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
ECI Patient Factsheet - Something in your eye
NSW Health (2009) Eye Emergency Manual (2nd Ed.) NSW Ministry of Health, Sydney
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)