Foreign Body Nurse Management Guidelines

Red Flag Exclusion Criteria

  • Child at risk of significant harm

  • Suspected non-accidental injury

  • Unplanned repeat ED presentation

  • Rectal / genital foreign body

  • Actual or suspected ingestion or inhalation of foreign body

  • Large or protruding foreign bodies (do not remove; stabilise if possible)

  • Foreign bodies close to eyes

  • Deeply embedded foreign bodies

  • Presence of neurovascular compromise

  • Wounds that appear infected (red, inflamed, discharging)

  • History of workplace injury

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

Additional Observations

If limb affected, conduct a full set of neurovascular observations.

Additional History

  • Description of object/s

  • Number of foreign bodies - estimated or actual

  • Anatomical location/s

  • Tetanus immunisation status

Management Principles

  1. Provide analgesia as required as per pain scale. Refer to Pain (any cause) NMG

  2. Clean external area of any wound/s with sterile water or 0.9% sodium chloride

  3. Attempt to remove small, superficial foreign bodies with a sterile needle and / or sterile fine forceps – if removal is unsuccessful discontinue NDEC and escalate to medical officer.

  4. Apply dressing/s where appropriate

  5. Consider administration of Tetanus Toxoid as per immunisation history and Tetanus Toxoid Standing Order

  6. Document assessment findings, interventions, investigations and outcomes.

References / Further Resources

  1. ECI Patient Factsheet - Something in your eye

  2. Chan, C., Salam, G.A., (2003) Splinter Removal American Family Physician 67 (12)

  3. Wagstrom Halaas G. (2007) Management of Foreign Bodies in the Skin American Family Physician 76 (5)

  4. ECI Patient Factsheet - Skin Cuts and Scrapes

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