Introduction:
The Nepal Health Professionals Council (NHPC) has in accordance with the NHPC Act 2053, approved this code of ethics according to clause 9 (1) of the NHPC Act 2053, for Ophthalmic Assistants those registered under it, are to abide by, the code of ethics is as follows:
It will come into force since Bhadra 1, 2061 (August 17th 2004):
1. Duties of professionals in general: The Health Professionals will:
1.1 Always maintain the highest standard of professional conduct.
1.2 Carryout professional duties with conscience and dignity.
1.3 Maintain the utmost respect for human life right from the time of conception as per the laws of land.
1.4 Not use knowledge contrary to the norms of humanity.
1.5 Dedicate life to the service of humanity.
1.6 Not permit motives of profit to influence the free and independent exercise of professional judgment on behalf of patient/clients.
1.7 Be dedicated to providing competent health service in sound technical and moral independence, with compassion and respect for human dignity.
1.8 Deal honestly with patients and colleagues.
1.9 Not self-advertising by health workers unless permitted by the laws of the country and the code of ethics of NHPC.
1.9.1 Respect the right of patient, of colleagues, and of other health professionals and with safeguard patient confidences.
1.10 Preserve absolute medical confidentiality.
1.11 Give emergency and life saving care as humanitarian duty unless any possibility to do better.
1.12 Observe the code of ethics approved by NHPC.
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1.13 Be a good character, diligent, modest, sober, patience, alert and prompt in action.
1.14 Work with full devotion and should always try to improve medical knowledge and skill so that clients and colleagues are optimum benefited.
1.15 Provide health service on scientific basis and should not be associated professionally with anyone who violates this principle.
1.16 Not allow discrimination of age, sex, religion, nationality, ethnicity, politics or social standing to intervene between professionals and patients.
2. Professional Guideline
2.1 Consultation Process:
When a patient comes to health professional a complete consultation and counseling process should take place in order to make an accurate diagnosis and to give an appropriate treatment and advice. During the consultation and counseling process Health Professional should include the following.
2.1.1 History Taking
To obtain relevant information regarding the symptoms of diseases.
2.1.2 Examination
To obtain physical signs of disease. Includes Inspection, Palpation, Percussion and Auscultation.
2.1.3 Diagnosis
According to the history and the findings of examination, a provisional diagnosis may be made. For the confirmed diagnosis investigation may be needed.
2.1.4 Making treatment plan
Treatment may consist of drug or non-drugs treatment or combination of both. Every disease or illness or symptoms do not require drug. Treatments include:
• Bed rest
• Physiotherapy
• Surgical therapy
• Proper feeding
• Psychotherapy
• Drug Therapy
If the drug treatment is necessary, the drug being prescribed must be:
• Effective
• Safe
• Suitable
• Economical
2.1.5 Advise and information:
Proper information should be given to the patient and family member about the health problem she/ he is suffering from and the treatment required. This will help to comply with the recommended treatment.
In order to achieve a safe, effective and economical use of medicines, prescribing should be based on some basic principles as follows:
2.2.1 Appropriate indication:
Prescribing drug should be based on a real medical indication, consistent with accurate diagnosis and when drug therapy is the best alternative for treating the patient’s health problem. Prescribing of drug should not be made for other reasons, for instance, because of the demands from the patient or to please the patient.
2.2.2 Appropriate drug:
Drugs those are most effective safe, suitable and economical should be prescribed. Health professionals are advised to follow the treatment recommendations mentioned in the guidelines
.
2.2.3 Appropriate for the patient:
The selected drug that is considered best to treat the problem can only be given to an individual patient if no contraindication exists. Otherwise, a safer alternative should be chosen, e.g. Penicillin cannot be given to patient with history of sensitivity to penicillin.
2.2.4 Appropriate administration, dosage and duration:
How drug will be administered, which formulation, what dosages, how often, and for how long, should be decided before prescribing drug to an individual patient. Most of drugs that are used to treat commonly occurring problems in primary eye care center and same level or private clinics are included in this guideline.
2.2.5 Appropriate counseling:
Providing proper information regarding the disease and the medication is an integral part of the prescribing process. Individual patient should be well informed, to ensure the correct use of drugs as well as compliance of the patients.
2.2.6 Appropriate follow-up:
Every treatment should be properly followed-up and evaluated. The expected effect or unwanted side effect should be properly monitored and communicated to patients during follow-up examination. The patient should be informed properly when they should come for follow-up visit.
2.3 Patient Communication:
2.3.1 Sufficient time should be spent with the patient to allow an effective communication regarding the health problem.
2.3.2 Information should be provided and shared on health problem from which the patient is suffering, including its cause, prognosis, and necessary preventive measures to be taken in the future.
2.3.3 It should be clearly explained to the patient and patients care taker regarding the treatment required, both drug and non-drug therapy.
2.3.4 Information about the drug treatment Including the name of drug, route of administration, adverse effect and other related information that patient need to know. Reassurance should be given to patients to help them comply with the treatment. Information should be clearly given to patient when they need to come back for follow-up, and its importance.
2.4 Appropriate dispensing:
Dispensing the prescribed medication correctly is important to ensure safe and effective treatment. The correct drug should be given to the right patient in right .doses, right time, right duration with the clear instruction labeled in the package as well. There are some important
steps for proper delivery of drug to the patient.
2.4.1 Reading & understanding the prescription
2.4.2 Collecting the prescribed drug correctly.
2.4.3 Preparing the required quantity.
2.4.4 Packing and labeling.
2.4.5 Delivery of drugs and counseling.
2.5 Appropriate prescribing and dispensing practices:
The following guidelines should be considered before prescribing a drug in order to comply with the principles of appropriate prescribing:
2.5.1 It depends on accurate diagnosis and knowledge about drug available for treatment.
2.5.2 Avoid prescribing many drugs as far as possible.
2.5.3 Never prescribe any drug just to please the patients. Try to resist any unnecessary demand from the patient for certain products e.g. injectable preparation, expensive combination products.
2.5.4 Do not misuse or overuse the drugs, e.g. do not use antibacterial drugs for problems that are not caused by bacteria like influenza, acute non-specific diarrhoea, scabies etc.
2.5.5 Essential drugs are those which are effective, safe, and economical and are selected to satisfy the needs of the majority of the population. Health professional should always try to adhere to the guidelines and national essential drug list while prescribing drug to the patient.
2.5.6 Every drug may have a risk of adverse reactions, in every case, the likely benefit should be weighed against the potential risk.
2.5.7 Patients with health problem requiring more sophisticated treatment, which is not possible at ophthalmic Assistant level should always be referred to higher facility without delay.
2.6 Prescription and its contents.
2.6.1 Prescription is a legal document. It is a direct means of communication between the health professional/ authorized prescriber and authorized dispenser regarding drug therapy of the patient.
2.6.2 Prescription should be written clearly, legibly, correctly and completely. It will enable the dispenser to understand the content fully, to dispense drugs correctly to the patients, avoiding life-threatening and other serious errors.
2.6.3 A prescription should contain information on three aspects i.e., patient, therapy and prescriber.
- Patient information: name, age, sex and diagnosis.
- Therapy prescribed: name of drug, doses, strength and quantity of drug, route of administration, frequency of administration and duration of administration.
- Prescriber’s name, address and registration number.
- If necessary, special instructions in taking the drugs need to be given to patient. It should be clearly written, e.g. before meal, or after meal.
- The prescriber must sign a prescription. The date of the prescription should also be given.
3. Scope of practice
The OphthalmicAssistant can diagnose and manage and provide appropriate advice and referral to Ophthalmologist for following eye health problems:
1.Common ocular disorders such as: blepharitis, hordeolum, preseptal-cellulitis, chalazion, entropion, ectropion, ptosis, lagophthalmos, trichiasis, distichiasis, symblepheron, epiblepheron, ankyloblepharon, blepharphimosis, telecanthus, tumours (Benign and Malignant) epicanthus, orbital cellulitis, proptosis, pseudo orbital tumours, dysthyroid ophthalmopathy, conjunctivitis (infective and allergic), conjuctival degenerations, sub conjunctival haemorrhage, dacryocystitis, dacryo adenitis, dry eye, Corneal ulcers (bacterial, viral and fungal), corneal degeneration and dystrophy, congenital anomalies, cataract, dislocation and sub-luxation of lens, glaucoma, uveitis (anatomical and clinical types). Pupil abnormalities, vitreous degeneration, retinal vascular disorder, retinitis pigmentosa, retinal detachment, optic neuritis, papillitis, papilloedema, optic atrophy, colour blindness, binocular vision disorder and squint, refractive error and low vision.
2.Common ocular emergency such as: central retinal artery occlusion (CRAO), central retinal vein occlusion (CRVO), vitreous hemorrhage, retinal detachment, corneal ulcer, ocular trauma injury, contusion, orbital fracture, deep corneal and intraocular foreign body, lid laceration, conjuctival laceration, scleral and corneal perforation, hypopion, lens sub-luxation and dislocation, iridodialysis, iris prolapse, hyphema, thermal and chemical burn and radiation injury.
3.Preoperative cares administer eye drops, maintain medication record and carry out routine preoperative investigation of surgical patient.
4.Postoperative care: Identify and manage common surgical complication such as conjunctiva discharge iris prolapse/loose suture, shallow anterior chamber/ wound gap, endophthalmitis, uveitis, corneal edema, hyphema, sub-conjunctival haemorrhage, striate keratitis, chemosis, cortex, anterior and posterior capsule of lens, fibrin in pupil, IOL dislocation, and perform initial management and refer to Ophthalmologist or operating surgeon.
5.Investigative procedure: Monitor vital sign (blood pressure, pulse, respiration, temperature), perform lacrimal syringing, intra-ocular pressure measurement (digital, indentation and applanation method), perform corneal scraping and conjunctival swabs for lab investigation, perform intra-muscular, intravenous, sub-conjuctival, sub-tenon, peribulbar, retrobulbar injections. Prepare site for intra-vitreal injections. Patch eye with eye shield and bandage, perform pressure patch and bandage, trimming of eyelashes, carry out investigations and procedures involved in diagnosing eye disorder such as biometry, visual filed examinations (confrontation, bjerrums screen, lister, friedman, goldman, humphrey), schirmer test, shiedle test, colour vision (ishihara and fansworth), ophthalmic photography, pachymetry autorefratometry and administered and perform fluorescein angiography.
6.Surgical procedure: perform entropion correction, pterygium excision, incision and curette of chalazion, and incision and drainage of lid abscess and stye, lid repair incase of punctum and canaliculus not involved in laceration, perform tarsorraphy, removal of conjunctival, tarsal and superficial corneal foreign body. Scrubbed surgical assisting in all kinds of ocular surgeries. Perform local anesthesia in extra ocular and intra ocular surgery.
7.Community programs, health education and counseling, organize, plan and manage an eye camp,
school screening programme and diagnostic screening and treatment (DST) programme, supervise and teach the primary eye care personnel, educate public on primary eye care including eye health promotion and prevention of preventable eye diseases, conduct training programme for village health worker and other health workers in primary eye care including preventive measures of eye diseases, counsel the patients regarding their ailments & help patients know their problems and mentally prepare them for surgery and treatment.
8.Optical dispensing: measure the visual acuity using varieties of charts and modifications, notations, perform subjective, objective and autorefraction and generate appropriate optical prescription with the help of essential equipment such as retinoscope, lensmeter, keratometer, trial frame, trial lens set, cross cylinder, astigmatic fan, Placido disc, duochrome test etc. Dispense appropriate glass based on prescription, patients need and comfort, examination, management provide appropriate advice and counselling orthoptics and contact lens optical fittings.
9.Low vision clinical assessment: differentiate normal vision, low vision and blindness according to the WHO functional definition. Perform subjective and objective refraction of a low vision person. Assess other visual function e.g. contrast sensitivity, illumination, color vision and visual field and binocular vision when necessary. Calculate and assess the need for magnification. Prescribe the optical devices (magnifying near and distance devices) and teach the client in the use of devices.
Ophthalmic Assistant can prescribe drugs such as:
1.1 Antibiotics Systemic
- Azithromycin Suspension/Tab
- Trimethoprim + Sulfamethoxazole
- Erythromycin
- Ciprofloxacin
- Ampicillin Capsule/Suspension Amoxycillin Capsule/Suspension Cefazoline
- Cloxacillin Capsule/Susp Tetracycline/Doxycycline Gentamycin
1.2 Antibiotics Local/Topical
- Ciprofloxacin eye drop/Oint
- Norfloxacin eye drop/Oint Ofloxacin eye drop/Oint •
- Chloramphenicol Eye Drop/Oint
- Gentamicin Eye Drops/Oint
- Tetracycline Eye Ointment
- Neomycin
- Polymyxin B
- Bacitracin
- Sulphacetamide
- Tobramycin Eye Drop/Oint
- Framycetin
1.3 Artificial Tear Local/Topical
- Hydroxy propyl methylcellulose Eye Drop
- Polyvinyl Alcohol
- Other eye smoothening/lubricating agents
1.4 Antiviral
- Acyclovir Eye Ointment/Tablets
1.5 Antifungals Local/Topical
- Miconazole Eye Ointment
- Natamycin Eye Drop
- Clotrimazole Eye Ointment
- Fluconazole
- Ketaconazole
1.6 Disinfectant
- Povidone Iodine
- Tincture Iodine
- Chlorhexidine
- Bleaching powder
- Formaline
1.7 Antacids
- Almunium hydroxide Gel/Tab
- Magnesium tricilicate Gel/Tab
- Ranitidine tab
- Omeprazole
- Famotidine
- Simithicone
1.8 Antiemetics
- Promethazine
- Metoclopramide
- Domperidon
1.9 Antispasmodics
- Dicyclomine hydrochloride
- Hyosine butylbromide
1.10 Antidiarrhoeal
- Oral Rehydration Solution
- Zinc
- V Dextrose, Normal Saline, Ringer lactate
1.11 Analgesics, Antipyretics, non-steroidal anti-inflammatory Systemic
- Acetyl Salicyclic Acid (Aspirin)
- Ibuprofen
- Paracetamol
- Diclofenac
- Nimesulide
- lndomethacine
1.12 Steroid Local/Topical/Systemic
- Dexamethasone Eye Drop/Oint/Tab/Inj
- Bethamethasone Eye Drop/Oint/Tab/Inj
- Prednisolone Eye Drop/Oint/Tab/Inj
- Fluorometholone Eye Drop
- Hydrocortisone Eye Oint/Tab/Inj
- Medrysone Eye Drop
- Triamcelone Eye Oint
1.13 Antiallergy Topical
- Sodium Cromo glycate Eye Drop
- Ketorolac Eye Drop
1.14 Non Steroidal Anti-inflammatory
- Flurbiprofen Eye drop
- Ibuprofen Eye drop
- Diclofenac eye drop
1.15 Antiglaucoma drugs
- Pilocarpine eye Drop
- Timolol Eye Drop
- Acetazolamide Tab
- Glycerol Oral Suspension
- Xalatine eye drop
- Mannitol IV infusion
1.16 Mydriatics and Cycloplegics Eye Drops
- Atropine Eye Drop/Oint
- Homatropine Eye Drop
- Cyclopentolate Eye Drop
- Phenylephrine Eye Drop
- Tropicamide Eye Drop
1.17 Other soothing eye drops: such as Tetrahydrazoline, Nephazoline, Phenylephrine etc.
1.18 Vitamins
- Vitamin A
- Vitamin B Complex
- Vitamin C (Ascorbic Acid)
- Multivitamin
1.19 Antihelminthics :
- Mebendazole
- Albendazole
- Pyrental pamoate
1.20 Antiamoebic
- Metronidazole with diloxanide
- Tinidazole
1.21 Local Anaesthetics
- Lignocaine
- Lignocaine with Adrenaline and hyaluronidase
- Bupivacaine
1.22 Anti-allergy/Anti-histamine
- Cetrizine
- Pheniramine
- Chlorpheniramine
1.23 Antioxidants such as Care Age tab
Since medical science is ever changing science, new medicines and technology can periodically be added in the scope of practice.
