NCLEX Review Guide: Penetrating Eye Injuries

Initial Assessment Priorities

• Visual acuity assessment should be performed immediately using a Snellen chart or counting fingers if chart unavailable
• Assess for pupillary response, extraocular movements, and presence of foreign objects without applying pressure to the eye
• Document the mechanism of injury, time of occurrence, and any first aid measures already taken
• Check for signs of globe rupture including teardrop-shaped pupil, hyphema, or vitreous hemorrhage

Immediate Actions

1. Do NOT remove the penetrating object - this can cause further damage and increase bleeding
2. Stabilize the object using bulky dressings or a protective cup taped around the object
3. Cover the unaffected eye with a patch to prevent consensual eye movement
4. Position patient in semi-Fowler's position to reduce intraocular pressure
5. Administer prescribed analgesics and antiemetics to prevent vomiting and increased pressure

Medications & Contraindications

• Avoid aspirin and NSAIDs due to increased bleeding risk
• Administer prescribed tetanus prophylaxis if wound is contaminated
• Topical antibiotics may be ordered to prevent infection
• Avoid medications that increase intraocular pressure such as anticholinergics

Post-Operative Care Instructions

• Instruct patient to avoid bending, lifting, or straining which increases intraocular pressure
• Teach proper technique for instilling prescribed eye drops using sterile technique
• Emphasize importance of keeping follow-up appointments with ophthalmologist
• Advise patient to report signs of infection including increased pain, discharge, or vision changes

Self-Assessment Checklist

• ☐ Can I identify the priority nursing actions for penetrating eye injuries?
• ☐ Do I understand why both eyes must be covered?
• ☐ Can I explain the rationale for not removing penetrating objects?
• ☐ Do I know which medications to avoid and why?
• ☐ Can I teach proper post-operative eye care?