# A 28-year-old construction worker presents to the emergency department with a penetrating eye injury from a metal fragment that appears embedded in the cornea. What is the most important initial assessment the nurse should perform? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=541611 > language: ko > subject: Adult Health ## 문제 A 28-year-old construction worker presents to the emergency department with a penetrating eye injury from a metal fragment that appears embedded in the cornea. What is the most important initial assessment the nurse should perform? A 28-year-old construction worker arrives at the emergency department after a metal fragment from a grinding wheel struck his right eye. The fragment appears to be embedded in the cornea. ## 보기 1. Visual acuity testing using a Snellen chart 2. Pupillary light reflex and consensual response 3. Assessment for signs of globe rupture or perforation **✔ 정답** 4. Intraocular pressure measurement using tonometry **정답: 3** ## 해설 Assessment for signs of globe rupture or perforation is the priority in penetrating eye injury, as it is a sight-threatening emergency requiring immediate surgical intervention. Other assessments like visual acuity or intraocular pressure can wait to avoid further injury. ## 심화 해설 Understanding the Priority Assessment in Penetrating Eye Injury When a patient presents with a penetrating eye injury and a visible foreign body, the immediate priority is not to measure how well the eye can see, but to determine the structural integrity of the globe itself. The correct answer is to assess for signs of globe rupture or perforation. This is a foundational safety principle in ocular trauma management. The clinical practice guideline from the Explosive Weapons Trauma Care Collective (EXTRACCT) emphasizes that the initial evaluation must rule out an open-globe injury before any other manipulation or diagnostic procedure is performed . This is because a ruptured globe is a surgical emergency requiring immediate protection of the eye to prevent further damage and potential loss of the eye. The rationale for this priority is rooted in the pathophysiology of penetrating trauma. A metal fragment striking the cornea at high velocity can create a full-thickness wound, violating the eye's sealed, pressurized environment. The EXTRACCT guideline details that specific clinical signs must be assessed immediately to identify this, including a peaked or irregular pupil, shallowing of the anterior chamber, and visible uveal tissue prolapse . If a rupture is present, any pressure applied to the eye—such as that from a tonometry probe to measure intraocular pressure (Option 4) or even the forced eyelid opening for a detailed visual acuity test (Option 1)—can cause extrusion of intraocular contents, leading to irreversible blindness. Therefore, these assessments are contraindicated until an open globe has been definitively ruled out. While assessing pupillary light reflex and consensual response (Option 2) is a critical neurological and local eye assessment, it is a component of the broader examination for globe integrity. An irregular or non-reactive pupil in this context is a key sign of perforation, not just a cranial nerve finding. The EXTRACCT guideline specifically lists a peaked, teardrop-shaped pupil as a cardinal sign of an open-globe injury, as the iris plugs the wound . Thus, the assessment in Option 2 is performed as part of the higher-priority assessment in Option 3. The primary nursing action is a focused inspection with the specific intent of identifying or excluding a rupture, using only observation and gentle, no-pressure techniques. The severe consequence of missing a globe rupture is the development of exogenous endophthalmitis, a devastating intraocular infection. The research on metal penetrating eye injuries highlights that these injuries carry a high risk of infection because the foreign body can inoculate the interior of the eye with bacteria and fungi . The study identifies that even after emergency surgery, systemic inflammatory markers are strongly correlated with poor infection control and visual outcomes . This evidence reinforces why the nurse’s initial assessment is so critical: recognizing the rupture immediately triggers the cascade of protective measures—placing a rigid eye shield, administering prophylactic systemic and topical antibiotics, and preparing for urgent surgical exploration and vitrectomy—all aimed at preventing the catastrophic complication of endophthalmitis . The nurse’s sharp clinical judgment at the first moment of contact directly influences the trajectory from a salvageable injury to a potentially blinding one. ## 임상 시나리오 Clinical Practice Guide: Initial Management of Suspected Open-Globe Injury Immediate Priorities - **Do not manipulate the eye.** Avoid any pressure on the globe, including forced eyelid opening, tonometry, or ultrasound. - **Protect the eye with a rigid shield.** A Fox shield or a paper cup taped over the eye prevents accidental pressure. Do not use a pressure patch. - **Keep the patient NPO** in anticipation of emergent surgical repair. - **Administer systemic analgesia and antiemetics** to control pain and prevent vomiting, which increases intraocular pressure. - **Update tetanus prophylaxis** as indicated for penetrating trauma. Focused Assessment for Globe Rupture Before any other diagnostic testing, inspect the eye for these cardinal signs of an open-globe injury: - **Peaked or irregular pupil:** The pupil points toward the wound site due to iris prolapse. - **Shallow anterior chamber:** Compare depth to the unaffected eye; a flattened chamber suggests corneal perforation with aqueous leakage. - **Visible uveal tissue or vitreous:** Darkly pigmented tissue (iris or ciliary body) or clear gel extruding from the wound. - **Positive Seidel test:** If performed, fluorescein dye diluted by leaking aqueous humor appears as a dark stream within the green dye pool under cobalt blue light. - **Subconjunctival hemorrhage with chemosis:** Extensive, boggy hemorrhage may mask an underlying scleral rupture. Contraindicated Interventions - **Intraocular pressure measurement (tonometry):** Applies direct pressure to the cornea and can extrude intraocular contents. - **Ocular ultrasonography (B-scan):** The probe pressure can worsen a rupture. - **Magnetic resonance imaging (MRI):** Contraindicated if the metal fragment is ferromagnetic. - **Eye patching with pressure:** A shield without pressure is required; a pressure patch can compress the globe. - **Attempted foreign body removal:** Removal in the emergency department is reserved for the ophthalmologist under microscopic control to avoid further injury. Nursing Considerations - Place the patient in a semi-Fowler's position to reduce intraocular pressure. - Instruct the patient to avoid coughing, sneezing, straining, or bending over. - Administer prophylactic broad-spectrum intravenous antibiotics as ordered to prevent endophthalmitis. - Prepare for emergent ophthalmology consultation and possible surgical exploration. - Provide emotional support; the patient may be anxious about potential vision loss. ## 핵심 개념 - **Open-globe injury** — A full-thickness wound of the eye wall (cornea or sclera) that violates the eye's sealed environment, often caused by penetrating or blunt trauma. - **Globe rupture** — A severe form of open-globe injury where the eyewall integrity is compromised, requiring emergent surgical repair to prevent vision loss. - **Seidel test** — A diagnostic procedure where fluorescein dye is applied to the eye to detect aqueous humor leakage, confirming a corneal or scleral perforation. - **Peaked pupil** — A teardrop-shaped or irregular pupil that points toward the site of a corneal laceration, indicating possible iris prolapse and globe rupture. - **Anterior chamber shallowing** — A decrease in the depth of the fluid-filled space between the cornea and iris, a critical sign of corneal perforation or globe rupture. ## 같은 주제 문제 - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541612) - [A nurse is caring for a client who sustained a penetrating eye injury from a metal fragmen…](https://mymerci.kr/pages/nclex_q.php?qn_id=541613) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541614) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541615) - [A nurse is caring for a client who presents to the emergency department with a metal fragm…](https://mymerci.kr/pages/nclex_q.php?qn_id=541616) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._