Policy & Procedure
Shiawassee County Medical Care Facility
Approved by Social Services Board
Date: 12/31/99
Nose Drops, Instillation of
Basic Responsibility: Licensed Nurse
If performed by individuals other than those listed in Basic Responsibility, check all that apply.
Procedure Performed by: LPN RN
Purpose
1. To relieve congestion and irritation.
General Resident Rights Guidelines
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If resident is in his/her room, knock on the door, wait for a response and identify yourself.
Identify resident and explain reason for procedure.
Explain benefits of the procedure to the resident.
Explain safety measures of the procedure to the resident.
Explain the adverse effects and/or complications of the procedure to the resident.
Place call light within reach and instruct resident to call for assistance, if needed.
Screen if appropriate for privacy.
Include resident’s family and surrogate health care decision-makers in care planning when
possible.
General Guidelines for Assessment may include, but are not limited to:
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Presence of pain or discomfort.
Congestion.
Respiratory distress.
Symptoms of the condition that necessitates administration of the nose drops.
Bleeding from the nose.
Condition of the nasal mucosa.
Allergies.
General Infection Control Guidelines
1. Observe (standard) universal precautions or other infection control standards as approved
by appropriate facility committee.
2. Wash your hands before and after all procedures. Wear gloves when appropriate.
3. Clean and dry skin around the nares.
4. Dispose of disposable equipment appropriately.
5. Thoroughly clean all equipment used and return to appropriate storage area.
6. Dispose of soiled linen appropriately.
Equipment
1. Medication as ordered.
2. Medication dropper.
3. Tissue wipes.
Precautions
1. Excessive use of astringents tends to cause chronic nasal congestion.
2. Aspirations of oily solutions may result in pneumonitis.
Procedure
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Policy & Procedure
Date: 12/31/99
1. Verify physician’s order.
2. Assist resident to sitting position or dorsal recumbent position with head tilted backward.
3. Ask the resident to blow his/her nose. Clean secretions from nasal area with tissue wipes
prior to instillation of medication.
4. Instill medication in the amount ordered.
5. Instruct resident to remain in this position for a few minutes and gently inhale. Instruct
resident not blow nose. Clean any medication that may have leaked from nose with tissue
wipes.
6. Position resident comfortably with call light within reach.
Possible Related Minimum Data Set Triggers
1. Psychosocial well-being.
2. Nutritional status.
3. Dehydration/fluid maintenance.
General Documentation Guidelines
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Date, time (or shift), as appropriate.
Other Documentation May Include:
Date, time, amount, strength and dosage of medication administered.
Resident’s tolerance to procedure.
Signature and title.
Follow up with documentation of effectiveness of medication.
General Resident Care Plan Documentation Guidelines
Problem
 Identify the appropriate problem that requires instillation of nose drops.
 Consider listing possible risks and complications.
Goal
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List MEASURABLE goal(s) to be accomplished.
List target date.
Approaches
 List responsible discipline for each approach.
 List instructions unique to this resident.
 List necessary monitoring and observation of the underlying condition that requires
instillation of nose drops.
 List monitoring of respiratory status.
 List monitoring of congestion.
 List monitoring of bleeding from the nose.
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