RLE116GEP
EENT 2. Wash hands thoroughly before and after
EYE INSTILLATION
Method of administering medication to the eye.
OBJECTIVES
• To provide direct route for local effect.
• To decrease intra- ocular pressure.
• To relieve irritation and pain.
• To prevent infection.
ASSESSMENT
• Assess patient's ability to cooperate during
administration, since medications are instilled into
the lower conjunctional sac.
• Check medication expiration date.
• Assess condition of eye and surrounding areas.
INDICATION
• Glaucoma
• Papillary dilation for surgery and examination
• Ophthalmic infections
• Patients requiring local anesthesia for tests
• Eye discomforts
EQUIPMENTS
→ Medication card, Cotton balls or tissue, Eye drops or
eye ointment, Applicator stick (PRN)
PREPARATION
o Obtain patient's medication record. Medication
record may be a drug card, medication sheet, or
drug Kardex, depending on the method of
dispensing medications in your facility.
o Compare the medication record with the most
recent physician's order.
o Wash your hands.
o Gather necessary equipment.
o Remove the medication from the drug box or tray on
medication cart.
o Compare the label on the medication bottle to the
medication record.
o Check that medication is to be administered via
right method, at right time, in right amount.
CHARTING
• Appropriate medication form for facility used Name
of drug
• Dosage
• Method of administration
• Times ordered
• Time administered
• Initials of nurse administering drug
• Nurses' notes: condition of eye and surrounding
tissue
NURSING CONSIDERATIONS
1. Ensure the patient is in a comfortable and stable
position, preferably lying down or sitting with their
head tilted slightly backward.
by: 元美安
administering eyedrops or eye ointment to prevent
the spread of infection.
3. Clean the patient's eye area using a clean, damp
cloth to remove any discharge or debris. Ensure that
the eye area is dry before instilling the medication.
4. For eyedrops, instruct the patient to look up or tilt
their head back. Gently pull down the lower eyelid to
create a pocket for the drops. Hold the dropper
above the eye, without touching it, and instill the
prescribed number of drops into the lower
conjunctival sac. For ointment, instruct the patient
to close their eyes gently and apply a small strip of
ointment along the lower eyelid margin.
5. Avoid touching the tip of the dropper or tube to the
eye or any other surface to prevent contamination.
Administer one drop of medication at a time,
ensuring that each drop is properly instilled before
administering the next one. Wait at least 5 minutes
between different types of eye medications if more
than one medication is prescribed.
6. After instilling eyedrops or eye ointment, instruct the
patient to close their eyes gently for a few seconds
to allow the medication to spread evenly over the
surface of the eye.
7. If excess medication or ointment spills out of the
eye, gently blot it with a clean tissue.
8. Provide clear instructions to the patient on the
purpose of the medication, proper administration
technique, frequency of administration, and any
potential side effects they may experience.
9. Monitor the patient for any signs of adverse
reactions, such as allergic reactions, irritation, or
discomfort, and report any concerns to the
healthcare provider. Document the administration
of eyedrops or eye ointment, including the type of
medication, dosage, time of administration,
patient's response, and any other relevant
information in the patient's medical record.
EVALUATION
o Patient cooperated with instillation of eye
medication.
o Desired therapeutic effect is obtained.
o Eye surgery or evaluation is accomplished.
o Intra-ocular pressure is reduced.
OTIC INSTILLATION
Administration of the medication into the ear
OBJECTIVES
• To soften the earwax
• To relieve pain and obtain desired therapeutic effect
• To apply anesthetic agent
• To provide route for antibacterial medications
ASSESSMENT
• Assess patient’s ability to cooperate with instillation
• Assess patient’s ability to be positioned on side
 RLE116GEP
INDICATION
• Otitis media
• Otitis externa
• Impacted cerumen
• Foreign body obstruction
Equipment
→ Medication card, Cotton wick, Dropper for instilling
medication, Clean gloves, Medication, Flashlight
(PRN)
NURSING CONSIDERATION
1. If necessary or if ordered, remove cerumen by
irrigation before instilling eardrops. Cleanse outer
ear thoroughly
2. Warm eardrops to approximately body
temperature before instillation.
3. Allow refrigerated solutions to warm to room
temperature
4. Keep in mind that cold eardrops may cause
vomiting and dizziness.
5. Do not place the medicine dropper tip or cotton
wick directly into the ear canal, as this can
traumatize the skin of the ear canal.
6. Do not touch anything with the tip of the medicine
dropper to prevent contamination.
7. If the patient experiences pain from eardrops, stop
using the medicine and contact the physician.
EVALUATION
o Patient cooperates with instillation.
o Desired therapeutic effect is obtained
NOSE SPRAY
→ Method of administering medication via the nasal
cavity.
→ Nasal sprays are liquid medicines you spray into your
nose
TYPES OF SPRAY
o DECONGESTANT SPRAY - shrink swollen blood
vessels and tissues in your nose that cause
congestion.
o ANTIHISTAMINE SPRAY - relieve congestion, itchy,
runny nose, and sneezing.
OBJECTIVES
• To treat problems within the nose and sinus area,
such as nasal congestion.
• To provide a patient airway
ASSESSMENT
• Assess the patient's medical history, allergies, and
current medications to identify any potential
contraindications or interactions.
• Evaluate the patient's ability to correctly administer
the nasal spray to ensure proper medication
delivery.
INDICATION
• Nasal congestion
by: 元美安
• Allergic rhinitis
• Acute and chronic sinusitis
NURSING CONSIDERATIONS
1. Ask the patient to gently blow their nose to clear it of
mucus before using the medication
2. Keep the head upright, insert nozzle tip into one
nostril keeping the other nostril open
3. Check the patient’s allergy band for any allergies
4. Check the product labels
5. Provide guidance on proper storage of the nasal
spray, including temperature consideration, to
maintain the effectiveness of medicine.
EVALUATION
o Patient cooperates with instillation.
o Desired therapeutic effect is obtained
o Patent airway is established and the patient is able
to breathe after the procedure
NOSE INSTILLATION
→ The method of administering medication via the
nasal cavity which involves introducing a medicine
solution into the nose using nose drops or nasal
sprays.
→ This procedure is designed for effective drug delivery
through the nasal route.
OBJECTIVES
• To loosen secretions and facilitate drainage
• To shrink swollen mucus membrane of nasal cavity
(astringent effect)
• To treat infections of the nasal cavity or sinuses
ASSESSMENT
• Review physician’s order and determine which
sinus is affected by referring to a medical record
• Assess patient’s history of hypertension, heart
diseases, diabetes mellitus, and hyperthyroidism
• Assess and determine whether the patient has any
known allergies to the medications for nasal
instillation
INDICATION
• Nasal Congestion
• Allergic Rhinitis
• Sinus Infections
• Nasal Dryness
• Nasal Polyps
NURSING CONSIDERATIONS
1. Have the patient gently blow their nose prior.
2. Many nasal medications require shaking to disperse
medication in liquid.
3. Provide patient with tissue paper for the
expectoration of secretions.
4. Position the patient by having them sit up with their
head tilted back. If specific sinuses are targeted for
the medication position accordingly:
• Posterior pharynx - position the head backward
 RLE116GEP
• Ethmoid / sphenoid sinuses - with patient
supine place pillow under shoulders and tilt
head back
• Frontal / maxillary sinuses - place head back
and turned toward the side intended to receive
the medication
5. Avoid touching the nares with the dropper because
it may cause the patient to sneeze.
6. Have the patient remain in position with their head
tilted back for a few minutes to prevent the escape
of the solution.
7. Instruct the patient to avoid blowing their nose
immediately after instillation to allow medication to
be absorbed.
8. Caution the client to avoid the use of nasal
decongestants for a prolonged period as it can lead
to a rebound effect in which the nasal congestion
worsens.
EVALUATION
o Patient cooperates with instillation.
o Desired therapeutic effect is obtained
o Patent airway is established and the patient is able
to breathe after instillation.
NASAL IRRIGATION
→ Nasal irrigation is rinsing your nasal cavities by
irrigating them with saline solution through the
nostrils.
→ It can help relieve upper respiratory symptoms,
allergies, nasal problems, and sinus infections.
OBJECTIVES
• Cleans mucus from the nose, so medication can be
more effective.
• Cleans allergens and irritants from the nose,
reducing their impact.
• Cleans bacteria and viruses from the nose,
decreasing infections.
• Decreases swelling in the nose and increases
airflow.
ASSESSMENT
• Assess the individual's past and present medical
history, including any allergies or past nasal
surgeries.
• Avoid nasal irrigation if ear infection, ear pressure,
blocked nostril, or ear/sinus surgery;
immunocompromised individuals consult doctor
before sinus rinse device use.
• Evaluate medication use and consider consulting a
healthcare provider for chronic nasal issues.
• Assess device suitability for the user's age. Some
children as young as 2 with nasal allergies may
benefit, if recommended by a pediatrician, but very
young children may not tolerate it well.
INDICATION
• Nasal irrigation clears mucus and flushes out
pathogens, allergens or other debris.
• Pathogens include germs, like bacteria and viruses.
by: 元美安
• Allergens include pollen, mold, dirt, and dust. When
these substances get trapped in your nose, they
irritate your sinuses and cause symptoms like:
- A stuffy or runny nose.
- Itchy feeling in your nose or sneezing.
- Trouble breathing.
- Symptoms associated with allergies, sinus
infections (sinusitis), colds, flu among other
conditions.
EQUIPMENT
→ Non iodized salt & Baking soda (Saline solution),
Neti pot, Nasal syringe, Clean basin,
Distilled/sterile/boiled water
NURSING CONSIDERATIONS
1. Nasal irrigation requires a physician's order.
2. Only use nasal irrigation when you need it.
3. Nasal irrigation should be performed first, before
using any nasal drops, spray or ointment. The nasal
medication is much more effective when sprayed
onto clean nasal membranes, and the spray will
reach deeper into the nose
4. Use “Sterile” Normal Saline Solution. Use only
sterile normal saline solution (Sodium Chloride
0.9%) for nasal irrigation to prevent bacteria and
other microorganisms from entering the nasal
cavity, which may lead to serious infection.
5. Do Not Use “Plain Water”. Plain water is hypotonic
to nasal tissue. Washing the nasal cavity with pure
water may cause pain and may damage the nasal
mucosa.
6. Gently Irrigate Nasal Passages. To avoid irritation,
let normal saline solution gently flow through the
nasal passages. Do not squirt or gush the solution.
7. After nasal irrigation, blow the nose gently with both
nostrils open. Blowing too hard or with one nostril
may create pressure that can cause ear fullness,
discomfort, or ear pain.
8. When using nasal Spray After Irrigation, wait 3-5
minutes for the nasal cavity to dry before using nasal
spray.
9. If one side of the patients nose is always blocked,
consult a physician before performing nasal
irrigation.
10. Nasal Irrigation in Children. Nasal irrigation is safe
to perform in children. Parents performing nasal
irrigation to their children for the first time should
consult a pediatrician to prevent discomfort and
nervousness. Very young children (those who
cannot blow their nose or hold their breath) may not
tolerate the procedure. Nasal congestion in infants
and young children may be relieved by placing a few
drops of normal saline solution in each nostril and
then immediately suction with bulb syringe.
11. Don’t do a saline flush if you have a facial wound
that hasn’t healed or neurologic or musculoskeletal
problems that put you at a higher risk of accidentally
breathing in the liquid.
12. If nasal drops or sprays are ordered, perform
irrigations prior to drop or spray instillation.
 RLE116GEP
EVALUATION ORAL HYGIENE FOR THE CONSCIOUS
o Mucus, pathogens, allergens, and irritants are It simply refers to the practice of maintaining the health
removed from their nose and sinuses. of your mouth, teeth, and gums.
o Symptoms such as a runny or stuffy nose due to
allergic rhinitis, sinusitis, common cold, influenza, OBJECTIVES
and COVID-19 are relieved. • To refresh the client
o Their sinus passages are kept moisturized. • To remove decomposing materials from the mouth
o The function of nasal cavity cell linings is improved, and teeth preventing bad breath
aiding in the clearance of excess mucus in the • To prevent sores formation
nasal passageway • To maintain the integrity of the mucous membrane,
teeth, gums and lips.
ORAL OINTMENT APPLICATION
→ Oral ointments are topical products designed for ASSESSMENT
specific oral health purposes. • Assess patient's knowledge of oral hygiene
→ These products may contain ingredients like technique. Assess/inspect integrity of lips, teeth,
numbing agents, anti-inflammatories, antivirals, buccal mucosa, gums, palate and tongue.
antibiotics, or antifungals. • Determine status of client's oral cavity and extent of
need for oral hygiene, integrity and need for
OBJECTIVES preventive care.
• To offer the most common, easiest, and least • Assess risk for oral hygiene problems. Certain
expensive route of administering medication. conditions increase likelihood of impaired oral
• To prevent inflammation and pain cavity.
• To prevent infection • Determine client's oral hygiene practices. Allows
nurse to identify errors in technique, deficiencies in
ASSESSMENT preventive oral hygiene and client's level of
• Assess condition of the patient's oral cavity, teeth, knowledge regarding dental care.
gums and mouth. a) Frequency of tooth brushing and flossing
• Check medication orders for completeness and b) Type of toothpaste and dentifrice used
accuracy. c) Last dental visit
• Assess if 12 rights in medication administration are d) Frequency of dental visits
followed e) Type of mouthwash or moistening
• Check to make sure you have the correct medication preparation
for the patient. • Assess client's ability to grasp and manipulate
toothbrush.
INDICATION • Determine level of assistance required.
• Mouth Ulcers
• Teething discomfort INDICATION
• Gum inflammation • Individuals who are fully conscious and alert.
• Cold sores • Patients who can communicate and follow
instructions during oral care procedures.
NURSING CONSIDERATIONS • Those who are not under sedation or anesthesia
1. Consider any allergies or contraindications to the during the dental or oral hygiene process.
oral ointment or its components. • People who do not have cognitive impairments or
2. Assess the patient's oral hygiene practices and conditions that would inhibit their ability to
provide guidance if necessary to ensure optimal participate in oral care.
outcomes.
3. Implement measures to alleviate any discomfort NURSING CONSIDERATIONS
experienced by the patient during the procedure, 1. Assess the patient's oral health status and any
such as providing a supportive headrest or adjusting specific needs or preferences.
the lighting. 2. Ensure proper positioning for optimal access and
4. Communicate effectively with the patient comfort during the procedure.
throughout the procedure, addressing any 3. Communicate effectively with the patient to explain
questions or concerns they may have and providing the procedure and obtain consent.
reassurance as needed. 4. Use appropriate oral care products and techniques
based on the patient's condition and preferences.
EVALUATION 5. Monitor for signs of discomfort, pain, or oral
o Pain is reduced. complications during the procedure.
o The wound is healing. 6. Provide education and encouragement for the
o There is a decrease in swelling, redness, and patient to participate in their oral care routine.
discomfort. 7. Document the procedure, including any findings or
patient responses, in the medical record.
by: 元美安
 RLE116GEP
EVALUATION mucous membranes. Use a soft sponge toothette
o The teeth are clear of plaque. for cleaning or substitute a salt–water rinse(1/2
o The mucosa is moist, unharmed, and displays teaspoon salt in one cup of warm water) for brushing
consistent coloration. The tongue and lips appear of teeth.
adequately hydrated and smooth.
o The removal of bacteria-causing agents from the oral EVALUATION
cavity prevents bad breath. o Teeth are free of plaque.
o The client does not report any oral discomfort. o Mucosa is moist, intact and has a uniform color.
o Tongue is well hydrated as well as the lips are
ORAL HYGIENE FOR THE UNCONSCIOUS smooth and hydrated.
A special care of the teeth, gums, lips and tongue of an o Bacteria producing agent is removed from oral
unconscious or debilitated patient. cavity thereby preventing halitosis.
o Client experiences no oral discomfort.
OBJECTIVES
• To remove plaque and bacteria producing agents PROCEDURE (REFER TO EVAL TOOL)
from the oral cavity To allow the nurse to assess the
patient's oral health status, knowledge and routine SIR ELMER NOTES:
of oral care
• To decrease the possibility of irritation or infection WHAT IF PATIENT CHOKES/ASPIRATES
of the oral cavity and prevent sore formation DURING/AFTER MOUTH CARE?
• To refresh and provide comfort to the patient → discontinue procedure, check v/s, check o2 & give if
• To remove unpleasant tastes and odors from the too low, check mouth for cause of aspiration
oral cavity thereby preventing bad breath → o2 added: at least 2-4l
(Halitosis)
• To provide teaching when appropriate IF INTUBATED:
1) Hyper-oxygenate patient first
ASSESSMENT 2) Suction patient (through ET tube or mouth)
• Assess condition of patient's oral cavity, teeth, 3) Check o2 sat (if ok, proceed, if low, hyper-oxygenate)
gums and mouth. Assess for color, lesions,
tenderness, inflammation, intactness of teeth and FOR TRACHEOSTOMY:
degree of moisture or dryness of the oral cavity. → DO NOT wet trach area to avoid harboring of bacteria
• Observe the external and internal lips.
• Assess the palate (roof and floor of mouth) and IF WITH MOUTH GROWTH:
inspect under the tongue. → use soft brush/cotton, don’t touch growth/cyst
• Assess the entire oral mucosa, noting the inside of
the nasopharyngeal area. o NO cotton balls placed in inner ear
• Observe the tongue, noting tip, sides, back position o Sneeze, do nasal irrigation BEFORE nasal instillation,
and underside. 3-5 mins head tilt/up
o If fluid leaks out of nose, head tilt again or wipe, DO
INDICATION NOT add more medication (overdose)
• Unconscious patients o OTIC: 15-20 mins, if sneezed, head tilt again, 1-2
drops, 1-2 cm away, 90 degrees
• Intubated patients with mechanical ventilator
o PERRLA: Pupil are Equal, Round and Reactive to
• Patients who are unable to maintain oral hygiene
Light and Accommodation
(e.g. stroke patients, cancer patients, locked in
syndrome)
EYE
EQUIPMENT OD ocular dexter RIGHT eye
OS ocular sinister LEFT eye
→ Soft toothbrush or sponge toothette/cotton
applicator, Tongue blade padded with 4x4 gauze, OU oculus oblique BOTH eyes
Water, mouthwash or hydrogen peroxide, Gloves,
Towel, Water-soluble lubricant for lips, Suction EAR
catheter with suction apparatus, Emesis basin AD auris dextra RIGHT ear
AS auris sinistra LEFT ear
NURSING CONSIDERATIONS AU auris oblique BOTH ear
1. Suction apparatus or bulb should be available at
bedside for emergency use.
2. If mouthwash is used, always rinse the mouth with
water following steps as in cleaning to avoid mouth
irritations.
3. A patient receiving chemotherapy medication may
have bleeding gums and extremely sensitive
by: 元美安
 RLE116GEP
EYE INSTILLATION PROCEDURE
STEP
1. Place medication on a tray if not using medication cart.
2. Take medication to patient's room, and check the room number against medication card or sheet.
3. Check patients identity band and ask patient to state name.
4. Wash your hands.
To prevent spread of microorganisms.
5. Explain procedure to the patient.
To gain cooperation.
6. Tilt patient's head slightly backward and ask him to look up.
The cornea is protected as it goes up under the eyelid.
7. Squeeze the prescribed amount of medication into eyedropper. Hold dropper with bulb in uppermost position.
8. Give tissue to patient for wiping off excess medication
9. Expose lower conjunctival sac by pulling down on cheek.
10. Drop prescribed medication into center of sac.
Do not place medication directly on cornea, since medication can cause injury to cornea
11. Ask the patient to close eyelids and move eyes but not to squeeze them shut.
This distributes solution over conjunctival surface and anterior eyeball.
12. Remove excess medication from surrounding tissue.
13. Wash your hands. Replace medication in appropriate place.
14. Assess client's response and document all interventions.
EYE INSTILLATION PROCEDURE (UPPER LID)
STEP
Repeat Procedures 1 - 5 of Instilling Eye Drops
6. Instruct the patient to look down.
7. Check Grasp patient's lashes near center of upper lid with your thumb and index finger. Draw lid down and away from
eyeball.
8. Wash With your opposite hand, place applicator horizontally along upper part of eyelid.

9. While pressing down on applicator, quickly turn eyelid up over the applicator.

10. Squeeze ointment over entire lid starting at the inner canthus.

11. Instruct patient to close lid and move eye to assist in spreading medication, if not contraindicated.

12. Remove excess medication from surrounding tissue

13. Wash your hands. Replace medication in appropriate place.
EYE INSTILLATION PROCEDURE (LOWER LID)
STEP
Repeat Procedures 1 - 5 of Instilling Eye Drops
6. Take protective guard off medication tip.
7. Gently separate patient's eyelids with your thumb or two fingers, and grasp lower lid near the margin of the lower lid
immediately below the lashes. Exert pressure downward over the bony prominence of the cheek.
8. Instruct the patient to look upward.
To keep cornea out of way of medication.
9. Place eye medication on the entire lower lid. Squeeze 2 cm of ointment from the tube starting at the inner canthus.

10. Ask patient to close eyelids and move eyes to assist in spreading ointment under the lids and over the surface of the
eyeball.
11. With a cotton ball or soft tissue, remove the excess medication from patient's eye and cheek.

12. Wash your hands. Replace medication in appropriate place.

by: 元美安
 RLE116GEP
OTIC INSTILLATION PROCEDURE
STEP RATIONALE
1. Place medication on a tray if not using a medication
For aesthetic purposes and to ensure accuracy
cart and take medication to patient's room and check
room number against medication card or sheet.
To ensure accuracy
2. Identify patient using two identifiers.
3. Explain to the patient what you are going to do, why it To gain cooperation
is necessary and how he/she can cooperate
4. Wash your hands and observe other appropriate
To prevent spread of microorganisms
infection control procedures. Put on gloves if infection
is suspected.
5. Provide privacy and position patient on one side, with To allow medication to enter external ear canal.
ear to be treated in the uppermost position.
6. Fill medication dropper with prescribed amount of
medication.
7. Prepare patient for instillation of ear medication as
follows:
a) (0-3 years old): Draw the auricle gently downward
These positions straighten out the ear canal.
and backward to separate the drum membrane
from the floor of the cartilaginous canal.
b) (above 3 years old): Lift the pinna upward and
backward.
8. Instill the correct number of drops along the side of
the ear canal and press gently but firmly a few
minutes on the tragus of the ear.
9. Instruct patient to remain on his side for 15 minutes
following instillation. Insert a small piece of cotton To prevent medication from escaping
fluff loosely at the meatus of the auditory canal.
10. Assess patient's response and document all nursing
assessment and interventions; also, record the name
Maintain continuity of care
of the drug or irrigating solution; the strength, the
number of drops and the response of the patient.

NOSE SPRAY PROCEDURE

STEP RATIONALE
To reduce errors in drug administration. Explaining the
1. Introduce self; verify patient's identity using two
procedure to patient reduces anxiety and promotes
identifiers and explain the procedure.
cooperation
2. Check the medication administration record (MAR),
To ensure accuracy
check the label on the medication carefully against the
medication card or the MAR.
3. Gather and assemble the equipment.
To save time, energy and effort
4. Perform hand washing and observe appropriate
To reduce transmission of pathogenic microorganisms
infection control procedure
5. Provide patient with tissues and ask to gently blow
This clears the nose prior to medication instillation.
his/her nose.
6. Prepare patient by positioning him/her on sitting
position with his/her head tilted back, if he/she is lying
down, tilt his/her head back with a pillow.
7. The head should be tilt forward slightly, with nose in
Relaxation minimizes discomfort
line with the toes.
8. Spray sufficient amount of solution depending on the
Breathing through the mouth will help prevent aspiration of
doctor’s order. Ask patient to breathe through the
the medication
mouth.
9. Close the nostril that is not receiving the medication.
Do this gently pressing on the side of patient’s nose.
10. Gently insert the bottle tip into the other nostril.
Breathe in deeply through that nostril as you squeeze Relaxation minimizes discomfort
the bottle. Remove the bottle and sniff once or twice
by: 元美安
 RLE116GEP
11. Have the patient remain in the position with his head
To prevent the medication from escaping
tilted back for 30-60 seconds
12. Remove gloves and assist patient to a comfortable and
To ensures patient safety and comfort
safe position
13. Perform hand hygiene. To prevent the spread of microorganisms
14. Assess patient’s response and document all nursing Assessing patients response determines if desired
assessment and interventions. Record the drug, therapeutic effects have been manifested. Documentation
number of drops or spray, the time and the response of promotes communication to the other members of the
the patient. health team

NOSE INSTILLATION PROCEDURE

STEP RATIONALE
1. Check the Medication Administration Record (MAR).
Check the label on the medication carefully against the To ensure accuracy.
medication card or the MAR.
2. Gather and assemble the equipment To save time,
To save time, energy and effort.
energy and effort
3. Perform hand washing and observe appropriate
To reduce transmission of pathogenic microorganisms
infection control procedure
4. Introduce self; verify patient's identity using two
identifiers and explain the procedure. Explaining the procedure to patient reduces anxiety and
5. JCAHO recommends two patient identifiers to reduce promotes cooperation
errors in drug administration.
6. Prepare patient by positioning him/her on sitting
position with his/her head tilted back, if he/she is lying Relaxation minimizes discomfort
down, tilt his/her head back with a pillow.
7. Provide the patient with a tissue paper for To wipe off secretions that may obstruct flow of medication
expectoration of secretions. to the desired area.
8. Draw sufficient amount of solution into the dropper for
the nare/s depending on the doctor's order. Hold up
the tip of the nose and place the dropper just inside the
nare about 1/3 of an inch.
9. Instill the prescribed number of drops in one nare and
then into the other.
10. Have the patient remain in the position with his head
Prevent the medication from escaping
tilted back for a few minutes.
11. Assess patient's response and document all nursing Assessing patient's response determines if desired
assessment and interventions. Record the drug, the therapeutic effect has been achieved or side effects have
strength, number of drops or spray, the time, and the been manifested. Documentation promotes
response of the patient. communication to the other members of the health team

NASAL IRRIGATION PROCEDURE

STEP
1. Introduce yourself to the patient and explain the procedure.
To establish rapport.
2. Wash hands.
3. To avoid contaminating the treated water that is to enter the nasal passage.
4. Fill the irrigation device with lukewarm distilled water or boiled water that has cooled.
5. If using a nasal rinse bottle, fill it with either a ready-to-use saline solution or prepare a saline solution as instructed
and shake it well.
Plain water can irritate your nose. The saline allows the water to pass through delicate nasal membranes with little
or no burning or irritation.
6. To create the saltwater solution, use a clean basin or jar to mix one-half teaspoon of non-iodized salt in an 8-ounce
glass of water. Then, add a pinch of baking soda, which is a small amount that can be picked up between two fingers.
Use the entire 8 ounces of saltwater during the nasal wash if congested; otherwise, 4 ounces should suffice.
Remember to discard any unused saltwater and prepare a fresh solution before the next nasal wash.
Non-iodized salt is preferred over iodized salt to prevent potential irritation over time.
7. Ask the patient to stand in front of a sink. Position their body by bending forward and flex the neck approximately 45
degrees, facilitating observation or interaction with the sink.
To prevent aspiration, keep the patient's head tilted forward.

by: 元美安
 RLE116GEP
8. Then, place the tip of the rinse bottle into patient’s nostril.
9. Instruct the patient to breathe through the mouth, then gently squeeze the bottle directing the stream towards the
back of the head rather than the top. This will squirt the solution into their nostril. The solution will start to drain from
the other nostril. Some may drain from the mouth. This is normal.
This allows for expelling some of the salt water from the mouth. It's not harmful if a small amount is swallowed.
10. Ask the patient to gently blow their nose
To remove remaining water or mucus.
11. Repeat steps 6 to 8 with the other nostril.
12. Mild irritation is typical initially and tends to subside over time.
13. Do after care of the equipment, Wash hands thoroughly, Record type of drainage returned.

ORAL OINTMENT APPLICATION PROCEDURE

STEP
1. Check the patient's Medication Administration Record (MAR) for the drug name, dose and strength.
To ensure accuracy.
2. Gather and assemble the equipment.
To save time, energy, and effort.
3. Introduce yourself and verify the patient's identity using two identifiers. Explain to patient what you are going to do
and how he/she can cooperate.
JCAHO recommends two patient identifiers to reduce errors in drug administration. Explaining the procedure to
patient reduces anxiety and promotes cooperation.
4. Assist the patient to a comfortable position and put on gloves.
5. Open the tube and discard the first bead.
The first bead is considered contaminated.
6. With your dominant hand, squeeze out the prescribed amount onto the application stick held by your non dominant
hand
7. Apply the ointment on affected area. Allow it to remain on the area for as long as possible.
8. Instruct patient to not eat or drink for about 30 minutes after applying the ointment.
This helps to prevent the medicine from being washed away too soon.
9. Assess patient's response and document all relevant assessments and interventions.

ORAL CARE FOR THE CONCIOUS PROCEDURE

STEP
1. Wash hands and assemble equipment
2. Explain the procedure to the client
3. Place client in a comfortable sitting position/semi-
fowler's position in bed.
4. Place the face towel around the client's neck
5. Place the kidney basin under and close to the chin
6. Let the client rinse his mouth with water
7. Prepare toothbrush with toothpaste and give to client
8. Let client brush his/her teeth
9. Let client rinse mouth with water followed by
mouthwash
RATIONALE
Washing hands helps prevent the spread of infection to the
client and ensures a clean environment for the procedure.
Assembling equipment beforehand ensures efficiency
during the process.
Providing clear communication builds trust and
cooperation with the client, reducing anxiety and
promoting their participation in the oral care process.
This position allows for better access to the client's mouth
and promotes comfort and relaxation during the
procedure.
The towel serves to protect the client's clothing from water
and toothpaste spills during oral care.
The basin collects saliva, toothpaste, and water during oral
care, preventing spills and keeping the environment clean.
Rinsing with water helps remove loose debris and
toothpaste residue from the mouth, promoting cleanliness
and freshness.
Preparing the toothbrush beforehand ensures efficiency
and convenience for the client, allowing them to focus on
the brushing process.
Allowing the client to brush their teeth promotes
independence and empowers them to take an active role in
their oral care.
Mouthwash helps kill bacteria, freshen breath, and
promote oral hygiene beyond brushing alone.

by: 元美安
 RLE116GEP
10. Dry client's lips and face Drying the lips and face enhances comfort and prevents
irritation or discomfort caused by moisture.
Ensuring the client's comfort promotes a positive
11. Place client in a comfortable position. experience and encourages future cooperation during oral
care procedures.
Aftercare of equipment ensures hygiene, prevents
12. Do the aftercare of the equipment. contamination, and maintains functionality for safe and
effective patient care.

by: 元美安