Eye Problems Nurse Management Guidelines

Red Flag Exclusion Criteria

  • Child at risk of significant harm

  • Suspected non-accidental injury

  • Unplanned repeat ED presentation

  • Known or suspected penetrating eye injury

  • Chemical burn (acid or alkaline)

  • Loss of vision

  • History of metallic foreign body ≥ 24 hours and / or rust ring evident

  • Periorbital swelling or cellulitis

  • Situations which preclude the RN from completing a thorough eye examination e.g. non-compliant patient

  • History of workplace injury

  • Yellow or Red Zones observations or additional criteria outlined in the NSW Health Standard Observation Charts

Additional Observations

Assess patient’s visual acuity bilaterally; with and without visual aids. Where available, document findings using NSW Health Eye Emergencies Form (SMR 040.200) or the Patient Care - Eye Examination ad-hoc chart within FirstNet.

Additional History

Tetanus immunisation status

Management Principles

  1. Remove patient's glasses or contact lenses prior to administration of eye drops

  2. Instil amethocaine 0.5% or 1.0% anaesthetic eye drops (1-2 drops; see standing order)

  3. Administer ongoing analgesia as indicated by pain score. See Pain (any cause) NMG

  4. If foreign body present (non-penetrating), attempt to irrigate or touch off with moistened cotton-tip

  5. When irrigation indicated, irrigate with 1L of neutral solution (0.9% saline, Hartmann’s)

  6. Use fluorescein drops to stain eye (1-2 drops; see standing order)

  7. After staining eye, use cobalt blue light source (slit lamp preferred) to assess for minor corneal or subconjuctival abrasions

    (Note: have a look at this video, also linked below in Further Resources. In the first 3 minutes there is a great introduction to this eye assessment technique)

  8. If indicated, instil chloramphenicol eye drops and provide ongoing treatment discharge instructions (see standing order)

  9. Document assessment finding, interventions, investigations and outcomes; ideally using NSW Health Eye Emergencies Form (SMR 040.200) or the Patient Care - Eye Examination ad-hoc chart within FirstNet if available

NOTE: Never give local anaesthetic drops to the patient to take home

References / Further Resources

  1. ECI Patient Factsheet - Something in your eye

  2. NSW Health (2009) Eye Emergency Manual (2nd Ed.) NSW Ministry of Health, Sydney

  3. Eye exam resources from the Emergency Care Institute

  4. Further detailed ophthalmology resources available from the ACI

  5. Root, Timothy - OphthoBook Eye Trauma Video (in the first 3 minutes there is a demonstration of the eye assessment technique using a cobalt lamp with fluoroscein)

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