CHAPTER 35 Ocular and Maxillofacial Trauma

Sheila Sanning Shea, RN, MSN, CEN, ANP

MAJOR TOPICS

General Strategy

Assessment

Analysis: Differential Nursing Diagnoses/Collaborative Problems

Planning and Implementation/Interventions

Evaluation and Ongoing Monitoring

Documentation of Interventions and Patient Response

Age-Related Considerations

Specific Traumatic Ocular Injuries

Corneal Abrasion

Extraocular Foreign Bodies

Retinal Detachment

Orbital Fracture

Chemical Burns

Hyphema

Eyelid Laceration

Globe Rupture

Specific Traumatic Maxillofacial Injuries

Fractured Tooth

Subluxed/Avulsed Teeth

Nasal Fracture

Fractured Larynx

Temporomandibular Joint Dislocation

Facial Lacerations and Soft Tissue Injuries

Mandibular Fractures

Maxillary Fractures

Zygomatic Fractures

I. GENERAL STRATEGY

A. Assessment

1. Primary and secondary assessment/resuscitation (see Chapters 1 and 31)

2. Focused assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)

(1) Blunt or penetrating forces

(2) Chemical exposure

b) Pain (see Chapter 9)

c) Time of injury

d) Airbag deployment if motor vehicle crash

e) Treatment prior to arrival

f) Changes in clinical status

g) Corrective (including contact) lens/safety glasses use

h) Visual acuity changes; decreased acuity, decreased visual fields, blurred vision, diplopia, tearing, eye pain

i) Efforts to relieve symptoms

(1) Home remedies

(2) Alternative therapies

(3) Medications

(a) Prescription

(b) Over-the-counter/herbal

2) Past medical history

a) Current or preexisting diseases/illness

(1) Diabetes

(2) Cardiovascular disease

(3) Hypertension

b) Ocular

(1) Corrective (including contact) or protective lens use

(2) Chronic eye problems; previous eye injuries

c) Maxillofacial

(1) Previous ear, nose, and throat (ENT) problems, facial trauma, or surgical procedures

d) Substance and/or alcohol use/abuse

e) Last normal menstrual period: female patients of childbearing age

f) Current medications

(1) Prescription

(2) Over-the-counter/herbal

g) Allergies

h) Immunization status

3) Psychological/social/environmental factors

a) Behavior appropriate for age and developmental stage

(1) Young male patients at higher risk for serious injury

(2) Contact lens wearers at greater risk for corneal abrasion

b) Occupation or profession

(1) Exposure to arc welding: symptoms develop 4 to 8 hours after exposure

(2) Construction work involving grinding metal or use of machinery has potential for embedded foreign bodies or globe penetration

(3) Mechanics and cleaning personnel have potential for acid and/or alkali burns to eye

c) Hobbies, avocation, recreational activities

(1) Injuries involving soil and organic material have increased potential for infection

(2) Home crafts and woodworking activities increase potential for eye injuries if safety precautions not taken

(3) Ball sports increase potential for eye injuries, as do contact sports in which no protective eyewear is worn

(4) BB guns and fireworks are frequent causes of eye trauma in children

d) Possible/actual assault, abuse, intimate partner violence situations (see Chapter 3)

(1) Victims of violence often sustain ocular and/or maxillofacial injuries

(2) Victims of child maltreatment often present with findings of intraocular and/or retinal hemorrhage related to direct trauma or shaking of child

b. Objective data collection

1) General appearance

a) Level of consciousness, behavior, affect

b) Vital signs

c) Odors

d) Gait

e) Hygiene

f) Level of distress/discomfort

2) Inspection

a) Eyelids and periorbital area for soft tissue swelling and ecchymosis

b) Eye surface for foreign body, penetrating wounds, tearing, and leakage of intraocular fluid

c) Pupillary size and function, extraocular muscle movements, visual fields

d) Conjunctiva and sclera for hemorrhage

e) Blood in anterior chamber

f) Opaque, gray-white cornea

g) Facial asymmetry, wounds, bleeding

h) Soft tissue swelling, ecchymosis, obvious deformity

i) Malocclusion or trismus, intraoral trauma, tooth avulsion, missing or fragmented teeth

j) Evidence of head or neck injury

3) Palpation/percussion

a) Facial bones and periorbital structures for stability, crepitus, movement, bony step-off or deformity, tenderness

b) Head and neck for tenderness or deformity

c) Facial sensation and muscle function

3. Diagnostic procedures

a. Laboratory studies

1) Complete blood count (CBC) with differential

2) Culture of wounds, discharge

3) Arterial blood gas (ABG)

b. Imaging studies

1) Facial radiographs

a) Waters’ view

b) Mandibular panoramic radiograph (Panorex)

c) Cervical spine

2) Facial, orbit, head, neck computed tomography (CT) scan or magnetic resonance imaging (MRI)

c. Other

1) Visual acuity

2) Direct ophthalmoscope examination

3) Fluorescein staining

4) Slit-lamp examination

5) Tonometry: intraocular pressure measurement

B. Analysis: Differential Nursing Diagnoses/Collaborative Problems

1. Ineffective airway clearance

2. Acute pain

3. Anxiety/fear

4. Impaired skin integrity

5. Disturbed sensory perception: visual

6. Deficient knowledge

C. Planning and Implementation/Interventions

1. Determine priorities of care

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish intravenous (IV) access for administration of crystalloid fluid/blood products/medications as needed

d. Obtain and set up equipment and supplies

e. Prepare for/assist with medical interventions

f. Administer pharmacologic therapy as ordered

2. Relieve anxiety/apprehension

3. Allow significant others to remain with patient if supportive

4. Educate patient and significant others

D. Evaluation and Ongoing Monitoring (see Appendix B)

1. Continuously monitor and treat as indicated

2. Monitor patient response/outcomes, and modify nursing care plan as appropriate

3. If positive patient outcomes are not demonstrated, reevaluate assessment and/or plan of care

E. Documentation of Interventions and Patient Response

F. Age-Related Considerations

1. Pediatrics

a. Growth or development related

1) Infants and small children may need to be restrained in a blanket to facilitate thorough examination

2) Children can fixate on objects by 4 months of age

3) Facial bone fractures in pediatric patients tend to be less severe; most common are comminuted and nondisplaced fractures because facial bones in children are softer and more pliable than in adults

b. “Pearls”

1) May need to use a picture chart or the “E” chart (patient indicates direction to which “E” points) to evaluate visual acuity

2) 20/20 vision may not be achieved until 7 to 8 years of age

2. Geriatrics

a. Aging related

1) Vision diminishes gradually until approximately 70 years and then more rapidly thereafter

2) Decreased accuracy of results from visual acuity testing

3) Ability of eye to accommodate, or adjust, to distances decreases with age

4) Chronic illness may cause visual changes

b. “Pearls”

1) Increased incidence of detached retina

2) Maxillofacial trauma more likely associated with head and neck injuries

II. SPECIFIC TRAUMATIC OCULAR INJURIES

A. Corneal Abrasion

Corneal abrasion occurs when there is an injury to an area of the corneal epithelium. Common causes include foreign bodies, contact lenses, and exposure to ultraviolet light. Abrasions may be superficial and may involve only the outer layer of the cornea, or they may be deep enough to damage the inner stromal layer. Contact lenses can scratch the cornea during insertion or removal or when a foreign body becomes trapped between the cornea and the lens. Prolonged use of the lenses can also lead to corneal abrasion. When the lens is removed, part of the cornea adheres to the lens as a result of the avascular nature of the cornea. Ultraviolet light exposure can occur from the sun, welding arcs, sun lamps, or snow reflecting sunlight, thus causing a punctate stippling type of abrasion. Corneal abrasion is one of the most common eye injuries seen in the emergency department.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Ocular injury, ultraviolet light exposure, contact lens use

b) Pain (see Chapter 9): ranging from mild to severe

c) Redness

e) Tearing and blinking

f) Foreign body sensation

g) Sensitivity to light

h) Use of corrective (including contact) or protective lenses

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous eye injuries or problems

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Mild to severe distress/discomfort

b) Inspection

(1) Injected conjunctiva

(2) Tearing, blinking

(3) Foreign body: evert upper eyelid

(4) Corneal ulceration

(5) Erythema or swelling of lids and surrounding tissue

2) Diagnostic procedures

a) Visual acuity: usually normal unless corneal abrasion is large or located over the visual axis (line of vision)

b) Fluorescein stain: uptake of dye if epithelial cells damaged

c) Slit-lamp examination

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Anxiety/fear

c. Deficient knowledge

d. Risk for infection

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Eye patching is controversial. Do not patch abrasions caused by contact lenses or false fingernails or abrasions involving vegetable matter because of the risk of Pseudomonas infection

b. Administer pharmacologic therapy as ordered

1) Topical ophthalmic anesthesia

2) Cycloplegic agent: reduces pain related to ciliary spasm

3) Topical ophthalmic antibiotics

4) Tetanus immunization

c. Educate patient and significant others

1) Rest eye for 12 to 24 hours: sunglasses, darkened room

2) Importance of follow-up care; recheck in 24 hours if injury is the result of contact lens use

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

B. Extraocular Foreign Bodies

Foreign bodies can enter the eye as a result of hammering, grinding, working under cars, or working above the head. Patients usually describe the sensation of “something going into the eye.” Foreign bodies can range from metal to sawdust to dust particles. Foreign bodies with a metallic component are of specific concern because these objects may form a rust ring in the cornea. If the rust ring is not removed, it may continue to invade the cornea and may interfere with vision. Ocular penetration with single or multiple foreign bodies must be considered with corneal injuries. This type of injury is usually related to occupation or avocation.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)

b) Pain (see Chapter 9)

c) Foreign body sensation, possible visual acuity changes

d) Tearing

e) Redness

f) Use of protective lenses

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous eye injuries or problems

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Mild to severe distress/discomfort

b) Inspection

(1) Tearing, blinking

(2) Mild to moderate conjunctival injection

(3) Possible visible foreign body: evert lid to inspect adequately

2) Diagnostic procedures

a) Visual acuity: normal to slightly abnormal

b) Fluorescein stain: abnormal; enhances corneal abrasion, foreign body, or rust ring if it is present

c) Slit-lamp examination

d) Possible orbital CT scan

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Anxiety

c. Deficient knowledge

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Possible gentle eye irrigation with normal saline

2) Foreign body removal with moistened cotton swab, 25-gauge needle, or foreign body spud

3) Rust ring removal with ophthalmic drill

4) Consultation with ophthalmologist if high-velocity injury suspected

b. Administer pharmacologic therapy as ordered

1) Topical ophthalmic anesthetic

2) Non-narcotic analgesics

3) Narcotics

4) Tetanus immunization

5) Topical ophthalmic antibiotics if corneal abrasion present

4. Evaluation and ongoing monitoring (see Appendix B)

a. Pain relief

b. Visual acuity

C. Retinal Detachment

Retinal detachment is a vision-threatening emergency. Rapid identification and management may lead to vision-saving surgical intervention. Retinal detachment involves separation of the neurosensory retinal layers from the retinal pigment epithelium (choroid). Accumulation of vitreous fluid or blood between the layers decreases blood and oxygen supply to the retina, and this change can result in blindness. The most common cause of detached retina is degenerative change in either the retina or the vitreous body in elderly patients; however, direct head trauma and injuries associated with sports activities may also result in detachment of the retina.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)

b) Painless unilateral loss of vision

(1) Cloudy, smoky vision

(2) Flashing lights or floaters in vision

(3) Curtain, veil, shower of black dots, or cobweb over visual field

(4) Gradual or sudden onset

2) Past medical history

a) Current or preexisting diseases/illness

(1) Diabetes

(2) Tumors

(3) Sickle cell disease

(4) Eclampsia

(5) Hypertension

b) Head or facial trauma

c) Past eye surgery

d) Medications, especially antihypertensives

e) Allergies

b. Objective data collection

1) Physical examination

a) General appearance

(1) Moderate to servere distress/discomfort

b) Inspection

(1) Pupil reaction usually normal; may have a relative afferent pupillary defect (unequal constriction and dilation of the pupil when examined with both direct and consensual light)

(2) Possible evidence of head or facial trauma

(3) Possible visual field deficit

2) Diagnostic procedures

a) Visual acuity: diminished

b) Funduscopy: indirect ophthalmoscopy by consultant for definitive diagnosis

c) Slit-lamp examination

d) Tonometry to measure intraocular pressure: may be decreased in affected eye

2. Analysis: differential nursing diagnoses/collaborative problems

a. Disturbed sensory perception: visual

b. Anxiety/fear

c. Deficient knowledge

d. Self-care deficit

3. Planning and implementation/interventions

a. Prepare for/assist with medical interventions

1) Shield both eyes to reduce eye movement and in cases of globe penetration

2) Maintain patient at bed rest and avoid movement

3) Assist with emergent ophthalmology consultation

4) Assist with hospital admission: surgical repair

4. Evaluation and ongoing monitoring (see Appendix B)

a. Visual acuity

D. Orbital Fracture

Orbital fractures may involve injury to the orbital rim or orbital floor. A “blow-out” fracture of the orbital floor can involve entrapment of extraocular muscles and/or the infraorbital nerve, which may require surgical intervention. A common cause of orbital fracture is blunt force to the orbit from an object, such as a fist or ball. The force causes an increase in intraorbital pressure, which may result in fractures of the thin, cancellous bone of the orbital floor or wall. Fractures of the inferior wall may involve the maxillary sinus, whereas medial wall fractures affect the ethmoid sinus.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Mechanism of injury (see Chapter 30)

b) Blurred vision

c) Diplopia: especially on lateral or upward gaze

d) Facial numbness

e) Pain (see Chapter 9) with eye movement

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous facial nerve injury

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Level of consciousness, behavior, affect: possibly altered if associated with head injury

(2) Moderate to severe distress/discomfort

b) Inspection

(1) Obvious facial trauma

(2) Periorbital soft tissue swelling, hematoma, ecchymosis

(3) Facial asymmetry

(4) Subconjunctival hemorrhage

(5) Enophthalmos or exophthalmos

(6) Pupils: equality, reaction

(7) Extraocular movements (EOMs): painful or limited upward or lateral gaze

(8) Possible ruptured tympanic membrane on affected side

(9) Obvious associated ocular or other injuries

c) Palpation

(1) Bony crepitus or subcutaneous air at fracture site

(2) Infraorbital paresthesia

2) Diagnostic procedures

a) Visual acuity

b) Funduscopy

c) Possible tonometry

d) Orbital CT scan

e) Orbital and facial radiograph including Waters’ view (assess for air-fluid levels or teardrop sign indicating fractures involving sinuses)

f) Possible cervical spine radiograph

2. Analysis: differential nursing diagnoses/collaborative problems

a. Acute pain

b. Anxiety

c. Deficient knowledge

d. Risk for infection

3. Planning and implementation/interventions

a. Maintain airway, breathing, and circulation (see Chapters 1 and 31)

b. Provide supplemental oxygen as indicated

c. Establish IV access for administration of crystalloid fluid/medications as needed

d. Prepare for/assist with medical interventions

1) Apply ice and elevate head of bed to decrease swelling

2) Have patient avoid blowing nose

3) Assist with surgical wound repair

4) Consultation with ophthalmology, ENT, or maxillofacial specialist

e. Administer pharmacologic therapy as ordered

1) Non-narcotic analgesics

2) Narcotics

3) Antibiotics: if sinus fracture involved

4) Tetanus immunization

4. Evaluation and ongoing monitoring (see Appendix B)

a. Hemodynamic status

b. Visual acuity

c. Pain relief

E. Chemical Burns

Chemical burns constitute a true ocular emergency, and treatment should be instituted immediately. Burn severity is greatly affected by the duration of exposure to the offending chemical. All chemical injuries to the eye should be evaluated by an ophthalmologist. A distinction between acid and alkali exposure to the eye will influence prognosis; however, such a determination need not be made before treatment is initiated. Acids, except hydrofluoric acid, cause immediate denaturation of tissue proteins, which act as a barrier against further penetration and damage. Hydrofluoric acid is a weak acid, but it easily permeates and penetrates tissues and produces intense pain and tissue damage. Alkaline agents rapidly combine with cellular lipids and produce coagulation necrosis with total cellular disruption. Immediate irrigation is imperative because of the seriousness of this injury; other assessments must be secondary. Risk factors include certain occupations such as auto mechanics and industries such as brick cleaning, glass etching, electropolishing, and leather tanning.

1. Assessment

a. Subjective data collection

1) History of present injury/chief complaint

a) Pain (see Chapter 9)

b) Variable degrees of visual loss

c) Chemical exposure

d) Occupational hazards

2) Past medical history

a) Current or preexisting diseases/illness

b) Previous eye problems

c) Medications

d) Allergies

e) Immunization status

b. Objective data collection

1) Physical examination

a) General appearance

(1) Moderate to severe distress/discomfort

b) Inspection

(1) Burns of varying degrees

(2) Visual acuity: decreased

(3) Conjunctival injection

(4) Chemosis (edema of bulbar conjunctiva)

(5) Corneal clouding: inability to define specific eye structures

2) Diagnostic procedures

a) Funduscopy

b) Fluorescein stain

c) Slit-lamp examination

2. Analysis: differential nursing diagnoses/collaborative problems

a. Disturbed sensory perception: visual

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