A nurse is caring for a client with hyphema following blunt trauma to the eye. Which nursing intervention should be the priority?
A 25-year-old construction worker presents to the emergency department after being struck in the right eye by a piece of debris. Assessment reveals blood in the anterior chamber of the eye, and the physician diagnoses hyphema.
1Elevate the head of the bed to 30-45 degrees and maintain strict bed rest✓ 정답
2Apply ice packs to the affected eye for 20 minutes every hour
3Instill prescribed mydriatic eye drops to dilate the pupil
4Encourage frequent eye movements to prevent blood clot formation
해설
Elevating the head of bed promotes blood settling and prevents rebleeding, which is critical in hyphema management. Other options like ice packs, mydriatics, or eye movements are not priority and may increase risk.
Core Nursing ExplanationKey Concept Analysis: This question tests the priority nursing intervention for a patient with Hyphema (blood in the anterior chamber of the eye). The priority is to prevent complications, primarily secondary hemorrhage (rebleeding) and a dangerous increase in Intraocular pressure (IOP). The pathophysiology involves trauma causing blood vessels in the iris or ciliary body to rupture. The initial clot is fragile, and increased activity or pressure can dislodge it, leading to a larger, more dangerous bleed that can severely damage vision.
Answer Rationale: Key Point! The correct answer is Elevate the head of the bed to 30-45 degrees and maintain strict bed rest. This dual intervention is the cornerstone of initial hyphema management. Elevation uses gravity to help the blood cells "settle" inferiorly in the anterior chamber, away from the visual axis and the trabecular meshwork (the eye's drainage system), which helps control IOP. Strict bed rest (often with bathroom privileges only) minimizes physical exertion and sudden increases in blood pressure or intraocular pressure that could trigger rebleeding. This directly addresses the primary risk.
Distractor Analysis:
Watch out for confusion! Option ②, "Apply ice packs," might seem logical for trauma to reduce swelling. However, for hyphema, the priority is internal management of the bleed. Ice is not a standard priority intervention and, if applied incorrectly, could increase pressure on the globe. The primary concern is not external edema but the internal hemorrhage.
Option ③, "Instill prescribed mydriatic eye drops," is a medical intervention, not the independent nursing priority. While Cycloplegics (which paralyze accommodation and dilate the pupil) like atropine or homatropine may be prescribed to rest the ciliary muscle, reduce pain, and prevent synechiae (adhesions), this is not the immediate, life/vision-saving action the nurse initiates independently. The nurse's first action is to position the patient safely.
Option ④, "Encourage frequent eye movements," is contraindicated and dangerous. Eye movement increases muscular activity and can disturb the fragile clot, directly increasing the risk of rebleeding. The goal is to keep the eye as still and rested as possible.
Related Concepts: Management of hyphema also includes administering prescribed topical steroids to reduce inflammation, analgesics for pain (avoiding aspirin/NSAIDs which can promote bleeding), and using a protective eye shield (not a pressure patch) to prevent accidental rubbing or trauma. Monitoring for signs of increased IOP (severe pain, nausea, vomiting, decreased vision) or rebleeding (a sudden increase in the visible blood level) is critical.
Concept Summary
Concept
Key Takeaway
Hyphema Definition
Accumulation of blood in the anterior chamber (space between cornea and iris).
Primary Risk
Secondary hemorrhage (rebleeding), usually 2-5 days post-injury, which carries a worse prognosis.
Prevent infection, promote epithelial healing, relieve photophobia and pain.
Focus on surface healing and infection prevention.
Chemical Burn to Eye
Immediate, prolonged irrigation with normal saline or lactated Ringer's.
Dilute and remove the chemical agent as quickly as possible to limit tissue damage.
Focus on emergency decontamination; time is critical.
Anatomy, Physiology & Pharmacology Points
Anterior Chamber: The fluid-filled space between the cornea and the iris. Blood here (hyphema) obstructs light and can clog the drainage angle.
Trabecular Meshwork: The drainage system for aqueous humor at the angle where the iris meets the cornea. Blood cells can clog this, leading to acute Glaucoma.
Cycloplegics (e.g., Atropine): These drugs paralyze the ciliary muscle (cycloplegia) and dilate the pupil (mydriasis). In hyphema, they are used to rest the eye, reduce pain from ciliary spasm, and prevent pupillary block from blood clots.
Corticosteroid Eye Drops: Used to control inflammation (iritis/uveitis) that commonly accompanies traumatic hyphema.
Memory Tips
HOB for Hema: Think "Head Of Bed" up for "Hyphema."
Settle Down! The blood needs to settle (gravity) and the patient needs to settle down (rest).
No MOVES: Remember what to avoid: Movement (eye/body), Overexertion, Valsalva (straining), Eye rubbing, Salicylates/NSAIDs.
High-Frequency NCLEX Topics
The NCLEX loves to test priority-setting and safety. Hyphema is a classic example where a simple, non-pharmacological nursing action (positioning/activity restriction) is the highest priority to prevent a serious complication (rebleeding and vision loss). Always ask: "What action will prevent the most immediate harm?"
Watch Out for Question Variations!
Symptom Identification: "The nurse should monitor for which finding indicating a complication of hyphema?" (Answer: Sudden increase in pain or blood, nausea/vomiting – signs of rising IOP).
Patient Education: "Which statement by the client indicates understanding of hyphema care?" (Correct: "I will sleep with my head elevated on two pillows." Incorrect: "I will do eye exercises to keep the muscle strong.").
Medication Contraindication: "The nurse should question an order for which medication for this client?" (Answer: Aspirin or Ibuprofen – due to antiplatelet effects).
Nursing Clinical Practice GuideClinical Scenario: You are the nurse in a busy Emergency Department. A 25-year-old male is brought in by coworkers after a metal fragment struck his right eye at a construction site. He is holding a cloth to his eye, reporting pain and blurred vision. On assessment, you note visible layering of red blood in the lower portion of his anterior chamber—a classic "layered hyphema" or "blood and fluid level."
Nursing Intervention Strategy:
Immediate Assessment & Safety: Quickly assess visual acuity in the unaffected eye first, then the injured eye (if possible). Apply a rigid Eye shield (not a patch) to protect the globe from accidental pressure. Do not apply pressure.
Priority Intervention: Assist the patient to a supine position, then elevate the head of the bed to 45 degrees. Explain the reason: "This helps the blood settle to the bottom of your eye and takes pressure off, which helps prevent more bleeding." Enforce strict bed rest—he may only get up to use the bathroom with assistance.
Ongoing Monitoring: Monitor pain (use prescribed analgesics like acetaminophen, avoid NSAIDs), assess for nausea/vomiting (sign of increased IOP), and document the size/amount of hyphema daily (e.g., "hyphema fills 30% of anterior chamber").
Collaboration & Medication Administration: Administer prescribed cycloplegic (e.g., atropine 1% BID) and steroid (e.g., prednisolone acetate 1% QID) eye drops. Educate on proper instillation technique without touching the dropper to the eye.
Discharge Education: Teach the patient to avoid bending over, lifting >10 lbs, straining during bowel movements, and any sports or strenuous activity for several weeks. Stress the importance of follow-up ophthalmology appointments to monitor for complications like glaucoma or corneal blood staining.
Patient Safety and Precautions:
Contraindication: Never apply a pressure patch to an eye with hyphema or suspected ruptured globe.
Medication Caution: Verify all medications for antiplatelet effects. A common error in other settings is administering ketorolac (Toradol) for pain, which is contraindicated.
Key Monitoring Point: A sudden complaint of severe pain or a visible increase in the blood level is an emergency, indicating rebleeding or spiking IOP. Notify the physician immediately.
Nursing Procedure & Medication FlowProcedure: Instilling Eye Drops for a Patient with Hyphema
Perform hand hygiene. Confirm patient identity and medication (right eye vs left eye).
Gently clean any discharge from eyelids with sterile saline and gauze (wipe from inner to outer canthus).
Have the patient tilt head back slightly and look up. Use a finger to gently pull down the lower eyelid to form a pouch.
Hold the dropper 1-2 cm above the eye pouch. Instill the prescribed number of drops into the center of the pouch, avoiding contact with the eye, lashes, or fingers.
Release the eyelid. Ask the patient to gently close the eye (not squeeze) and apply gentle pressure to the Lacrimal punctum (inner corner of the eye) for 1-2 minutes to minimize systemic absorption.
If multiple drops are required, wait at least 5 minutes between different medications.
A Word from Your Senior Nurse
"Eye injuries can be incredibly frightening for patients—imagine the fear of losing your sight. Your calm, confident explanation of why they need to lie still with their head up is powerful nursing care. In clinical practice, you'll be the one ensuring they don't bend over to pick up a dropped remote or strain on the bedpan, actions that seem small but can have big consequences. When you study, link 'elevate HOB and bed rest' not to a rote answer, but to the real goal: letting that fragile clot stabilize to save a young construction worker's vision. That's the heart of nursing judgment the NCLEX is testing."
Hyphema — Accumulation of blood in the anterior chamber of the eye, typically due to blunt trauma.
Intraocular Pressure — The fluid pressure inside the eye. Elevated IOP is a serious complication of hyphema that can damage the optic nerve.
Secondary Hemorrhage — Rebleeding within the eye, typically 2-5 days after the initial injury, which carries a worse prognosis for vision.
Cycloplegic — A type of eye drop (e.g., atropine) that paralyzes the ciliary muscle, dilates the pupil, and is used in hyphema to reduce pain and prevent adhesions.
Strict Bed Rest — A key nursing intervention for hyphema involving limiting all activity to minimize increases in blood pressure and intraocular pressure that could cause rebleeding.