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
If limb affected, conduct a full set of neurovascular observations.
Description of object/s
Number of foreign bodies - estimated or actual
Tetanus immunisation status
Provide analgesia as required as per pain scale. Refer to Pain (any cause) NMG
Clean external area of any wound/s with sterile water or 0.9% sodium chloride
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.
Apply dressing/s where appropriate
Consider administration of Tetanus Toxoid as per immunisation history and Tetanus Toxoid Standing Order
Document assessment findings, interventions, investigations and outcomes.