Form ACI/D13/2736 "Nurse Delegated Emergency Care Basic Eye Problems Management Competency Assessment Tool" - New South Wales, Australia

Form ACI/D13/2736 is a New South Wales Agency for Clinical Innovation - issued form also known as the "Nurse Delegated Emergency Care Basic Eye Problems Management Competency Assessment Tool".

Download a PDF version of the latest Form ACI/D13/2736 down below or find it on the New South Wales Agency for Clinical Innovation Forms website.

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Download Form ACI/D13/2736 "Nurse Delegated Emergency Care Basic Eye Problems Management Competency Assessment Tool" - New South Wales, Australia

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Rate (4.5 / 5) 26 votes
1 of 2
N
D
E
C
B
E
P
M
C
URSE
ELEGATED
MERGENCY
ARE
ASIC
YE
ROBLEMS
ANAGEMENT
OMPETENCY
1
A
T
SSESSMENT
OOL
This competency assessment tool allows a facilitator to assess nurse confidence and competence in undertaking a basic nursing eye
assessment and commencing basic nursing management of eye problems as guided by the Emergency Care Institute’s Nurse Delegated
Emergency Care “Eye Problems” Nursing Management Guideline.
This assessment tool may be applicable to other basic nursing eye assessment contexts; however, facilitators should note that the tool is
designed within the guidelines and principles of the Nurse Delegated Emergency Care (NDEC) program.
2
3
4
5
Confidence
Performance Criteria
Competent
NYC
Comments
CENA
ANMC
General Understanding of Basic Eye Problems Management
Describes the types of eye problems that can
present to an Emergency Department
(Traumatic – blunt and penetrating, chemical, foreign body,
lacerations to eye lid or surrounding tissue.
Non traumatic – infection, allergies, degenerative processes)
Summarises eye problems that are considered
suitable for inclusion through NDEC
(Low acuity / low risk – Australasian Triage Scale category 4 or
5 and no Red Flags as per the Nursing Management Guideline.
Examples could include “red eye”, “Welder’s flash”, non-
embedded foreign body)
States further patient care resources for eye
management
(Eye Emergency Manual, ECI, local guidelines or protocols)
Employs principles of infection control and Work
Health and Safety throughout eye problem
management
NDEC Eye Assessment
Sets up correct equipment for eye exam
(Visual acuity / Snellen chart, Pinhole occulder or equivalent,
ophthalmoscope, Fluorescein drops, ophthalmoscope)
Identifies potential aids that a patient may require
during the exam
(Glasses, contact lens, interpreters, alternate visual charts –
pictures instead of letters or figures)
Prepares patient correctly for visual acuity
assessment
(Patient comfortable and correct distance from visual chart
being used. Can identify the correct distance required as per
the chart being used)
Demonstrates visual acuity assessment on both
eyes and explains clinical significance of findings
(Descending order of letters on the visual chart. Uses other
charts if appropriate. Any acute alteration in vision requires
medical review – not an NDEC patient)
Describes or demonstrates procedure for
continued testing if visual acuity is less than 6/6
(Pin hole disk on affected eye to improve vision, other methods
of assessing vision using hand signals then light perception)
Demonstrates correct method for instilling
Fluorescein eye drops (or using blotting paper)
for eye exam
(Pull down lower eyelid to form a ‘pocket’, tilt head slightly back
and get patient to look up, instil drops into pocket formed [or
place blotting paper on eye lid], instruct patient to close eyes
and move eye side to side/ up and down to spread medication)
1
Adapted from Sydney / Sydney Eye Hospitals Clinical Nursing Services Department (2012) Assessment of Visual Acuity and Assessing and Performing Instillation of Eye Drops / Ointment SSEH
CNSD
2
Completed by the participant. Confidence is a declaration from the participant that they are confident in the particular performance criteria prior to formal assessment.
3
NYC = Not Yet Competent. Competence is not adequately demonstrated.
4
CENA = Criteria mapped to: College of Emergency Nursing Australasia (2007) Practice Standards for the Emergency Nursing Specialist (http://cena.org.au/CENA/Documents/Standards.pdf)
5
ANMC = Criteria mapped to: Australian Nursing and Midwifery Council (2006) National Competency Standards for the Registered Nurse (http://www.nursingmidwiferyboard.gov.au)
www.ecinsw.com.au
ACI/D13/2736 V1.0
1 of 2
N
D
E
C
B
E
P
M
C
URSE
ELEGATED
MERGENCY
ARE
ASIC
YE
ROBLEMS
ANAGEMENT
OMPETENCY
1
A
T
SSESSMENT
OOL
This competency assessment tool allows a facilitator to assess nurse confidence and competence in undertaking a basic nursing eye
assessment and commencing basic nursing management of eye problems as guided by the Emergency Care Institute’s Nurse Delegated
Emergency Care “Eye Problems” Nursing Management Guideline.
This assessment tool may be applicable to other basic nursing eye assessment contexts; however, facilitators should note that the tool is
designed within the guidelines and principles of the Nurse Delegated Emergency Care (NDEC) program.
2
3
4
5
Confidence
Performance Criteria
Competent
NYC
Comments
CENA
ANMC
General Understanding of Basic Eye Problems Management
Describes the types of eye problems that can
present to an Emergency Department
(Traumatic – blunt and penetrating, chemical, foreign body,
lacerations to eye lid or surrounding tissue.
Non traumatic – infection, allergies, degenerative processes)
Summarises eye problems that are considered
suitable for inclusion through NDEC
(Low acuity / low risk – Australasian Triage Scale category 4 or
5 and no Red Flags as per the Nursing Management Guideline.
Examples could include “red eye”, “Welder’s flash”, non-
embedded foreign body)
States further patient care resources for eye
management
(Eye Emergency Manual, ECI, local guidelines or protocols)
Employs principles of infection control and Work
Health and Safety throughout eye problem
management
NDEC Eye Assessment
Sets up correct equipment for eye exam
(Visual acuity / Snellen chart, Pinhole occulder or equivalent,
ophthalmoscope, Fluorescein drops, ophthalmoscope)
Identifies potential aids that a patient may require
during the exam
(Glasses, contact lens, interpreters, alternate visual charts –
pictures instead of letters or figures)
Prepares patient correctly for visual acuity
assessment
(Patient comfortable and correct distance from visual chart
being used. Can identify the correct distance required as per
the chart being used)
Demonstrates visual acuity assessment on both
eyes and explains clinical significance of findings
(Descending order of letters on the visual chart. Uses other
charts if appropriate. Any acute alteration in vision requires
medical review – not an NDEC patient)
Describes or demonstrates procedure for
continued testing if visual acuity is less than 6/6
(Pin hole disk on affected eye to improve vision, other methods
of assessing vision using hand signals then light perception)
Demonstrates correct method for instilling
Fluorescein eye drops (or using blotting paper)
for eye exam
(Pull down lower eyelid to form a ‘pocket’, tilt head slightly back
and get patient to look up, instil drops into pocket formed [or
place blotting paper on eye lid], instruct patient to close eyes
and move eye side to side/ up and down to spread medication)
1
Adapted from Sydney / Sydney Eye Hospitals Clinical Nursing Services Department (2012) Assessment of Visual Acuity and Assessing and Performing Instillation of Eye Drops / Ointment SSEH
CNSD
2
Completed by the participant. Confidence is a declaration from the participant that they are confident in the particular performance criteria prior to formal assessment.
3
NYC = Not Yet Competent. Competence is not adequately demonstrated.
4
CENA = Criteria mapped to: College of Emergency Nursing Australasia (2007) Practice Standards for the Emergency Nursing Specialist (http://cena.org.au/CENA/Documents/Standards.pdf)
5
ANMC = Criteria mapped to: Australian Nursing and Midwifery Council (2006) National Competency Standards for the Registered Nurse (http://www.nursingmidwiferyboard.gov.au)
www.ecinsw.com.au
ACI/D13/2736 V1.0
2 of 2
6
7
8
9
Confidence
Performance Criteria
Competent
NYC
Comments
CENA
ANMC
Demonstrates correct use of cobalt blue light to
assess for abnormalities after Fluorescein
instillation.
(Correctly uses ophthalmoscope with cobalt blue light to assess
for corneal abrasion)
Distinguishes how any abnormalities will appear
with cobalt blue light and explains clinical
significance of findings
(The appearance of a corneal abrasion post Fluorescein
instillation during cobalt blue light assessment will appear as a
green discolouration. This is a clinically significant abnormality,
will require topical antibiotic eye drops in addition to usual
NDEC follow-up)
Management
Demonstrates or describes the management
strategies as outlined in NDEC
(Symptom relief, topical application of eye drops, appropriate
referral)
Explains the NDEC nursing management of
abnormalities as found during above patient
exam
(Consider direct notification to medical officer – withdraw from
NDEC model. Otherwise topical antibiotic eye drops and
referral)
Demonstrates instructing a patient or carer in
correct eye drop application technique
(Wash hands, tilt head up, pull lower lid down to form a pocket
behind the lid, deliver recommended drops / dose without
touching bottle tip to eye, shut eyelid and keep shut for 1
minute, recap bottle and wash hands. Provides appropriate
factsheet to patient / carer)
Documentation
1.4, 2.1,
2.2, 6.3,
Produces a medical record that documents
2.3, 7.1
6.4, 7.8,
9.2, 10.2
assessment findings, and subsequent
management (including medication
administration)
Competent
Not Yet Competent
(must meet all above criteria)
Facilitator Name: ___________________ Facilitator Signature: ___________________
Facilitator Comments:
Participant Name: __________________ Participant Signature: ___________________
Participant Comments:
Date: __ / __ / __
LHD: ______
Facility: ______
6
Completed by the participant. Confidence is a declaration from the participant that they are confident in the particular performance criteria prior to formal assessment.
7
NYC = Not Yet Competent. Competence is not adequately demonstrated.
8
CENA = Criteria mapped to: College of Emergency Nursing Australasia (2007) Practice Standards for the Emergency Nursing Specialist (http://cena.org.au/CENA/Documents/Standards.pdf)
9
ANMC = Criteria mapped to: Australian Nursing and Midwifery Council (2006) National Competency Standards for the Registered Nurse (http://www.nursingmidwiferyboard.gov.au)
www.ecinsw.com.au
ACI/D13/2736 V1.0
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