A nurse is assessing a 45-year-old factory worker who presents to the emergency department with a metallic foreign body in the right eye. What is the most important initial assessment the nurse should perform?
1Check visual acuity in both eyes
2Irrigate the eye with normal saline
3Apply pressure to control bleeding
4Assess for signs of globe penetration✓ 정답
해설
Assessing for signs of globe penetration is the most important initial assessment because it determines if immediate surgical intervention is needed to prevent vision loss. Other actions (checking visual acuity, irrigating, applying pressure) are contraindicated or secondary until penetration is ruled out.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing assessment for an ocular foreign body, specifically a high-risk metallic one. The core principle is Key Point!First, rule out an open globe injury. A metallic object, especially from industrial work, can have high velocity and cause a penetrating injury to the cornea or sclera. Performing other interventions before assessing for penetration can cause irreparable damage, such as extrusion of intraocular contents.
Answer Rationale: The correct answer is to Assess for signs of globe penetration. This is the priority because it dictates all subsequent care. Signs include a teardrop-shaped pupil (indicating iris prolapse), visible uveal tissue (dark tissue at the wound site), a shallow or flat anterior chamber, or obvious loss of intraocular contents. If penetration is suspected, the eye must be protected with a rigid shield (not a patch), and any manipulation (like irrigation or checking acuity) is strictly contraindicated until evaluated by an ophthalmologist.
Distractor Analysis:
Watch out for confusion!Checking visual acuity (Option 1) is a standard part of an eye exam but is not the initial priority in a potential penetrating injury. Forcing the patient to open the eye wide or move it to read a chart could worsen the injury. Watch out for confusion!Irrigating the eye (Option 2) is a common intervention for chemical exposures or superficial particles. However, irrigation is contraindicated if globe penetration is suspected, as it can introduce microorganisms into the eye or cause further tissue damage. Watch out for confusion!Applying pressure (Option 3) is almost never correct for an eye injury. Pressure on a potentially open globe can extrude intraocular contents, leading to permanent vision loss.
Related Concepts: The nursing approach follows the principle of "Do No Harm." For any eye trauma, the sequence is: 1) Stabilize/Protect (rule out penetration, apply shield if needed), 2) Assess (history, limited exam), 3) Intervene (as directed, often by a specialist). Understanding the anatomy of the eye and the seriousness of an open globe is critical for safe triage.
Concept Summary
Concept
Description
Nursing Implication
Open Globe Injury
Full-thickness wound of the cornea or sclera. A surgical emergency.
Priority is assessment to identify it. Apply a rigid eye shield. Avoid all pressure, manipulation, or instillation of drops.
Metallic Foreign Body
High risk for penetration and causing a corneal rust ring if embedded.
Requires urgent ophthalmology consult for removal, often under magnification. Do not attempt to remove if embedded.
Visual Acuity Check
Assessment of central vision using a Snellen chart or near card.
Important baseline data, but deferred if it risks worsening a penetrating injury.
Eye Irrigation
Flushing the eye with sterile fluid (e.g., Normal Saline or Lactated Ringer's).
First-line treatment for chemical burns. Contraindicated in penetrating injuries or alkali burns requiring prolonged irrigation.
Side-by-Side Comparison!
Assessment/Intervention
Superficial Foreign Body (e.g., Eyelash, Dust)
Suspected Penetrating Foreign Body (e.g., Metal, Glass)
Initial Nursing Action
Inspect, attempt irrigation with NS, consider eyelid eversion.
Assess for signs of penetration. Do NOT irrigate or manipulate.
Eye Shield/Patch
May use a soft patch after removal for comfort.
Apply a rigid, non-pressure eye shield (e.g., Fox shield) immediately.
Visual Acuity Check
Perform as part of initial assessment.
Defer if it causes squeezing or pressure; document "deferred due to risk of extrusion."
Prevent further injury, prepare for emergency surgical repair to save vision.
Anatomy, Physiology & Pharmacology Points
Anatomy: The cornea is the clear, avascular front window. The sclera is the white, fibrous outer layer. A break in either constitutes an open globe.
Pathophysiology: Penetration disrupts the eye's closed system. Intraocular pressure can force the iris, lens, or vitreous humor out through the wound. This leads to infection (endophthalmitis), retinal detachment, and catastrophic vision loss.
Pharmacology: Prophylactic systemic antibiotics (e.g., IV fluoroquinolones) and tetanus prophylaxis are standard for open globe injuries to prevent infection.
Memory Tips
Acronym: P.E.N.E.T.R.A.T.E. = Protect first, Evaluate for penetration, No pressure, Eye shield, Tetanus shot, Refer to ophthalmology, Antibiotics, Test acuity later, Educate on signs of infection.
Rule of Thumb: "If you suspect a hole, protect the whole." Think of the eye like a water balloon—poking it or squeezing it makes everything worse.
High-Frequency NCLEX Topics
The NCLEX loves to test priority-setting and contraindications. Eye injuries are a classic scenario. Remember: Assessment (for life/limb-threatening conditions) comes before intervention. In this case, assessing for penetration is the assessment that determines if your next action is protective (shield) or harmful (irrigation).
Watch Out for Question Variations!
Shift from Assessment to Intervention: "The nurse confirms no signs of globe penetration. What is the next action?" (Answer might then be to check visual acuity or irrigate).
Change in Foreign Body Type: "A patient has concrete dust in the eye after sanding." (Irrigation may now be the correct first action, as penetration is less likely).
Focus on Patient Education: "Which instruction is most important for a patient discharged with a corneal abrasion?" (Answer: Do not rub the eye; use prescribed antibiotic drops; follow up).
Nursing Clinical Practice GuideClinical Scenario: You are the triage nurse in the ED. Mr. Johnson, 45, arrives holding a tissue over his right eye. He states, "A piece of metal flew into my eye at work about an hour ago. It feels like something's still in there, and it's really painful and watery."
Nursing Intervention Strategy:
Immediate Assessment & Stabilization:
Keep the patient calm. Instruct him not to rub or squeeze the eye.
Perform a focused history: Mechanism of injury (grinding, hammering?), use of safety glasses, time of injury, tetanus immunization status.
Assess for signs of globe penetration WITHOUT applying pressure. Gently separate the lids. Look for:
Obvious foreign body protruding.
Teardrop or irregular pupil.
Dark tissue (uvea) on the surface of the eye.
Flat anterior chamber (the space between cornea and iris looks shallow compared to the other eye).
Blood in the anterior chamber (hyphema).
If any sign of penetration is present or suspected: Key Point!STOP the exam. Apply a rigid eye shield (tape it to the brow and cheekbone, not over the orbit). Notify the physician/ophthalmologist immediately. Keep the patient NPO (nothing by mouth) in case surgery is needed.
If Penetration is Ruled Out:
Proceed to check visual acuity in both eyes (the unaffected eye first).
Perform gentle irrigation with normal saline to attempt to flush out a loose foreign body.
Evert the upper eyelid to check for hidden particles.
Instill prescribed topical anesthetic drops for the exam only (not for ongoing pain relief).
Documentation & Preparation:
Document findings meticulously: Visual acuity (if taken), description of the foreign body and its location, pupil shape and reaction, patient's complaints.
Prepare for ophthalmology consultation. Anticipate orders for a orbital X-ray or CT scan to locate a metallic fragment, tetanus booster, and antibiotic drops/ointment.
Patient Safety and Precautions:
Absolute Contraindication: Never patch an eye with a suspected penetrating injury. A patch applies pressure.
Medication Caution: Do not instill any ointment into an eye with a potential open globe, as it can enter the eye and cause inflammation.
Monitoring: Monitor for increased pain, worsening vision, or signs of infection (increased redness, purulent discharge), which could indicate developing endophthalmitis.
Nursing Procedure & Medication FlowApplying a Rigid Eye Shield:
1. Explain the procedure to the patient.
2. Have the patient look straight ahead or gently close the eyelids.
3. Place the concave side of the rigid shield over the orbit.
4. Secure it with tape from the center of the forehead to the center of the cheek, avoiding pressure on the eyeball.
5. Label the shield "PROTECT - DO NOT REMOVE" if the patient is being transported. Medication: Post-removal, the patient will likely be prescribed:
- Topical antibiotic (e.g., Ofloxacin drops): To prevent infection. Teach instillation technique without touching the dropper tip to the eye.
- Cycloplegic agent (e.g., Cyclopentolate drops): To paralyze the ciliary muscle, reducing pain from spasm.
- Oral analgesic (e.g., Acetaminophen): For pain management. Avoid NSAIDs if there is bleeding (hyphema).
A Word from Your Senior Nurse
"Eye injuries can be terrifying for patients. Your calm, confident, and knowledgeable assessment is their first step toward recovery. Remember, in the rush to 'do something,' the most important thing you can do is to prevent making it worse. Taking those extra 30 seconds to look for signs of a ruptured globe before reaching for the irrigation bottle isn't just following a protocol—it's protecting someone's sight for a lifetime. On the NCLEX and in practice, thinking 'safety first' and 'assess before you act' will guide you to the right answer and the right action every time."
Open Globe Injury — A full-thickness wound of the eye wall (cornea or sclera). It is an ophthalmologic emergency requiring immediate surgical repair to prevent vision loss and infection.
Hyphema — Blood in the anterior chamber of the eye, often resulting from trauma. It appears as a visible layer of blood or a reddish tinge. The patient must maintain head elevation to allow the blood to settle.
Endophthalmitis — A severe, purulent inflammation of the intraocular fluids (aqueous and vitreous humor) usually caused by bacterial or fungal infection. It is a feared complication of penetrating injuries and can lead to rapid, permanent vision loss.
Rigid Eye Shield — A protective device (e.g., Fox shield) placed over an injured eye to prevent accidental pressure or contact. It is used when a penetrating injury is suspected, as it protects without applying direct pressure to the globe.
Corneal Rust Ring — A brownish ring that can form around an embedded metallic foreign body in the cornea due to oxidation of iron. It requires removal by an ophthalmologist, often with a burr drill, to prevent ongoing inflammation and scarring.