Nursing Process Worksheet

Fill out the NPW, please. This it the scenario: Traumatic hyphema

Astute triage leads to an evidence-based treatment plan.

By Aaron M. Sebach, PhD, DNP, MBA, AGACNP-BC, FNP-BC, CP-C, CLNC, CGNC, CNE, CNEcI, SFHM, FNAP, FAANP

BRIAN WRIGHT*, a 34-year-old man with a cein staining. Aside from a Grade Il hyphema, history of essential hypertension, is struck in the ophthalmologic examination is unremark-the right temple with a bat during a softball able with intraocular pressures 16 mmHg on game. Mr. Wright’s teammates drive him to the the left and 19 mmHg on the right.

emergency department (ED) for evaluation.

The ophthalmologist prescribes pred-

They wait 3 hours to be seen.

nisolone acetate 1% ophthalmic drops four times per day, for 7 days, and oxycodone, 5 mg

History and assessment

every 6 hours as needed, for severe pain. Mr.

Jane*, an experienced ED nurse, completes the

Wright is discharged home with daily outpa-

triage for Mr. Wright, who says he felt dizzy and tient ophthalmology follow-up and instruc-nauseous immediately after being hit by the bat.

tions to limit strenuous physical activity and to

Mr. Wright says he also experienced right eye

wear his right eye shield at all times.

pain (10/10), photophobia, and blured vision.

Mr. Wright’s vital signs are temperature 97.5° Education and follow up

F (36.4° C), HR 106 BPM, RR 18 breaths per

Traumatic hyphema is most common in men

minute, BP 142/78 mmHg, and Sao, 98% on and children with an incidence of 12/100,000 room air. While obtaining Mr. Wright’s vital individuals. Penetrating or blunt ocular trau-signs, Jane begins her triage assessment. She ma, which typically occurs as a result of athlet-notes the presence of blood in the anterior ic or recreational injuries, requires emergent chamber of his right eye and assigns an emer- evaluation to prevent vision loss. Patients fre-gency severity index score of 2 (out of 5) and quently experience vision loss, eye pain, photo-takes Mr. Wright directly to the trauma treat- phobia, nausea, or vomiting. Sickle cell disease, ment area for immediate evaluation.

anticoagulant use, and clotting disorders in-crease complications associated with hyphema.

Taking action

Diagnosis is primarily clinical, although globe

Jane assesses Mr. Wright’ visual acuity (left eye

rupture must be ruled out.

20/30, right eye 20/200, and both eyes 20/40).

Traumatic hyphema requires prompt identi-

Before notifying the attending ED physician

fication and ophthalmology evaluation. Indi-

about this traumatic injury, Jane elevates the viduals with a Grade II hyphema (less than 50% head of the stretcher to 45 degrees, applies a of the anterior chamber occupied by blood) can right eye shield, dims the examination room be managed as outpatients, with daily ophthal-lights, and instructs Mr. Wright to remain on mology evaluations to assess intraocular pres-the stretcher.

sures, administration of ocular glucocorticoids

The ED physician affirms the presence of a

to prevent rebleeding and control inflamma-

hyphema and consults with ophthalmology.

tion, limited physical activity, and eye shield-

She orders an I.V. and 4 mg of morphine sulfate

ing. Grade II hyphema typically resolves within

and 4 mg of ondansetron before transporting

7 days. In Mr. Wright’s case, Jane’s astute triage

Mr. Wright for a computed tomography scan

assessment facilitated timely implementation of

of the orbits and maxillofacial bones to rule

an evidence-based treatment plan.

AN

out fracture and globe rupture.

*Names are fictitious.

Outcome

Fortunately, Mr. Wright didnt sustain any maxillofacial or globe ruptures. He’s evaluated by ophthalmology in the ED with slit-lamp ex-amination of the anterior segment and fluores-

Access references at myamericannurse.com/?p=369784.

Aaron M. Sebach is dean of the College of Health Professions and Natural Sciences at Wilmington University, in New Castle, Delaware, and a nurse practitioner at TidalHealth Peninsula Regional, in Salisbury, Maryland.