centre of the pad, diagonally from 1 to 7 o’clock. For the left eye, it is placed diagonally from 11 to 5 o’clock. The second and third pieces of tape are placed each side of this central piece, parallel to it. Position the ends of each piece of tape on each other so that removal is easier and kinder to the patient. Pads may be applied to post-operative patients undergoing certain oculoplastic procedures. Cartella shields are now in common use in most ocular surgical cases instead of a pad. In cases of chemical injury, the eye should never be padded.
Disadvantages of eye pads
_ Corneal abrasion can be caused if the eye is not closed under the pad.
_ Pads create a good medium for bacterial growth.
_ Pads are flammable.
_ Pads are uncomfortable to wear.
_ If the lids are swollen, a lid abrasion may occur.
_ The corneal healing rate is reduced.
1. Take the bandage twice around the forehead.
2. Bring it up under the ear on the affected side and over the centre of the eye pad.
4 Take the bandage once more around the forehead and secure it.
5 Take care when bandaging not to occlude the ‘good eye’ or the patient’s ears.
Removing a corneal rust ring
Use the same technique as removing corneal foreign body. Note that when all the rust has been removed, you will observe some rust staining on the cornea. This can be safely left alone. Ensure that there is no sign of corneal infiltrate.
Testing for tear film break-up time: assessing the quality of tears
The quality of tears can be measured by applying a drop of fluorescein to the lower bulbar conjunctiva and asking the patient to gently close his eyes, and position the patient on the slit lamp. The patient is asked to open his eyes and to stop blinking. Using the blue filter of the slit lamp, the tear film is scanned and the operator starts counting from one until the appearance of the first dry spot. The time that elapses before the appearance of the first dry spot is the tear film break-up time. The normal break-up time is about 10–15 seconds. The break-up time is shorter in eyes with aqueous and mucin tear deficiency.
Irrigating the eye
Irrigation of the eye is performed to clean the eye thoroughly of all foreign substances, especially corrosive matter. As an emergency measure, speedy dilution of any substance is very important, and irrigating the eye immediately with the nearest tap water may greatly reduce the amount of damage to the tissues.
_ pH indicator;
_ Irrigation set;
_ A bottle of sterile water or sodium chloride;
_ Local anaesthetic drops;
_ Desmarres lid retractor;
_ Paper tissues;
_ Protective plastic bibs or cape;
_ Paper towels;
_ Receptacle for paper towels;
Sit the patient in a chair with his head well supported and turned slightly to the affected side.
Test pH of conjunctival sac to ascertain length of time for which eye needs to be irrigated. Post-irrigation pH should be between 7.3 and 7.7.
Instil anaesthetic drops.
Place a protective bib and paper towels around the patient’s neck.
Place the receiver against the patient’s face on the affected side. Ask the patient to hold it if no other help is available.
Initially, run a stream of fluid up the cheek towards the eye to prepare the patient for fluid entering the eye.
Evert the lower lid, asking the patient to look up, and irrigate the lower fornix.
Evert the upper lid, asking the patient to look down, and irrigate the upper fornix.
Double-evert the upper lid using Desmarres lid retractor if necessary. This is to ensure that no solidified material (e.g. cement) is in the upper fornix.
Complete the irrigation by asking the patient to move his eye from side to side and up and down, holding the lids open.
These steps ensure all anterior surfaces of the eye, especially the fornices, are irrigated.
Re-test the pH of the conjunctival sac. Allow approximately five minutes between irrigation and pH testing; testing sooner than this would mean that you are testing the irrigation fluid still in the eye and not the tear film.
Repeat irrigation as required until the pH is normal.
Wipe patient’s face dry, for patient comfort.
_ Do not hold the irrigation nozzle too close or too far away from the eye – about 2.5cm is best. If too close, it may touch the eye; if too far away, the stream of fluid may not be sufficient to reach the eye.
_ It may be necessary to instill local anaesthetic drops over the everted upper lid.
They are indicators for body functions. These signs may be watched, measured, and monitored to check an individual's level of physical functioning. Vital signs include:
1. Body temperature (T)
2. Pulse (heart beat) (P)
3. Respiration (breathing) (R)
4. Blood pressure (BP)
Other vital signs
1. Pain 2. Oxygen saturation
Normal vital signs change with age, sex, weight, exercise tolerance, and condition. The normal vital sign ranges for the average healthy adult while resting are:
Blood pressure: 90/60 mm/Hg to 119/79 mm/Hg
Breathing: 12 - 20 breaths per minute
Pulse: 60 - 100 beats per minute
Temperature: 36.6 – 37.4 degrees Celsius (° C) average 37 degrees Celsius (° C)
Purposes of measuring Vital Signs
1. Make diagnosis
2. Planning of care
3. Showing progress of patient health
4. Identify reactions to medications, treatment, and care.
Body temperature reflects the balance between the heat produced and the heat lost from the body.
Methods of measuring body temp.
3- Temperature sensitive tape
4- Automated monitoring
Sites of measurement of body temp.
1. Mouth – Oral temp.
2. Rectum – Rectal temp.
3. Axilla (armpit) – Axillary temp.
4. Ear – Tympanic temp.
5. Forehead – temporal temp.
Types of clinical thermometers
1- Glass thermometer
2- Electronic and digital thermometer
4- Temporal thermometer.
Body temperature is measured in degrees Celsius (° C) or degrees Fahrenheit (° F)
C = F – 32 X 5/9
F = (C X 9/5) + 32
Alteration in body temperature
Pyrexia: a body temperature above the usual range is called pyrexia, hyperthermia or fever.
very high fever such as 41oC is called hyperpyrexia
Pressure (force) exerted by the blood as it moves through the arteries; moves in waves with the pumping action of the heart.
Korotkoff sounds:arterial sounds heard through a stethoscope applied to the brachial artery distal to the cuff of a sphygmomanometer that change with varying cuff pressure and that are used to determine systolic and diastolic blood pressure. (Tapping, Swishing, Knocking, and Muffling sounds). Find the sounds at http://vimeo.com/8068713
Systolic pressure: is pressure of the blood as result of contraction of the ventricles.
Diastolic pressure: is the pressure when the ventricles are at rest.
Pulse pressure: is the difference between systolic and diastolic pressures.
Hypertension: BP that is persistently above normal contributing factor to Myocardial Infarction (MI).
Primary hypertension: If cause of hypertension is unknown.
Secondary hypertension: If cause of hypertension is known.
Hypotension: Systolic reading between 85 and 110 in an adult whose BP is normally higher than this.
Causes of orthostatic hypotension: 1- Peripheral dilation 2- Analgesics 3- Bleeding 4- Severe burns 5- Dehydration.
Nursing care for Hypotension:
Place pt in supine position for 2-3 min
Record BP & P
Assist pt to slowly sit or stand
After 1 min recheck BP & P
A rise of 40 BPM in pulse or drop in BP of 30 mm Hg indicates abnormal orthostatic vital signs.
Physiological factors (body functions) which affect BP:
Circulating blood volume
Variations in measurement of BP:
1- age 2- sex 3- race 4- obesity 5- exercise 6- stress 7- pain and discomfort 8- circadian rhythm 9- cardiovascular/renal disease 10- medications: Immune-suppressants, Cox 2 inhibitors like Celebrex and Vioxx, Decongestants, Birth control pills, Anti-inflammatories, Steroids, Asthma preparations, Herbs, Dietary supplements 11- disease process 12- Eating or smoking 13- Need to urinate 14- Cold or hot 15- Talking and fatigue
BP sites: 1- Arm – brachial artery 2- Thigh – popliteal artery
Methods of measuring BP:
1- Directly (invasive) in the inner blood vessels.
2- Indirectly (noninvasive) by Sphygmomanometer.
Auscultatory BP: assessing BP by stethoscope
Palpatory BP: assessing BP by palpation without using stethoscope.
Sterilization is the process where all the living microorganisms, including bacterial spores are killed.
Disinfection is the process of elimination of most pathogenic microorganisms (excluding bacterial spores) on inanimate objects. Disinfection can be achieved by physical or chemical methods. Chemicals used in disinfection are called disinfectants. Some methods of disinfection such as filtration do not kill bacteria, they separate them out.
Decontamination is the process of removal of contaminating pathogenic microorganisms from the articles by a process of sterilization or disinfection. It is the use of physical or chemical means to remove, inactivate, or destroy living organisms on a surface so that the organisms are no longer infectious.
Sanitization is the process of chemical or mechanical cleansing, applicable in public health systems. Usually used by the food industry. It reduces microbes on eating utensils to safe, acceptable levels for public health.
Asepsis is the employment of techniques (such as usage of gloves, air filters, uv rays etc) to achieve microbe-free environment.
Antisepsis is the use of chemicals (antiseptics) to make skin or mucus membranes devoid of pathogenic microorganisms.
Bacteriostasis is a condition where the multiplication of the bacteria is inhibited without killing them.
Bactericidal is that chemical that can kill or inactivate bacteria. Such chemicals may be called variously depending on the spectrum of activity, such as bactericidal, virucidal, fungicidal, microbicidal, sporicidal, tuberculocidal or germicidal.
Antibiotics are substances produced by one microbe that inhibits or kills another microbe. Often the term is used more generally to include synthetic and semi-synthetic antimicrobial agents.
Administration of medications
Drug (medication) (medicine): is a substance used in the diagnosis, treatment, cure, relief of symptoms, prevention of diseases, placebo.