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
Remove patient's glasses or contact lenses prior to administration of eye drops
Instil amethocaine 0.5% or 1.0% anaesthetic eye drops (1-2 drops; see standing order)
Administer ongoing analgesia as indicated by pain score. See Pain (any cause) NMG
If foreign body present (non-penetrating), attempt to irrigate or touch off with moistened cotton-tip
When irrigation indicated, irrigate with 1L of neutral solution (0.9% saline, Hartmann’s)
Use fluorescein drops to stain eye (1-2 drops; see standing order)
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)
If indicated, instil chloramphenicol eye drops and provide ongoing treatment discharge instructions (see standing order)
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
- Eye Emergency Manual
- Eye exam resources from the Emergency Care Institute
- Further detailed ophthalmology resources available from the ACI
- 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)