A nurse is caring for a client who presents to the emergency… | 마이메르시 MyMerci
Adult Health
문제

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 nurse's priority action?

해설
The priority is to stabilize the embedded object and cover both eyes to prevent further damage from movement. Removing the object or applying pressure can cause additional injury.

심화 해설

Core Nursing Explanation This question tests the critical nursing priority for a patient with a penetrating eye injury with an embedded foreign body. The core principle is preventing further injury and preserving the globe. Any manipulation of the eye—such as removal, irrigation, or pressure—can convert a potentially salvageable injury into a catastrophic one. Key Concept Analysis The scenario describes a penetrating ocular trauma. The metal fragment is not just on the surface; it is embedded, meaning it has breached the cornea or sclera. The primary threats are: 1) Extrusion of intraocular contents (vitreous humor, lens, retina) if the object moves, and 2) Infection (endophthalmitis). The nursing priority is immediate stabilization to mitigate these risks. Answer Rationale Key Point! The correct action is to stabilize the object and cover both eyes. Stabilization prevents movement that could lacerate internal structures. Covering both

임상 시나리오

Nursing Clinical Practice Guide Clinical Scenario You are the triage nurse in the ED. A 32-year-old construction worker is brought in by coworkers. He is holding a cloth over his right eye, reporting immediate pain and blurred vision after a piece of metal "flew into his eye" while using a grinder without eye protection. Nursing Intervention Strategy
  1. Immediate Action & Assessment: Approach calmly. Instruct the patient and anyone with him not to touch the eye or the cloth. Gently ask him to remove the cloth while keeping both eyes closed. Do a quick visual survey: note the embedded metal fragment. Do not attempt to assess visual acuity in the injured eye at this moment.
  2. Stabilization Procedure:
    • Explain to the patient: "I need to protect your eye. It's very important that you try not to move your eyes or blink hard."
    • If available, place a Fox shield or improvise with the bottom half of a paper cup over the injured eye. The goal is to create a rigid dome that does not touch the object.
    • Secure it lightly with tape to the bony prominences of the forehead and cheek.
    • Then, place a standard eye patch or shield over the uninjured left eye and tape it securely. This forces the eyes to rest.
  3. Ongoing Care & Preparation: Keep the head of bed elevated to reduce intraocular pressure. Administer prescribed analgesics and antiemetics (vomiting increases intraocular pressure). Notify the ophthalmologist STAT. Document the time of injury, mechanism, and all actions taken. Prepare for immediate CT scan to locate the fragment.
Patient Safety and Precautions
  • Key Point! Never use a pressure patch (one that presses on the eyelid) for a penetrating injury.
  • If the object is very large and prevents shield placement, build a "cage" around it with gauze rolls to prevent accidental contact.
  • Maintain NPO status in anticipation of possible emergency surgery requiring sedation.
Nursing Procedure & Medication Flow
StepActionRationale/Precaution
1. PreparationGather rigid eye shield, tape, eye patch. Don gloves.Prevents delay. Standard precautions.
2. Patient PositioningAssist to supine or semi-Fowler's with head stabilized.Minimizes movement. Elevation reduces orbital edema and IOP.
3. Shield ApplicationPlace shield over injured eye WITHOUT applying pressure. Tape to bone.Protects from external contact. Anchoring to bone avoids pressure on globe.
4. Patch ApplicationPatch the uninjured eye securely.Eliminates conjugate movement, forcing complete rest.
5. Medication AdminIV access. Administer IV antibiotics (e.g., Cefazolin) and tetanus toxoid per protocol.Prophylaxis against endophthalmitis and tetanus. IV route for rapid effect.
A Word from Your Senior Nurse "Eye injuries are one of the few true 'do not touch' emergencies in nursing. That instinct to help by flushing something out or wiping it away has to be overridden by knowledge. Your primary role is to be the calm protector who creates a safe, stable environment until the specialist arrives. Mastering this distinction—between when to act aggressively (like with a chemical burn) and when to act with deliberate restraint (like with an embedded object)—is a mark of a sharp, thinking nurse. On the NCLEX, they're testing if you have the judgment to know the difference. In clinicals, you'll be the one ensuring a patient has the best possible chance of keeping their sight."

핵심 개념

  • Penetrating Eye Injury — A traumatic injury where a foreign object breaches the cornea or sclera, entering the interior of the eye. This is an ophthalmologic emergency requiring stabilization, not removal, of the object.
  • Endophthalmitis — A severe, purulent inflammation of the intraocular cavities (aqueous and vitreous humor) often caused by bacterial or fungal infection. It is a feared complication of penetrating injuries and can lead to permanent vision loss.
  • Conjugate Gaze — The coordinated movement of both eyes in the same direction simultaneously, controlled by central nervous system pathways. Covering the uninjured eye in trauma prevents this movement, protecting the injured eye.
  • Expulsive Hemorrhage — A catastrophic complication where increased intraocular pressure (e.g., from applying pressure to a penetrating injury) forces intraocular contents out through the wound. It results in irreversible blindness.
  • Fox Shield — A rigid, perforated eye shield used in emergency settings to protect an injured eye from external pressure and contact. It is a key tool for stabilizing a patient with a penetrating orbital injury.

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