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Sensory-Med Surg

Terms in this set (56)

-Burns to the eye often occur at home or the workplace. It is a medical emergency. Depending on the chemical causing the burn, the damage mayy be deep or superficial.
-Acute pain and burning are the primary symptoms associated with any topical burn to the eye.
-The pain may be transitory and slight, or spasmodic and deep. If underlying structures are involved, pain may be absent because the nerves have been severed.

Burns:
Subjective data:
-Includes the degree of pain
-Assess the substance causing the burn and any first aid treatment that has been provided
-Vision loss is determined by the physician
Objective data:
-Noting the extent of the burn in and around the eye, including eyelashes and eyebrows, and assessing the condition of the eyeball.

Medical Management:
-Treated with eye irrigation (flush) with tap water for 15-20 minutes immediately after injury (this will help prevent scar formation)
-Separate the eyelids during the flush procedure
-The patient is then treated in a local emergency department or office for follow-up care
-Home remedy first aid treatment should not be done
-Topical antiineffective agents are ordered for the eye.

NCLEX:
-Chemical burn of the eye is an eye injury in which a caustic substance enters the eye.
-If a chemical splash to the eye occurs, treatment should begin immediatel-flush the eyes at the scene of the injury with water for at least 15-20 minutes.
-At the scene of the injury, obtain a sample of the chemical involved.
-The solution is directed across the cornea and toward the latheral canthus.
-Apply an antibiotic ointment as prescribed and cover with an eyepatch as prescribed.

Priority Nursing Actions to take if a client sustained a chemical eye injury:
1. Irrigate the eye
2. Check the pH of the eye
3. Assess visual acuity
4. Document the event, actions taken, and the client's response

Emergency care after a chemical burn includes irrigating the eye immediately with sterile normal saline or occular irrigating ssolution. If the injury occuredd outside the hospital, the eye is irrigated immediately with tap water and then the client is brought to the emergency department. In the ED, the irrigation should be maintained for at least 10 minutes and with at least 1 liter of fluid. After irrigation, the pH of the ee is checked and if a pH of 6-7 has not returned, the irrigation should be continued. Lactated Ringer's solution could be used as well for eye irrigation (based on doctor's orders) due to the fact the the pH of that solution is 6 to 7.5 which is closer to the pH of tears-7.1 than that of normal saline which ranges from 4.5-7. After this emergencyy treatment, visual acuity is assessed. It is also important for the nurse to find out what chemical splashed into the eye. Finally , the event is documented as well as the actions taken and the client's response.