Mr. J. Jones presents to the triage desk of the ED complainingof a “teardrop”on his right eye. Mr. Jones reports that he had beenhammering on a screwdriver in his home workshop yesterday. He wasattempting to straighten the screwdriver with a hammer when he feltsomething fly into his right eye. He suspects it was a metal sliverfrom the screwdriver. Initially he had a small amount of pain andtearing of his right eye. both of which subsided quickly. It wasnot until the next day that fie’ realized that he had ateardrop-like protrusion which he describes as being located at thelower margin of the iris and the sclera of his right eye. Mr. Jonesdoes not wear corrective lenses. He was not wearing protectiveglasses at the time of the injury.
Mr. Jones’ primary and secondary assessments are within normallimits. He denies any significant medical problems. He deniessmoking and does not use alcohol or recreational drugs. He is on nomedications and denies any known drug allergies.
His last tetanus immunization was 2 years ago when heaccidently punctured his foot with a nail. Triage Assessment,Acuity Level IV: penetrating trauma to eye. foreign-body sensationpresent. Mr. Jones had bilateral eye patches placed and was takenimmediately to the treatment area.
1. Why is Mr. Jones’ case such an acute emergency since he isnot experiencing pain and the event occurred yesterday?
2. What assessments should be performed in evaluating theseverity of the patient’s injury? What medical interventions arerequired for Mr. Jones?
3. What are the usual medical interventions that the nurse cananticipate once a foreign body has been removed, provided surgeryis not indicated?
4. What are the pertinent nursing diagnoses for a patient withan intraocular foreign body?
5. Since Mr. Jones will be admitted for surgery, what nursingactions are appropriate related to these diagnoses?
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