A nurse is caring for a client who sustained a hyphema following blunt trauma to the eye. Which nursing intervention is the priority?

Elevating the head of the bed and maintaining bed rest helps prevent rebleeding and allows blood to settle, reducing intraocular pressure. Other options are supportive but not the priority.

Core Nursing Explanation Key Concept Analysis: This question tests the priority nursing intervention for a patient with a Hyphema (bleeding into the anterior chamber of the eye). The priority is to prevent complications, primarily rebleeding and elevated intraocular pressure (IOP). A hyphema is a collection of blood in the space between the cornea and the iris, often caused by blunt trauma. The primary goals of immediate care are to promote clot stabilization, allow the blood to settle, and minimize stress on the injured eye to prevent secondary hemorrhage, which can be more severe than the initial bleed.

Answer Rationale: Key Point! Elevating the head of the bed to 30-45 degrees and maintaining bed rest (option ①) is the priority. This positioning uses gravity to help the blood cells settle inferiorly (layering in the anterior chamber), which improves vision and facilitates absorption. More critically, it helps reduce intraocular pressure (IOP). Increased IOP is a major risk because it can lead to optic nerve damage and permanent vision loss. Bed rest minimizes physical activity, which in turn reduces the risk of dislodging the initial clot and causing a rebleed.

Distractor Analysis:
Watch out for confusion! Option ② (Apply ice packs) is incorrect because while cold compresses can reduce swelling and pain in the initial moments after trauma, they are not the priority for managing the established hyphema itself. More importantly, pressure on the globe must be avoided. A simple ice pack application could inadvertently put pressure on the eye, potentially increasing IOP or disturbing the clot.
Option ③ (Administer analgesics) is a supportive measure for comfort but is not the priority intervention. Furthermore, the nurse must be cautious with analgesic choice. Aspirin and other NSAIDs (Nonsteroidal Anti-inflammatory Drugs) are typically contraindicated due to their antiplatelet effects, which could promote further bleeding. Acetaminophen is usually the preferred agent.
Option ④ (Encourage eye movements) is contraindicated and dangerous. The patient should be instructed to limit eye movement

Nursing Clinical Practice Guide Clinical Scenario: You are the nurse in the Emergency Department. A 24-year-old male presents after being hit in the eye with a baseball. He complains of pain and blurred vision in his left eye. On examination, the physician diagnoses a traumatic hyphema. You see a visible layer of blood in the lower portion of his iris.

Nursing Intervention Strategy:

1. Immediate Priority (Assessment & Stabilization):
   • Assess visual acuity (as able), pain level, and inspect the eye.
   • Implement: Elevate the head of the bed to 30-45 degrees. Place the patient on bed rest or strict chair rest with bathroom privileges only. Apply a rigid eye shield (not a patch) to protect the eye from accidental pressure or trauma.
2. Ongoing Monitoring & Care:
   • Monitor for signs of rebleeding (sudden worsening of vision, increased pain) and elevated IOP (severe throbbing eye pain, headache, nausea, vomiting, seeing halos around lights).
   • Administer medications as ordered: topical steroids, cycloplegic drops, and analgesics (acetaminophen).
   • Provide a quiet environment and assist with activities of daily living to minimize exertion.
3. Patient Education & Discharge Planning:
   • Teach the patient to avoid all activities that increase IOP or risk of re-injury for at least 5-7 days: no bending at the waist, lifting >10 lbs, straining during bowel movements, coughing forcefully, sneezing with mouth closed, or vomiting.
   • Instruct on proper use of the eye shield (especially during sleep).
   • Emphasize medication adherence and follow-up appointments with ophthalmology.

Patient Safety and Precautions:

• Contraindication: Never apply pressure to the affected eye. Do not use an eye patch that puts pressure on the globe; use a rigid shield that rests on the orbital bone.
• Medication Caution: Verify all medications with the provider. Aspirin, ibuprofen, naproxen, and other NSAIDs are contraindicated. Also review for any other antiplatelet/anticoagulant use (e.g., clopidogrel, warfarin).
• Key Monitoring: Frequent checks of pain level and vision (asking "Is your vision the same, better, or worse?"). Any acute change is an emergency.

Nursing Procedure & Medication Flow Procedure: Applying a Protective Eye Shield

1. Wash hands and don gloves.
2. Explain the procedure to the patient.
3. Ensure the eye is clean (if ordered to instill drops, do so first).
4. Position the rigid plastic or metal shield over the affected eye, with the curved edge resting on the bony orbit above the eyebrow and on the cheekbone.
5. Secure the shield gently with medical tape to the forehead and cheek. Ensure no tape is placed on the eyelid and the shield does not press on the eyeball.
6. Document the procedure and patient tolerance.

Medication: Administering Cycloplegic Eye Drops (e.g., Atropine 1%)

• Purpose: To paralyze the ciliary muscle, reducing pain from spasm and preventing adhesions.
• Precaution: These drops cause pupil dilation (mydriasis) and cycloplegia (loss of accommodation). The patient will have blurred near vision and sensitivity to light. Advise them accordingly.
• Administration: Use clean technique. Have the patient tilt head back, look up, pull lower lid down to form a pouch, instill the prescribed number of drops into the pouch without touching the dropper to the eye. Gently close the eye for 1-2 minutes without squeezing.

A Word from Your Senior Nurse "Eye injuries can be incredibly frightening for patients because they threaten a primary sense—vision. Your calm, competent care is essential. Remember, with a hyphema, you're not just treating the visible blood; you're guarding against the invisible threat of a secondary bleed or spiking eye pressure that could steal their sight. Positioning and teaching are your most powerful tools here. In clinicals and on the NCLEX, always ask yourself: 'What is the greatest immediate threat to this patient's outcome?' For hyphema, it's rebleeding. Your priority actions should always aim to mitigate that threat first."