Name: ________________________________________
Date: _________________________________________
Procedure 38-5:
Instilling Eye Medication
Objective: Instill eye medication following the physician’s orders.
Equipment and Supplies: Sterile medication; sterile eyedropper (if needed); tissues; sterile gauze
squares; nonsterile gloves; drape or towel
Affective Behaviors: Affective behaviors provide a professional approach to a skill that enhances
the patient encounter. These behaviors may also display sensitivity to a patient’s rights and
enhance communication. Pay close attention to these skills, which will be in bold, italicized font.
Skills Assessment Requirements
Read and familiarize yourself with the procedure. Complete each procedure within a reasonable
amount of time, with a minimum of 85% accuracy.
Documentation
Use the area below for any documentation needed to complete the procedure.
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GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
1. Perform hand hygiene.
2. Check the physician’s orders.
3. Identify the patient, introduce
yourself, and explain the
procedure.
4. Check the name of the
medication, expiration date, and
concentration three times.
5. Ask if the patient has any
known allergies to the
medication.
6. Give the patient a tissue to blot
cheeks.
7. Put on gloves.
8. Position the patient with head
tilted back and looking up.
9. Pull down the lower eyelid,
exposing the conjunctiva
(Figure A).
10. Place the dropper about ½
inch above the eyeball with the
dominant hand. Insert the proper
number of drops to the center of
the conjunctiva, or if ointment is
used, apply as a thin strip from
inner to outer canthus.
11. Do not touch the dropper or
ointment tube to the eye.
12. Ask the patient to gently close
the eye and rotate the eyeball.
13. Using sterile gauze, dry the
excess medication from the inner
canthus to the outer canthus.
14. Explain to the patient that
vision may be blurry.
POINT VALUE
= 3–6 points
= 7–9 points
Name: ________________________________________
Date: _________________________________________
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GRADED
TRIAL
# 1
GRADED
TRIAL
# 2
NOTES
15. Clean the area and dispose of
unused medication.
16. Remove gloves and perform hand
hygiene.
17. Document the procedure
appropriately.
GRADING
Points Earned
Points Possible 126 126
Percent Grade (Points Earned/
Points Possible)
PASS: YES
NO
N/A
YES
NO
N/A
Instructor Sign-O
Instructor: ______________________________________________ Date: _________________________
POINT VALUE
= 3–6 points
= 7–9 points
Name: ________________________________________
Date: _________________________________________
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