/policies/,/policies/clinical/,/policies/clinical/uwhc-clinical/,/policies/clinical/uwhc-clinical/department-specific/,/policies/clinical/uwhc-clinical/department-specific/nursing-patient-care/,/policies/clinical/uwhc-clinical/department-specific/nursing-patient-care/integumentary/,

/policies/clinical/uwhc-clinical/department-specific/nursing-patient-care/integumentary/412.policy

201609260

page

100

UWHC,

Policies,Clinical,UWHC Clinical,Department Specific,Nursing Patient Care,Integumentary

Eye Irrigation for Removal of Foreign Material or Chemical Substance (4.12)

Eye Irrigation for Removal of Foreign Material or Chemical Substance (4.12) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Integumentary

4.12

NURSING PATIENT CARE POLICY & PROCEDURE






Effective Date:
August 30, 2016

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 4.12

Original
Revision

Page
1
of 3

Title: Eye Irrigation for Removal of Foreign
Material or Chemical Substance

I. PURPOSE

To establish guidelines for Registered Nurses (RNs), Licensed Practical Nurses
(LPNs), and Medical Assistants (MAs) who perform eye irrigation to remove foreign
material or chemical substance from the eye.

II. POLICY

Eye irrigation, also known as eye flushing, requires a provider’s order.

III. EQUIPMENT

A. IV pole
B. IV macrodrip tubing
C. Sterile irrigant, as prescribed (1,000 mL IV bag of lactated Ringer's [LR] solution
or normal saline [NS])
D. Bath towel and waterproof underpad
E. pH indicator tape
F. 18 or 20 gauge over the needle catheter with the stylet removed or Morgan
ophthalmic irrigation lens (available in the Emergency Department)
G. Gloves and other personal protective equipment

IV. PROCEDURE

A. Obtain provider's order for topical anesthetic, type of irrigant, amount and/or
duration of irrigation.
1. Do not delay irrigation when a chemical exposure is suspected. To help
identify the causative agent, obtain a baseline pH (pH greater than 12
generally are alkaline substances. Acidic substances have a pH less than
2).
2. LR solution is preferred over NS as the pH of LR is is closer to tears than
NS.
3. For acidic exposure, with the exception of hydrofluoric and heavy metal
acids, immediately irrigate with a minimum of 1,000 mL of LR solution
per eye. Measure the pH of the eye after a liter and after each irrigation
until normal pH. Continue with irrigation until the pH is normal (7.0).
4. For alkaline exposure, immediately irrigate with a minimum of 2,000 mL
of LR or NS per eye over about 1 hour. If alkali burns are suspected,
continuous irrigations may be ordered until the Burn Center staff or an
ophthalmologist sees the patient.


Page 2 of 3

B. Patient Preparation
1. Check for allergies.
2. Explain the procedure to the patient.
3. Perform hand hygiene according to Hospital Administrative Policy 13.08,
Hand Hygiene and don non-sterile gloves
4. Instill topical anesthetic into affected eye as ordered. The topical
anesthetic may require a repeat instillation if enough time has lapsed.
Clarify the provider order for repeating this, if needed.
5. For chemical exposure, measure a baseline pH of the eye.
6. The preferred patient position is supine with head slightly tilted toward
affected side, if tolerated . Use towels or waterproof underpad around
patient’s head and neck for comfort and to protect from excessive
dampness during the procedure. A basin may be used to catch the irrigant
or the patient may be positioned over the sink, if tolerable.
C. Irrigating (Morgan) Lens
1. Do not use a Morgan Lens if there has been a penetrating injury or a
possible ruptured globe injury.
2. Spike the IV tubing into the IV fluid and attach the Morgan Lens.
3. Prime the tubing and Morgan Lens with fluid to moisten the surface of the
lens. Stop the fluids prior to insertion.
4. Ask the patient to look down. Insert Morgan Lens under upper lid. Have
patient look up and then retract the lower lid, drop lens in place. This
procedure is similar to inserting a contact lens.
5. Start the irrigant and adjust the flow rate to a level tolerated by the patient.
A wide-open flow may create too much pressure.
6. Instruct the patient to keep the eyes closed to ensure that the lens stays in
the eye.
7. Do not allow the fluid to run dry; avoid getting irrigating solution into
unaffected eye.
8. If both eyes require irrigation, use a different lens for each eye. Both eyes
may be irrigated at the same time.
9. Measure the pH of the eye after a liter and after each irrigation until
normal pH is achieved. Continue with irrigation until the pH is normal
(7.0).
10. Assess patient's comfort periodically. Instill additional ophthalmic
anesthetic as necessary as ordered by the provider.
11. Recheck the conjunctival pH approximately 20 minutes after completion
of the irrigation to ensure that the pH remains in the normal range. Inform
provider if pH is not within normal limits. Perform additional pH checks
and irrigation, as ordered.
12. Remove the lens by asking the patient to look upward. Continue the flow
when removing the lens. Retract the lower lid, lift one side of the lens to
break the suction, and gently slide the lens from the cornea.
13. Document in the patient’s clinical record the irrigation solution used,
amount, pH and condition of conjunctiva.
D. Manual Irrigation (May need eye protection, masks and gown with possible
splashing)


Page 3 of 3

1. Spike the IV tubing into the IV fluid and attach the catheter (needle
removed). Irrigant (drip) runs by gravity flow when clamp is open.
2. Use gauze pads to hold the eyelids open if the patient is unable to do so.
Direct the flow of the irrigant onto the conjunctiva from the inner to the
outer canthus. Avoid a direct stream onto the cornea, as it can be harmful.
Avoid getting irrigating solution into unaffected eye.
3. Instruct the patient to roll the eyes in all directions to irrigate all parts of
the eye.
4. Measure the pH of the eye after a liter and after each irrigation until
normal pH is achieved. Continue with irrigation until the pH is normal
(7.0).
5. Assess patient's comfort periodically. Instill additional ophthalmic
anesthetic as necessary as ordered by the provider.
6. Recheck the conjunctival pH approximately 20 minutes after completion
of the irrigation to ensure that the pH remains in the normal range. Inform
provider if pH is not within normal limits. Perform additional pH checks
and irrigation, as ordered.
7. Document in the patient’s clinical record:
A. Irrigation solution used
B. Amount
C. pH
D. Condition of conjunctiva.

V. REFERENCES

A. Egging, D. (2010). Ocular emergencies. In P. K. Howard & R.A. (Eds.). Sheehy’s
Emergency Nursing Principles and Practice (6th Ed., pp. 602-615). Philadelphia,
PA: Elsevier.
B. Proehl, J. A. (2008). Eye Irrigation. Emergency Nursing Procedures (4th Ed., pp.
755-761). Saunders.
C. www.morganlens.com

VI. REVIEWED BY

Clinical Nurse Specialist, Emergency Department
Nursing Patient Care Policy and Procedure Committee, August 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer