EYE CAREEYE CARE

By:By:

Francis Marven Francis Marven Lee R. Pintac, RNLee R. Pintac, RN

LEARNING LEARNING

To determine the different ways of Eye Care

To identify differentEye wears and

OBJECTIVES:OBJECTIVES:

To identify the importance of Eye Care

determine the different means of care.

ASSESSMENT• Nursing History

»Obtain data about the Obtain data about the client’s history (e.g. recent client’s history (e.g. recent eye examination or if eye examination or if client has contact lenses client has contact lenses or eye glasses)or eye glasses)

• Physical Assessment

»Inspect all external structures for signs of:

-inflammation-drainage-

encrustations-other

abnormalities

IMPLEMENTATIONEye Care

-Dried secretions that has

accumulated in the lashes must be softened and

wiped away.

-Softened dry secretions by placing a

sterile cotton balls

moisten with sterile water or normal

saline over the lid margins.

2. Wipe the loosened secretions

from the inner canthus of the eye to the outer

canthus.

•Eyeglass Care–Purpose: To prevent breaking

or scratching the lenses.

1.1.Glass lenses can be Glass lenses can be clean with warm water clean with warm water

and dried with a soft and dried with a soft tissue that will not tissue that will not scratch the lenses.scratch the lenses.

Positioning and Moving Clients

Risk factors that may contribute to complications of immobility:

a Paralysis b. Impaired mobility c. Impaired Circulationd. Age: very young or very adults

Positioning and Moving Clients

Risk factors that may contribute to complications of immobility:

e. Level of consciousness nd mental status

Positioning and Moving Clients

3. Assess client’s physical ability to help with moving and positioning.

a. Ageb. Level of consciousness and mental statusc. Disease Process

Positioning and Moving Clients

3. Assess cllity to help with moving and positioning.d. Strength and Coordination

e. ROM

Positioning and Moving Clients

4. Assess physician’s orders. Clarify whether any positions are contraindicated because of client’s condition.

5. Perform hand hygiene.

6. Raise level of bed to co

Positioning and Moving Clients

4. Assess physicia6. Raise level of bed to comfortable to comfortable working height, and get extra help if needed

Positioning and Moving Clients

7. Explain the procedure to the client.

8. If tolerated, position client flat in bed before changing to another position or moving the client.9. On count of three, rock and shift weight

from front to back leg at the same time Client pushes with heels and elevates trunk.

Positioning and Moving Clients

Before flattening the bed of patient, account for all tubing, drains and equipment toprevent dislodgement.

Positioning and Moving Clients

Moving Client Up in Bed

Assist Client in moving up in bed 1.Remove pillow from under head and shoulders, and place pillow at head of bed.

2. Face head of bed.

a.each nurse should have one arm under client’s shoulder and one arm under client’s thighs.

Positioning and Moving Clients

3.Place feet apart with foot nearest head of bed behind other foot (forward backward stance)

4. When possible, ask client to flex knees with feet flat on bed.

5. Instruct client to flex neck, tilting chin towards chest.

1.Instruct client to assist moving by pushing with feet on bed surface.

Positioning and Moving Clients

7. Flex knees and hips, bringing forearm closer to the level of bed.

8. Instruct client to push with heels and elevate trunk while breathing out.9. On count of three, rock and shift weight from front to back leg at

the same time Client pushes with

heels and elevates trunk.

Positioning and Moving Clients

Moving immobile client up in Bed (one nurse)

1. Place client on back with head of bed flat. Stand on one side of the bed.

2. Remove pillow from underhead and shoulders, and place pillow at head of bed.

Positioning and Moving Clients

3. Begin at client’s feet. Face foot of bed at 45 degree angle. Place feet apart with foot nearest head of bed behind other foot (forward backward stance) Flex knees and hips as needed to bring arms level with client’s legs Shift weight from front to back leg and slide client’s head diagonally toward head of bed.

Positioning and Moving Clients

4. Move parallel to client’s hips. Flex knees and hips as needed to bring arms level with Client’s hips.

5. Slide client’s hips diagonally toward head of bed.

6. Move parallel to client’s head and shoulders. Flex knees and hips as needed to bring arms level with the client’s body.

Positioning and Moving Clients

7. Slide arm closest to head of bed under client’s neck with hand reaching under and supporting client’s opposite shoulder

8. Place other arm under client’s back.

9. Slide client’s trunk, shoulders, head and neck diagonally toward head of bed.

10. Elevate side rail, move to other side of bed and lower side rail.

Positioning and Moving Clients

Moving immobile client up in bed with draw sheet or pull sheet (two nurses)

1. Place draw sheet, or pull sheet under client by turning side to side. Have sheet extend from shoulders to thighs. Return client from supine position.

2. Position one nurse at each side of client.

Positioning and Moving Clients

3. Grasp draw sheet firmly near the client

4. Place feet apart with forward backward stance. Flex knees and hips. Shift weight from to back leg and move client and draw sheet.

5. Realign client in correct body alignment.

Positioning and Moving Clients

Moving the client to the side of the bed

1. Stand as close as possible at the side of the bed. 2. Place the client's near arm across the chest.

3.Move the client's head and trunk.

4. Move the client's buttocks.

5. Move the client's legs and feet.

Positioning and Moving Clients

Position client in lateral (side-lying) position

1.Lower the head of bed completely or as low as client can tolerate.

Positioning and Moving Clients

2. Position client to side of bed.

3.Prepare to turn client unto side. Flex client’s knee that will not be next to mattress. Place one hand on client’s hip and one hand on client’s shoulder.

4. Roll client unto side toward you.

5. Place pillow under client’s head and neck.

Positioning and Moving Clients

6. Bring shoulder blade forward.

7. Position both arms in slightly flexed position. Upper arm is supported by pillow level with shoulder, other arm by mattress.

8. Place tuck-back pillow behind client’s back.

9. Place pillow under semi-flexed upper leg level at hip from groin to foot.

10 Place sandbag parallel to plantar surface of dependent foot.

Positioning and Moving Clients

Position clients in prone position

1.With client supine, roll client over arm positioned close to body, with elbow straight And hand under hip. Position on abdomen in center of bed.

Positioning and Moving Clients

2. T urn client to one side and support head with pillow.

3. Place small pillow under client’s abdomen below level of diaphragm.

4. Support arms in flexed position level at shoulders.5. Support lower legs with pillows to elevate toes.