Lesson 9 — Ophthalmology and Otolaryngology Assisting

1. Sanitize your hands.

   Purpose

   To ensure infection control.

2. Prepare the area, make sure the room is well-lit and that a distance marker is 20 feet from the chart.
3. Identify the patient by name and date of birth, and explain the procedure. Instruct the patient not to squint during the test because this temporarily improves vision. The patient should not have an opportunity to study the chart before the test is given. If the patient wears corrective lenses, they should be worn during the test.

   Purpose

   Explanations help gain the patient's cooperation and alleviate apprehension.

4. Position the patient in a standing or sitting position at the 20 ft marker.

   Purpose

   Twenty feet is the standard testing distance.

5. Check that the Snellen chart is positioned at the patient's eye level. If the occluder is not disposable, disinfect it before the procedure starts. Instruct the patient to cover the left eye with the occluder and to keep both eyes open throughout the test to prevent squinting.

   Purpose

   Traditionally, the right eye is tested first.

6. Stand beside the chart and point to each row as the patient reads it aloud, starting with the 20/70 row.

   Purpose

   Starting with larger letters gives the patient confidence and allows for accommodation of vision.

7. Proceed down the rows of the chart until the smallest row that the patient can read with the maximum of two errors is reached. If one or two letters are missed, the outcome is recorded with the minus sign and the number of errors (e.g., 20/40–2). If more than two errors are made, the previous line should be documented.
8. Record any of the patient's reactions while reading the chart. Reactions such as squinting, leaning, tearing, or blinking may indicate that the patient is having difficulty with the test.
9. Repeat the procedure with the left eye, covering the right eye.
10. Repeat the procedure with both eyes uncovered.
11. Disinfect the occluder, if it is not disposable, and sanitize your hands.

    Purpose

    To follow infection control procedures.

12. Document the procedure in the patient's record. Include the date and time, visual acuity results, and any reactions. Also record whether corrective lenses were worn.

    Purpose

    Procedures that are not recorded are considered not done.

1. Assemble the equipment and prepare the room for testing. The room should be quiet and illuminated with natural light.

   Purpose

   Natural light is needed to test colors correctly.

2. Check the provider's order. Then introduce yourself and verify the patient's identity by name and date of birth. Explain the procedure. Use a practice card during the explanation and make sure the patient understands that he or she has 3 seconds to identify each plate.

   Purpose

   To make sure you have the right patient. Also, an informed patient is a cooperative patient.

3. The first plate is a practice plate and is designed to be read correctly. Hold up the first plate at a right angle to the patient's line of vision and 30 inches from the patient. Be sure both of the patient's eyes are kept open during the test.
4. Ask the patient to tell you the number on the plate. Record the plate number and the patient's answer.
5. Continue this sequence until all 11 plates have been read. If the patient cannot identify the number on the plate, place an X in the record for that plate number. Your record should look like this: Plate 1 = pass, Plate 2 = pass, Plate 3 = X, Plate 4 = pass, and so on.
6. Include any unusual symptoms in your record, such as eye rubbing, squinting, or excessive blinking.
7. Place the book back in its cardboard sleeve and return it to its storage space.

   Purpose

   The Ishihara color plates must be stored in a closed position away from external light to protect the colors.

8. Document the procedure in the patient's health record, including the date and time, the testing results, and any patient symptoms shown during the test.

   Purpose

   Procedures that are not recorded are considered not done.

1. Sanitize your hands.

   Purpose

   To ensure infection control.

2. Check the provider's orders to determine which eye requires irrigation (or whether both eyes require it) and the type of solution to be used.
3. Assemble the materials needed. Check the expiration date of the solution. Follow medication safety procedures and check the label of the solution three times: (1) when you remove it from the shelf; (2) when you pour it; and (3) when you return it to the shelf.

   Purpose

   To follow the rules for safely administering medications.

4. Identify the patient by name and date of birth and explain the procedure.

   Purpose

   To make sure you have the right patient. Also, explanations help gain the patient's cooperation and ease apprehension.

5. Assist the patient into a sitting or supine position, making sure that the head is turned toward the side of the affected eye. Place the disposable drape over the patient's neck and shoulder.

   Purpose

   This position causes the solution to flow away from the unaffected eye, reducing the chance of cross-contamination of the healthy eye.

6. Put on gloves and rinse your gloved hands under warm water to remove all powder from the gloves, or wear powder-free gloves.

   Purpose

   Gloves help hold the eye open, but powder may irritate the eyes.

7. Place (or have the patient hold) a drainage basin next to the affected eye to receive the solution from the eye. Place a poly-lined drape under the basin to prevent the solution from getting on the patient.
8. Moisten a gauze square with solution and cleanse the eyelid and lashes. Start at the inner canthus (near the nose) and move to the outer canthus (farthest from the nose). Dispose of the gauze square in the biohazard waste container after each wipe.

   Purpose

   Debris on the lids or lashes must be cleaned away before the conjunctiva is exposed.

9. If you are using a bulb syringe, pour the required volume of room-temperature irrigating solution into the basin and draw the solution into the bulb syringe. If an irrigating solution in a prepackaged dispenser is used, remove the lid.

   Purpose

   Cold solution causes the patient pain and discomfort.

10. Separate and hold the eyelids with the index finger and thumb of one hand. With the other hand, place the syringe or dispenser on the bridge of the nose parallel to the eye.

    Purpose

    To support and steady the dispenser.

11. Squeeze the bulb or dispenser, directing the solution toward the lower conjunctiva of the inner canthus; allow the solution to flow steadily and slowly from the inner to the outer canthus. Do not touch the eye or eyelids with the applicator.

    Purpose

    To prevent possible injury to the eye.

12. Refill the syringe or continue to gently squeeze the prepackaged bottle, and continue the procedure until the amount of solution ordered by the provider has been administered or until drainage from the eye is clear.
13. Dry the eyelid with sterile gauze, moving from the inner canthus to the outer canthus. Do not use cotton balls because fibers might remain in the eye.
14. Dispose of the irrigation results and disinfect the work area.
15. Remove your gloves, dispose of them in the biohazard waste container, and sanitize your hands.

    Purpose

    To ensure infection control.

16. Document the procedure in the patient's health record; include the date and time, the type and amount of solution used, which eye was irrigated, any significant reactions by the patient, and the results.

    Purpose

    Procedures that are not recorded are considered not done.

1. Sanitize your hands.

   Purpose

   To ensure infection control.

2. Check the provider's order to determine which eye requires medication (or whether medication is ordered for both eyes) and the name and strength of the medication to be used.

   Purpose

   To prevent a medication error.

3. Assemble the equipment and supplies. Check the expiration date of the solution. Follow medication safety procedures and check the label of the medication three times: (1) when you remove it from the shelf; (2) when you pour it; and (3) when you return it to the shelf.

   Purpose

   To follow the rules for safely administering medications.

4. Introduce yourself, identify the patient by name and date of birth, and explain the procedure.

   Purpose

   To make sure you have the right patient. Also, explanations help gain the patient's cooperation and ease apprehension.

5. Put on nonsterile gloves and rinse your gloved hands under warm water to remove all powder from the gloves or wear powder-free gloves.

   Purpose

   Gloves help hold the eye open, but powder may irritate the eyes.

6. Assist the patient into a sitting or supine position. Ask the patient to tilt the head backward and look up. For eye drops, draw the medication into the dropper. For an eye ointment, remove the cap.

   Purpose

   Looking up helps prevent the applicator's tip from touching the cornea. It also helps keep the patient from blinking as the medication is instilled.

7. Pull the lower conjunctival sac downward.

   Purpose

   To create a pocket for the medication.

8. Administer the prescribed number of drops or amount of ointment into the eye. For eye drops, place the drops in the center of the lower conjunctival sac, with the tip of the dropper held parallel to the eye and 1/2 inch above the eye sac. For eye ointment (ung), squeeze a thin ribbon along the lower conjunctival sac from the inner canthus to the outer canthus, making sure not to touch the eye with the applicator.

   Purpose

   Placing the medication in the conjunctival sac rather than on the eyeball prevents injury to the cornea. Touching the eye with the applicator could injure the eye and contaminates the applicator.

9. Instruct the patient to close the eye gently and rotate the eyeball.

   Purpose

   Gently closing the eye prevents the medication from being dispelled, and rotating the eyeball distributes the medication evenly.

10. Dry any excess drainage from the inner canthus to the outer canthus, and explain that the medication may temporarily blur vision.
11. Discard the unused medication, and disinfect the procedure area.
12. Remove your gloves, dispose of them in the biohazard waste container, and sanitize your hands.

    Purpose

    To ensure infection control.

13. Record the procedure in the patient's health record, including date and time, name and strength of the medication, dose administered, eye treated, teaching instructions given (if treatment is to continue at home), and any observations.

    Purpose

    Procedures that are not recorded are considered not done.

1. Sanitize your hands, assemble the equipment, and bring the patient into a quiet area.

   Purpose

   The testing room should be free of distractions and noise so the patient can concentrate completely on the hearing evaluation.

2. Introduce yourself, identify the patient by name and date of birth, and explain the procedure.

   Purpose

   To make sure you have the right patient. Also, explanations help gain the patient's cooperation and ease apprehension.

3. Explain that the audiometer measures whether the patient can hear various sound wave frequencies through the headphones. Each ear is tested separately. When the patient hears a frequency, he or she should raise a hand or push the button to signal the medical assistant.

   Purpose

   Patient education is needed for compliance with the examination.

4. Place the headphones over the patient's ears, making sure they are adjusted for comfort. The audiometer tests each ear separately, starting at a low frequency. If the results are not automatically recorded by the machine, the medical assistant documents the patient's response to the frequencies on a graph or audiogram. Results for the left ear are marked with an X, and those for the right ear are marked with an O. More advanced machines automatically record the results.
5. The medical assistant must have specialized training to conduct this test.
6. Frequencies are increased gradually to test the patient's ability to hear. Each response by the patient is documented. After one ear has been tested, the other ear is then tested, and the results are documented.
7. The results are given to the provider for interpretation or downloaded into the patient's electronic health record for the provider to review.

   Purpose

   Procedures that are not documented did not occur.

8. The equipment is sanitized and disinfected according to the manufacturer's guidelines.
9. Sanitize your hands.

   Purpose

   Medical Asepsis

1. Sanitize your hands.

   Purpose

   To ensure infection control.

2. Check the provider's order and assemble the materials needed. Check the label of the solution three times: (1) when you remove it from the shelf; (2) when you pour it; and (3) when you return it to the shelf.

   Purpose

   To prevent a medication error.

3. Prepare the solution as ordered. The solution should be kept at body temperature to help loosen the cerumen.
4. Introduce yourself, identify the patient by name and date of birth, and explain the procedure.
5. Inspect the affected ear with an otoscope to locate the cerumen impaction.
6. Place the patient in a sitting position with the head tilted toward the affected ear. Place a water-absorbent towel over a poly-lined barrier on the patient's shoulder, and the collecting basin on the towel at the base of the ear. The patient can assist you by holding the collecting basin in place.

   Purpose

   To minimize the risk of getting the patient's clothing wet and to direct the flow of water into the collecting basin.

7. Put on gloves and wipe any particles from the outside of the ear with gauze squares.

   Purpose

   To prevent the introduction of foreign material into the ear canal.

8. Test to make sure the solution is warm; then fill the syringe and expel air.

   Purpose

   Cold medication may increase the pain level or cause symptoms of nausea and vertigo; trapped air in the syringe increases the pressure of the irrigation, causing discomfort.

9. Straighten the external ear canal. For adults and children older than age 3, gently pull the pinna of the ear up and back; for children younger than age 3, pull the earlobe down and back.

   Purpose

   Straightening the canal allows the irrigating fluid to circulate through it.

10. Place the tip of the syringe into the meatus of the ear. Gently direct the flow of the solution toward the roof of the external auditory canal.

    Purpose

    This helps prevent injury to the tympanic membrane, aids in the removal of embedded material, and provides the most comfort for the patient.

11. Refill the syringe with warm solution and continue until the material has been removed. Note the particles in the collecting basin to be evaluated when the material has been successfully removed.
12. Dry the patient's external ear with gauze squares and the visible ear canal gently with cotton-tipped applicators.

    Purpose

    Inserting the applicator into the canal may cause serious trauma.

13. Inspect the ear with an otoscope to determine the results.
14. Place a clean, absorbent towel on the examination table and allow the patient to rest quietly with the head turned to the irrigated side while you wait for the provider to return to check the affected ear.
15. Disinfect the work area and the equipment. Dispose of your gloves in the biohazard container, and sanitize your hands.

    Purpose

    To ensure infection control.

16. Document the procedure in the patient's health record, including the date and time; the ear irrigated; the type and amount of irrigating solution used; the characteristics of the material returned from the irrigation; the visibility of the tympanic membrane after irrigation; and any reactions by the patient.

    Purpose

    Procedures that are not recorded are considered not done.

1. Sanitize your hands and gather the equipment and supplies.

   Purpose

   To control infection and to reduce procedure time.

2. Check the medication label three times: (1) when you remove it from the shelf; (2) when you prepare it; and (3) when you return it to the shelf.

   Purpose

   To prevent a medication error.

3. Introduce yourself, identify the patient by name and date of birth, and explain the procedure.
4. Have the patient sit up and tilt the head away from the affected ear, or lie down on the side with the affected ear upward.

   Purpose

   To expose the ear for treatment, allow gravity to help the medication flow into the canal, and ensure the patient's comfort.

5. Check the temperature of the medication bottle. If it feels cold, gently roll the bottle back and forth between your hands to warm the drops.

   Purpose

   Cold medication may increase the pain level or cause symptoms of nausea and vertigo.

6. Hold the dropper firmly in your dominant hand. With the other hand, gently pull the pinna up and back if the patient is older than age 3, or the earlobe down and back if the patient is younger than age 3.

   Purpose

   To straighten the ear canal and make it easier for the medication to reach the target tissue.

7. Place the tip of the dropper in the ear canal meatus and instill the number of ordered medication drops along the side of the canal, making sure that the tip of the dropper does not touch the ear canal.
8. Instruct the patient to rest on the side opposite the affected ear and to remain in this position for approximately 3 minutes.

   Purpose

   To help the medication reach the base of the canal and prevent it from immediately running out of the ear.

9. If instructed by the provider, place a moistened cotton ball into the ear canal.

   Purpose

   To protect the ear canal and prevent medication from leaking out of the ear.

10. Disinfect the work area. Dispose of your gloves in the biohazard waste container, and sanitize your hands.

    Purpose

    To ensure infection control.

11. Document the procedure in the patient's health record, using the appropriate abbreviations; include the date and time; name, dose, and strength of the medication; the ear treated; and any reactions by the patient.

    Purpose

    Procedures that are not recorded are considered not done.

1. Sanitize your hands.

   Purpose

   To ensure infection control.

2. Gather the materials needed.
3. Introduce yourself, identify the patient by name and date of birth, and explain the procedure.
4. Put on gloves and face protection.

   Purpose

   To follow Standard Precautions.

5. Position the patient so that the light shines into the mouth.

   Purpose

   To illuminate the area to be swabbed.

6. Remove the sterile swab from the sterile wrap with your dominant hand and grasp the sterile tongue depressor with your nondominant hand.

   Purpose

   To achieve better control of the swabbing process.

7. Instruct the patient to open the mouth and say "Ah." Depress the tongue with the depressor.

   Purpose

   Saying "Ah" helps elevate the uvula and reduces the tendency to gag. The tongue is depressed so that you can see the back of the throat and prevent contamination of the sterile swab.

8. Swab the back of the throat between the tonsillar pillars, especially any reddened, patchy areas of the throat, white pus pockets, purulent areas, and the tonsils; take care not to touch any other areas in the mouth.

   Purpose

   Pathogenic organisms are found in the back of the throat and on the tonsils.

9. Place the swab in the transport medium, label it, and send it to the laboratory. If direct slide testing is requested, return the labeled swab to the laboratory.

   Purpose

   A transport medium prevents the swab from drying. Labeling immediately after collection prevents specimens from becoming mixed up.

10. Dispose of contaminated supplies in the biohazard waste container.

    Purpose

    To prevent the spread of infection.

11. Disinfect the work area.
12. Remove your gloves and discard them in the biohazard waste container.
13. Sanitize your hands.

    Purpose

    To ensure infection control.

14. Document the procedure in the patient's health record.

    Purpose

    Procedures that are not recorded are considered not done.

Knowledge-check items

Click an answer to lock it in — you'll see the rationale below. Reset any time to re-attempt. Items originally formatted as true/false, fill-in-blank, or drag-and-drop have been normalized to multiple choice; the source format is noted in the eyebrow.

L09-01 · Assess Visual Acuity

L09-02 · Assess Color Acuity

L09-03 · Eye Irrigation

L09-04 · Eye Instillation

L09-05 · Assess Hearing Acuity

L09-06 · Ear Irrigation

L09-07 · Ear Instillation

L09-08 · Throat Culture