A nurse is caring for a client who presents to the emergency department with a metal fragment embedded in the right eye following a workplace accident. What is the most appropriate initial nursing action?
1Remove the metal fragment immediately to prevent further damage
2Cover both eyes to prevent sympathetic movement and keep the client still✓ 정답
3Irrigate the affected eye with normal saline to flush out debris
4Apply direct pressure around the embedded object to control bleeding
해설
Covering both eyes prevents sympathetic movement that could displace the embedded fragment, which is the priority. Removing the object, irrigating, or applying pressure can cause further injury.
Correct Answer: 2. Cover both eyes to prevent sympathetic movement and keep the client still
Emergency Management of Penetrating Ocular Injury
When a client presents with a penetrating eye injury involving an embedded foreign body, such as a metal fragment, the most appropriate initial nursing action is to cover both eyes and instruct the client to remain still. The primary rationale for this intervention is the physiological phenomenon of conjugate eye movement (or sympathetic movement). The extraocular muscles of both eyes work in tandem; therefore, any movement of the unaffected eye will cause the injured eye to move involuntarily. This movement can cause the embedded fragment to shift, potentially lacerating delicate intraocular structures such as the cornea, lens, or retina, and worsening the injury.
Rationale for Incorrect Options
* Option 1 (Remove the metal fragment immediately): This action is strictly contraindicated in the pre-surgical setting. Removal of a penetrating object by a non-ophthalmologist can disrupt a possible sealed wound, precipitate vitreous humor leakage, and cause catastrophic intraocular hemorrhage or retinal detachment. This is a surgical emergency managed by an ophthalmologist under microscopic control.
* Option 3 (Irrigate the affected eye with normal saline): Irrigation is the standard of care for chemical burns or superficial foreign bodies. In the case of a full-thickness corneal or scleral laceration with an embedded object, irrigation can introduce pathogens, physically dislodge the object, and force debris deeper into the globe.
* Option 4 (Apply direct pressure around the embedded object): Applying any form of direct or indirect pressure to a ruptured globe is contraindicated. Intraocular pressure is already potentially compromised, and external pressure can extrude intraocular contents through the wound, leading to permanent vision loss.
Psychosocial Context and Long-Term Implications
While the immediate priority is preventing secondary mechanical injury, it is crucial for NCLEX-RN examinees to recognize that ocular trauma is a leading cause of acquired low vision in working-age adults. A study on patients with ocular trauma-related low vision highlights that the impact extends far beyond the initial physical insult, often resulting in long-term functional disability and significant psychosocial burden, including heightened anxiety and altered perceived social support . The emergency nurse's calm, confident, and protective actions—explaining the need for bilateral eye covering to prevent movement—serve as the first step in mitigating the psychological trauma associated with the event. By stabilizing the injury and preventing further harm, the nurse helps preserve the anatomical integrity of the eye, which is the critical foundation for any future surgical repair and subsequent vision rehabilitation or continuity nursing interventions designed to improve vision-related quality of life .
Clinical Practice Guide: Penetrating Eye Injury with Embedded Foreign Body
Immediate Nursing Actions
Do not attempt removal of the embedded object. Stabilize the object if large, but never manipulate it.
Cover both eyes with a rigid eye shield or a paper cup. Patching both eyes eliminates conjugate eye movement and prevents further laceration from the shifting fragment.
Keep the client supine with the head elevated 30 degrees and instruct them to avoid eye movement, coughing, or Valsalva maneuver.
Administer antiemetics as ordered to prevent vomiting, which increases intraocular pressure.
Key Contraindications
Never irrigate the eye in penetrating injuries; this can disrupt the wound and introduce pathogens.
Avoid direct pressure on the globe; this can extrude intraocular contents.
Do not administer ocular medications (drops/ointments) unless specifically ordered by ophthalmology.
Withhold food and fluids in anticipation of possible surgical repair.
Ongoing Assessment
Monitor for signs of ruptured globe: teardrop-shaped pupil, flat anterior chamber, or visible brown tissue (iris prolapse).
Assess visual acuity in the unaffected eye only if it does not require movement of the injured eye.
Update tetanus prophylaxis based on injury mechanism and vaccination history.
Conjugate Eye Movement — The coordinated movement of both eyes in the same direction, meaning movement of the unaffected eye will cause involuntary movement of the injured eye.
Penetrating Ocular Injury — A full-thickness wound of the eye wall (cornea or sclera) caused by a sharp object, requiring emergency surgical management.
Sympathetic Ophthalmia — A rare bilateral granulomatous uveitis that can occur after penetrating trauma to one eye, though the term 'sympathetic movement' here refers to motor coordination.