# A nurse is caring for a client who sustained a penetrating eye injury from a metal fragment during industrial work. What is the most appropriate initial nursing intervention?

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## 문제

A nurse is caring for a client who sustained a penetrating eye injury from a metal fragment during industrial work. What is the most appropriate initial nursing intervention?

## 보기

1. Remove the metal fragment immediately to prevent further damage
2. Apply direct pressure to the eye to control bleeding
3. Irrigate the eye with normal saline to flush out debris
4. Stabilize the object in place and cover both eyes with protective shields **✔ 정답**

**정답: 4**

## 해설

For a penetrating eye injury, the priority is to stabilize the object in place and cover both eyes with protective shields to prevent further damage from sympathetic eye movement. Removing the object, applying pressure, or irrigating can cause additional intraocular injury.

## 심화 해설

Understanding Penetrating Eye Injury

A penetrating eye injury with a retained foreign body, such as a metal fragment, is a critical ophthalmic emergency. The primary goal of initial management is to prevent further injury to the delicate intraocular structures. Any manipulation of the object or pressure on the globe can lead to irreversible vision loss by causing extrusion of intraocular contents, increased intraocular pressure, or further laceration. The intricate structure of the eye and the necessity for its refractive components to remain transparent make these emergencies particularly delicate [3].

Why Other Interventions Are Contraindicated

- Removing the metal fragment (Option 1) is strictly prohibited outside of the operating room. The fragment may be plugging a wound; premature removal can cause the aqueous or vitreous humor to leak out, leading to globe collapse and permanent blindness.

- Applying direct pressure (Option 2) is dangerous because it increases intraocular pressure and can force intraocular contents out through the wound, causing further structural damage.

- Irrigating the eye (Option 3) is contraindicated in a penetrating injury. The force of the irrigation fluid can dislodge the object, introduce contaminants deeper into the eye, and cause additional tissue trauma.

Correct Initial Intervention: Stabilize and Shield

The most appropriate initial nursing intervention is to stabilize the object in place and cover both eyes with protective shields. This approach is grounded in core trauma care principles, which emphasize affordable and achievable standards to prevent secondary injury [1]. The rationale is twofold:

1.  Stabilization prevents movement of the foreign body, which could enlarge the wound or damage sensitive structures like the retina and lens.

2.  Covering both eyes with a rigid shield (not a pressure patch) minimizes concomitant eye movement. Because the eyes move together (consensual movement), covering only the injured eye would still allow it to move when the unaffected eye tracks objects. A shield placed over the injured eye, with the unaffected eye patched or covered, effectively immobilizes the globe, reducing the risk of further injury. This intervention is critical in the pre-operative phase, especially in settings where prompt surgical care may be delayed, to preserve the potential for sight [1][3].References (research sources)

- [1]Guidelines for Essential Trauma Care: Second Edition (2026).GuidelineMock C, Hardcastle TC, Gaarder C, Gupta A, Gyedu A, Joshipura M, Steyn E, Essential Trauma Care revision author group. (2026) · DOI: 10.1002/wjs.70321

- [3]Seeing the unseen: The low treatment rate of eye emergencies in Africa.Research articleBale BI, Zeppieri M, Idogen OS, Okechukwu CI, Ojo OE, Femi DA, Lawal AA, Adedeji SJ, Manikavasagar P, Akingbola A, Aborode AT, Musa M. (2025) · DOI: 10.5662/wjm.v15.i3.102477

## 임상 시나리오

Penetrating Eye Injury with Retained Foreign BodyInitial Stabilization and Shielding Protocol
The primary goal is to prevent further injury and intraocular content extrusion. Never manipulate, remove, or apply pressure to the object or globe.

Immediately stabilize the protruding object with bulky dressings or a paper cup to prevent movement. Cover both eyes with rigid protective shields to minimize consensual eye movement.

CautionDo not irrigate the eye, apply direct pressure, or attempt to remove the fragment. These actions risk globe collapse and permanent vision loss. Keep the patient NPO and elevate the head of the bed 30-45 degrees.

## 핵심 개념

- **Open Globe Injury** — A full-thickness wound of the eye wall (cornea or sclera) that compromises the integrity of the globe, requiring emergency surgical repair.
- **Prolapse of Intraocular Contents** — Extrusion of internal eye structures such as the iris, lens, or vitreous humor through a wound, often caused by manipulation or increased intraocular pressure.
- **Eye Shielding** — A rigid protective device placed over the injured eye and the unaffected eye to minimize ocular movement and prevent further trauma.

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