RETURN DEMONSTRATION EVALUATION TOOL

FOR EYE IRRIGATION

Name: __________________ Grade: __________

Time started: _________ Time Ended: ______ Date of RD: ________

AREA FOR EVALUATION RATING COMMENTS

SKILSS (35%) 5 4 3 2 1 0
ASSESSMENT/PLANNING
1. Reviews physician’s order.
R: This is a dependent nursing
intervention.
2. Assesses reason for eye irrigation.
R: This is to know if the patients needs
this procedure.
3. Does a complete eye examination.
R: To evaluate the condition of the eye
of the patient if there is swelling,
irritation or foreign bodies.
4. Assesses the eye.
R: To check overall eye
characteristics.
5. Asks the patient to rate level of
pain.
R: Determines or describes
uncomfortable sensation.
6. Assesses the patient’s level of
consciousness and ability to
cooperate.
R: To determine the degree to which
patient can respond to the procedure.
7. Prepares the irrigation set, fluid
and all the materials /equipment
needed.
R: Facilitates orderly performance of
the procedure.
8. Identify the patient.
R: To ensure that you are doing the
procedure to the right patient.

9. Discusses the procedure with the

patient.
R: Decrease client’s anxiety and
promotes cooperation.
IMPLEMENTATION
1. Washes hands.
R: To deter microorganism.
2. Don clean gloves.
R: Protect the nurse from
secretion/infection.
3. Removes any contact lens if
present.
R: Avoids trapped dirt and eye
infections caused by harmful bacteria.
4. Places the patient in supine
position and turn the head in the
affected side.
R: This is to do the procedure easily
and properly. Turning the head in the
affected side avoids spreading the
secretion all over the face of the
patient.
5. Positions the examination light to
illuminate the affected eye.
R: Facilitates viewing and illumination
of the patient’s eyes.

6. Places an under pad or towel on the

bed.
R: It draws/absorbs moisture from
contact.
7. Places towel just below the
patient’s face and emesis basin just
below the patient’s cheek.
R: This to avoid soiling the bed linens.
8. Cleanses visible secretions or
foreign material from eyelids and
lashes with gauze/ cotton ball.
R: Facilitates irrigation and gauze
absorb excess secretions/fluids.

9. Gently retracts eyelids.

R: Exposing the sclera and prevents
reflex blinking.

10. Fills the irrigation syringe with

fluid. With the non-dominant hand,
gently but firmly pull the upper
eyelid toward the eyebrow and pull
the lower lid down towards cheeks
to expose the conjunctival sac.
 R: Prevents pressure to the eyeball and
blinking.
11. Asks the patient to look downward.
R: To clean the whole area of the eye.

12. Holds the irrigation syringe about

½ to 1 inch above the eye and
gently depress the plunger or bulb
of the syringe to irrigate the eye,
directing the stream from the nasal
edge of the eye across to the outer
edge.
R: Ensure even and safe pressure and
avoid possible injury to the cornea.
Prevent fluid from flowing down the
naso-lacrimal duct.
13. Repeats the irrigation until the
desired result occurs or the total
amount of solution has been used.
R: As ordered and as necessary.
14. Allows the patient to close eyes
between washings if large amount
of solution is required.
R: Avoids irritation and uncomfortable
feeling like itching and pain.
15. Blot excess moisture from eyelids
and face with gauze or cotton balls.
R: Prevents infection.
16. Disposes the soiled supplies.
Removes gloves and perform
handwashing. Cleans the area.
R: To avoid cross contamination.
EVALUATION
17. Observe for verbal and non-verbal
signs of anxiety during irrigation.
18. Assess patient’s comfort level after
irrigation.
19. Inspect the eye for movement and
to determine if pupils are equal,
round, react to light and
accommodation.
20. Ask patient about improved visual
acuity.
DOCUMENTATION
21. Record in the nurse’s notes
condition of eye and patient’s
 report of pain and visual
symptoms.
22. Record amount and type of
irrigation
23. Report continuing symptoms of
pain and blurred vision.
R: Serves as a legal document.
KNOWLEDGE (15%)
1. Gives rationale of the procedure
2. Explain the elements and mechanics of
the procedure
3. Knows the elements of nursing process
as applied
4. States principles applied in procedure
ATTITUDE (10%)
1. Is well groomed.
2. Wears prescribed, neat and clean
uniform.
3. Arrives on time for the RD.
4. Speaks to CI and client tactfully.
5. Minimizes use of energy, time and
effort.
6. Utilizes supplies efficiently.
7. Considers client’s safety, privacy
and comfort.
8. Is well organized.
9. Keeps working area clean at all
times.
10. Gives high value for aesthetics.

Comments:
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Clinical Instructor’s Signature: ___________________________