# A nurse is caring for a client who presents to the emergency department with a metallic foreign body in the right eye. What is the most appropriate initial nursing intervention?

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## 문제

A nurse is caring for a client who presents to the emergency department with a metallic foreign body in the right eye. What is the most appropriate initial nursing intervention?

## 보기

1. Attempt to remove the foreign body with sterile tweezers
2. Irrigate the eye with normal saline solution
3. Apply pressure to the affected eye to prevent further injury
4. Cover both eyes with sterile gauze and keep the client calm **✔ 정답**

**정답: 4**

## 해설

Covering both eyes prevents consensual eye movement that could embed the foreign body deeper. Keeping the client calm minimizes movement until ophthalmologic evaluation.

## 심화 해설

Understanding the Emergency: Metallic Intraocular Foreign Body

When a client presents with a metallic foreign body in the eye, the clinical priority shifts from simple first aid to the management of a potential open globe injury. An open globe injury is a full-thickness wound of the eyewall (cornea or sclera), and it constitutes a major ophthalmic emergency. The presence of a metallic object, particularly one resulting from high-velocity activities like hammering or grinding, carries a high index of suspicion for an intraocular foreign body (IOFB). Research indicates that IOFB injuries are a significant cause of visual impairment globally, and their complex nature requires meticulous initial management to prevent catastrophic vision loss [1].

Rationale for the Correct Answer: Covering Both Eyes

The most appropriate initial nursing intervention is to cover both eyes with sterile gauze and keep the client calm.

This intervention is critical because any movement of the injured eye causes simultaneous, conjugate movement of the unaffected eye. By covering both eyes, you effectively immobilize the injured eye, minimizing the movement of extraocular muscles. This is paramount to prevent further damage from a sharp IOFB, which can lacerate delicate intraocular structures like the retina or lens with even the slightest eye motion. The goal is to stabilize the globe and prevent extrusion of intraocular contents through a potential open wound. Keeping the client calm reduces intraocular pressure spikes that can occur with anxiety, crying, or squeezing the eyelids shut, further protecting the eye's integrity.

Analysis of Incorrect Options

Option 1: Attempt to remove the foreign body with sterile tweezers.

This action is strictly contraindicated. Any manipulation of a protruding or penetrating object in the eye is reserved for an ophthalmologist in a controlled surgical setting. Attempting removal in the emergency department can cause further tissue trauma, trigger massive vitreous or uveal tissue prolapse, and convert a potentially salvageable injury into an irreversible one. The clinical presentation of IOFB cases often involves vitreous prolapse and hemorrhage, making unsterile or unguided manipulation extremely dangerous .

Option 2: Irrigate the eye with normal saline solution.

While irrigation is the primary intervention for chemical burns to the eye, it is contraindicated in suspected open globe injuries. The pressure from the irrigation stream can disrupt a self-sealing wound, flush the foreign body deeper into the posterior segment, or introduce pathogens, increasing the risk of devastating endophthalmitis. The integrity of the globe must be assumed to be compromised until definitively ruled out by imaging, such as a CT scan.

Option 3: Apply pressure to the affected eye to prevent further injury.

Applying any pressure to an eye with a suspected open globe injury is one of the most harmful actions. Pressure on the globe dramatically increases intraocular pressure (IOP), which can force intraocular contents (vitreous humor, retina, uveal tissue) out of the wound, leading to permanent and profound vision loss. The principle of management is to protect the eye from any external force, including the pressure from a patch that is not properly shielded.

Connecting to Prognosis and Definitive Care

Your initial action directly influences the client's long-term visual prognosis. Studies on IOFB management show that the final visual outcome is closely linked to the initial presenting visual acuity and the extent of damage, which can be exacerbated by improper pre-surgical handling [1, 2]. After stabilization, definitive management typically involves advanced imaging to localize the foreign body and surgical extraction via pars plana vitrectomy (PPV), a procedure used to remove the IOFB, clear vitreous hemorrhage, and repair retinal damage . A case of a missed intraorbital foreign body highlights how an initially underestimated injury can lead to misdiagnosis and delayed, more complicated treatment, reinforcing the need for a high index of suspicion and meticulous initial assessment . By correctly immobilizing the eye and preventing secondary injury, you are preserving the anatomical structure necessary for the ophthalmologist to achieve the best possible surgical and visual outcome.References (research sources)

- [1]Clinical Characteristics and Prognostic Factors for Visual Outcome in Intraocular Foreign Body Cases Treated at a Tertiary Eye Hospital in Indonesia.Research articleAdriono GA, Triyoga IF, Kadharusman MM, Wijaya AN, Paramitha AN, Juffry SK, Victor AA, Djatikusumo A, Yudantha AR, Hutapea MM. (2026) · DOI: 10.2147/opth.s580427

## 임상 시나리오

Suspected Open Globe with IOFBImmediate Nursing Stabilization Protocol
The primary goal is eye immobilization to prevent further intraocular laceration. Immediately cover both eyes with a rigid eye shield or sterile gauze. This stops conjugate movement of the unaffected eye.

Keep the client calm and maintain head of bed elevation at 30-45 degrees to minimize intraocular pressure. Instruct the client to avoid blinking forcefully or squeezing the eyelids shut.

CautionNever attempt to remove the foreign body, irrigate the eye, or apply pressure. Do not administer any topical ointments or drops. These actions risk extrusion of intraocular contents and permanent vision loss. Keep the client NPO for potential surgical repair.

## 핵심 개념

- **Open Globe Injury** — A full-thickness wound of the cornea or sclera, constituting a major ophthalmic emergency with a high risk of vision loss.
- **Intraocular Foreign Body (IOFB)** — A projectile object that penetrates the eye and lodges within the globe, often requiring surgical removal and risking retinal or lenticular damage.
- **Conjugate Eye Movement** — The simultaneous movement of both eyes in the same direction, meaning movement of the unaffected eye will cause movement of the injured eye.
- **Eye Immobilization** — The critical nursing action of preventing extraocular muscle movement to stabilize a penetrating injury and prevent further internal laceration.
- **Extrusion of Contents** — The leakage of intraocular fluid (vitreous humor) or tissue through an open wound, a severe complication that can lead to permanent structural collapse of the eye.

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