The client arrives in the emergency room with a penetrating eye injury from wood chips while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action?
A. Remove the piece of wood using a sterile eye clamp.
B. Apply an eye patch.
C. Perform visual acuity tests.
D. Irrigate the eye with sterile saline.
Correct Answer: C. Perform visual acuity tests.
If the laceration is the result of a penetrating injury, an object may be noted protruding from the eye. The only option that will prevent further disruption is to assess visual acuity. Up to 40% of penetrating eye injuries are complicated by the presence of an intraocular foreign body (IOFB). It may be toxic (iron, copper, vegetable matter) or inert (glass or plastic). Vision loss may result from the mechanical injury or from post-traumatic complications such as endophthalmitis, retinal detachment, metal toxicity and sympathetic ophthalmia.
Option A: This object must never be removed except by the ophthalmologist because it may be holding ocular structures in place. Do not attempt to pull out any foreign material that may be sticking out of the eye. Avoid any pressure on the globe; for example, do not press on the sclera.
Option B: The application of an eye patch may disrupt the foreign body and cause further tearing of the sclera. Protect the eye from further damage by using an eye shield. Administer systemic analgesics. Administer prophylactic broad-spectrum systemic antibiotics.
Option D: Irrigation of the eye may disrupt the foreign body and cause further tearing of the sclera. Prompt diagnosis, referral, removal of the IOFB, and surgical repair will help to preserve the visual acuity and the globe anatomy. Record the baseline best-corrected visual acuity in each eye and conduct a complete examination of both eyes and adnexae. Use Desmarres retractor to avoid undue pressure on the globe during an examination.
No comments:
Post a Comment