eye trauma - emergency care

nurseprnRN, BSN, RN · Mar 4, 2012

nclex often asks you questions like this. if the others are not crystal clear, always seriously consider the one that has you obtaining more information. in this case, i'd choose a. you can do it fast, it provides valuable information, and it's part of a nursing plan of care that does not have to appear in a medical plan of care to be applied.

forget the pressure patch-- if there is still acid or other foreign body in the eye, pressure would be a very bad thing. you can't "swab the eye" with antibiotics unless it is in the medical plan of care, and there is no mention of that in the scenario. covering the eye with a ns patch, or anything else, will keep the eye closed and therefore holding in whatever bad thing is in there, not a good idea.

you are correct that eye irrigation should be done, but that's not one of your choices. the distractors are all things that look like procedures, and new grads (and students) often gravitate towards "do something!" choices because they are still thinking in terms of that lab check-off list of procedures. the ones that vaguely remember the saline flush will take the saline patch, without really knowing why; the ones who remember pressure being put on things in the er will take that, without really thinking through the physiology of what's going on here; the ones who think about medicines will choose the antibiotics, without noticing that it is not an independent nursing action and they are being asked to act as a nurse. therefore, act like a nurse: gather more information.

ilovecake, LPN · Mar 4, 2012

thanks for your help, I just assumed that assessing visual acuity would come after the initial emergency treatment?

psu_213, BSN, RN · Mar 4, 2012

In the real world, we would do a quick visual acuity....not have them stand at 20ft and do the whole eye chart thing, but at least something to see how much damage there is and give us a baseline to see if they improve with tx.

Esme12, ASN, BSN, RN · Mar 5, 2012

You swab nothing until eval, you don't pressure dress them either. Visual acuity is done first.....can they see anything? Is it all blurry? Not really read the letters as most can't with chemical burns.