Skill Checklists for Taylor's Clinical Nursing Skills: A Nursing Process Approach

105

Copyright © 2011 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Skill Checklists for Taylor's Clinical Nursing Skills:

SKILL 5-20

Instilling Nose Drops (Continued)

Comments

b. Ask the patient to state his or her name and birth date,

based on facility policy.

c. If the patient cannot identify him- or herself, verify the

patient’s identification with a staff member who knows

the patient for the second source.

15. Complete necessary assessments before administering med-
    ications. Check the patient’s allergy bracelet or ask the
    patient about allergies. Explain the purpose and action of
    each medication to the patient.


16. Scan the patient’s bar code on the identification band, if
    required.


17. Put on gloves.


18. Provide patient with paper tissues and ask patient to blow
    his or her nose.


19. Have patient sit up with head tilted well back. If patient is
    lying down, tilt head back over a pillow.


20. Draw sufficient solution into dropper for both nares. Do
    not return excess solution to a stock bottle.


21. Ask the patient to breathe through the mouth. Hold tip of
    nose up and place dropper just above naris, about^1 ⁄ 3 inch.
    Instill the prescribed number of drops in one naris and
    then into the other. Protect dropper with a piece of soft
    tubing if patient is an infant or young child. Avoid touch-
    ing naris with dropper.


22. Have patient remain in position with head tilted back for a
    few minutes.


23. Remove gloves. Assist the patient to a comfortable position.


24. Remove additional PPE, if used. Perform hand hygiene.


25. Document the administration of the medication immediately
    after administration.


26. Evaluate the patient’s response to the procedure and
    medication within appropriate time frame.

ExcellentSatisfactoryNeeds Practice