I. INTRODUCTION Endophthalmitis is an inflammation of the inside of the eye. Inflammation affects the vitreous fluid in center of the eye.

Vitreous fluid is a clear, gel-like substance. The inflammation can extend to surrounding tissues responsible for vision and causes such as retained native lens material after an operation or from toxic agents. Endogenous endophthalmitis is rare, occurring in only 2-15% of all cases of endophthalmitis. Average annual incidence is about 5 per 10,000 hospitalized patients. In unilateral cases, the right eye is twice as likely to become infected as the left eye, probably because of its more proximal location to direct arterial blood flow from the right innominate artery to the right carotid artery. Since 1980, candidal infections reported in IV drug users have increased. The number of people at risk may be increasing because of the spread of AIDS, more frequent use of immunosuppressive agents, and more invasive procedures (eg, bone marrow transplantation). Most cases of exogenous endophthalmitis (about 60%) occur after intraocular surgery. When surgery is implicated in the cause, endophthalmitis usually begins within 1 week after surgery. In the United States, postcataract endophthalmitis is the most common form, with approximately 0.10.3% of operations having this complication, which has increased over the last 3 years. Although this is a small percentage, large numbers of cataract operations are performed each year making the chances that physician may encounter this infection higher. Posttraumatic endophthalmitis occurs in 4-13% of all penetrating ocular injuries. Incidence of endophthalmitis with perforating injuries in rural settings is higher when compared with nonrural settings. Delay in the repair of a penetrating globe injury is correlated with increased risk of developing endophthalmitis. Incidence of endophthalmitis with retained intraocular foreign bodies is 7-31%. As stated earlier, current treatment regimens for bacterial endophthalmitis include direct intravitreal injections of vancomycin (1.0 mg/0.1 ml) and ceftazidime (2.2 mg/0.1 ml) for broad-spectrum coverage of Gram-positive and Gram-negative organisms, respectively. Systemic antibiotics are administered for

cases of endogenous endophthalmitis. At present, vancomycin has 99% susceptibility against all Gram-positive organisms causing endophthalmitis. Recent reports have emerged regarding endophthalmitis cases caused by vancomycin-resistantEnterococcus. The potential effectiveness of commonly used antibiotics can be variable owing to the development of resistance. Sensitivities of Gram-negative ocular isolates to ceftazidime, a third-generation cephalosporin, were reported to be 100%. However, Han et al. reported a series of Gram-negative endophthalmitis cases in which 89% of patients were successfully treated, but the remaining 11% were infected with Gram-negative bacteria resistant to both amikacin and ceftazidime. Structural improvements made to the cephalosporin drug class have improved the efficacy of these drugs against Gram-negative organisms. Second-generation (cefoxitin, cefamandole, cefotetan) and third-generation (ceftriaxone, ceftazidime, moxolactam) cephalosporins have superior activity against Gram-negative bacteria, but decreased activity against Gram-positive bacteria. Intravitreal ceftazidime has been reported to be safer than aminoglycosides, with toxicity observed only when ceftazidime was administered at high dosages. A recent clinical report demonstrated that the risk of endophthalmitis was reduced by 93% when the second-generation cephalosporine cefuroxime was used as an intracameral prophylactic injected prior to surgery. Synergy between antibiotic combinations is important to consider, especially for a rapidly blinding infection such as endophthalmitis. Vancomycin/amikacin and vancomycin/ceftazidime are synergistic in combination. However, Roth and Flynn suggested that synergy in antibiotic combinations may not be as important for endophthalmitis due to the high levels of the individual drugs injected at the site of infection. Inflammation, typically necessary to clear infections, may cause damage to the retina. Intravitreal administration of bacterial wall components induces significant intraocular inflammation, but only a mild and recoverable loss in retinal function. Because the intraocular inflammatory response has the potential to cause collateral intraocular damage, arresting the immune response with intravitreal steroids may serve as an adjunct to antibiotic therapy. Clinical and

experimental studies on the value of intravitreal corticosteroids have been controversial and generally conflict on the benefit of these drugs for use in endophthalmitis. Most clinical and experimental reports agree that the corticosteroid dexamethasone is not toxic to the retina when intravitreally injected. However, clinical reports conflict on whether intravitreal dexamethasone is helpful or of little useas an adjunct to antibiotic therapy for bacterial endophthalmitis. Experimental results on the effectiveness of intravitreal steroids during bacterial endophthalmitis also vary. Intravitreal dexamethasone/antibiotic combinations have been shown to be effective or ineffective in reducing inflammation during experimental bacterial endophthalmitis. Intravitreal prednisolone/antibiotic combinations were also ineffective in reducing inflammation during experimental Bacillusendophthalmitis compared with that of intravitreal antibiotics alone. Although there is a lack of definitive evidence for either position, corticosteroids (i.e., dexamethasone at 0.4 mg) are commonly used in conjunction with antibiotics for the treatment of endophthalmitis. In recently published European prophylactic intracameral cephalosporin studies, the incidence of postoperative endophthalmitis after unilateral cataract surgery weight-averaged to 1 in 331 (0.3%) without prophylactic intracameral antibiotics and to 1 in 1977 (0.05%) with prophylactic intracameral antibiotics, whereas studies in the United States using only topical antibiotics reported infection rates as low as 0.028%. Four cases of bilateral simultaneous endophthalmitis after ISBCS have been reported in the past 60 years, all with breaches of aseptic protocol. No bilateral simultaneous endophthalmitis occurred in the 95606 ISBCS cases collected. The overall rate of postoperative endophthalmitis after ISBCS was 1 in 5759. Infection rates were significantly reduced with intracameral antibiotics to 1 in 14352 cases. Endopthalmitis cause by either a virus or a trauma, the group decided to take such topic for the case study. Another justification to be considered is that to be able to impart the best possible care to the patient, the student nurses must enhance their understanding and competence on the occurrence of such

disease. Learning is not just based on the discussions and lectures inside the classroom; it should also be derived from the people where the outmost concerns is bestowed. Through the course of the study, the group would also want to familiarized itself on the different causative factors and treatment for the disease so that for them to become more efficient in rendering proper care and service to their patient. In addition, as student nurses and as part of the health care team in the future, they may equip themselves with the proper knowledge regarding the disease and its processes, enhance their skills with the proper management of the patient's condition and provide interventions to prevent from occurring or reoccur. II. NURSING ASSESSMENT

Personal Data The patient X is a 46 year old male and a Filipino citizen. He is the second among the 7 children of Mr. Y and Mrs. Z. X is affiliated in the Roman Catholic Church. He is married to Mrs. W with 7 children. He was born August 13, 1965 at one of the tertiary hospital in Pampanga. X was admitted last June 15, 2012 due to fever and pain in right eyes. The family is compose of 9 members consist of Mr. X, Mrs. W and their 7 children and this type of family is called nuclear type. Mrs. W and Mr. X had 7 children, the first one is a boy age was 24 years old and the youngest one is a girl whose age is 16 years. Socio-economic and cultural factors Mrs. W 41 years old who is a plain house wife and a Barangay health worker while Mr. X 46 years old works as a laborer and their estimated income for a month is P 8, 000.00. Based on the minimum parameters of the National Economic Development Authority (NEDA) regarding family allowance, a family

member should have at least Php2768.60 allowance per individual in order to meet the daily requirements of all the members of the family. In their case, they are receiving 888.89 per individual. Therefore, the amount of money that they receive every month is not adequate to meet the needs of the whole family. The expenditure of the family includes their electric consumption, water used for washing clothes, dishes, food, rice, and foods. Their monthly expenses for the water bill P500.00, electricity P1,500.00, food P3,000.00. Mr. Xs family is affiliated with Roman Catholic and doesnt attend mass regularly. Based from the interview with Mrs. W, the family believe in herbolarios and manghihilot and they also prefer doctors order and they are the one who understand and knowledgeable they accessing the health center when they experiencing illnesses. When it comes in taking care in persons health. As with the common ailments, they do self-medication.

History of Past Illness Mr. X, experienced the common illnesses like fever, cough, colds and headaches. He managed it by taking over the counter drugs like Paracetamol Biogesic. Sometimes he takes Alaxan 1 tablet, two times a day for body pain and Ibuprofen 250mg for headache until pain suppresses. He also experienced common cough and colds and managed it by using the herbal medicinal plant Oregano and the water therapy for at least two liters a day. 5. History of Present Illness Prior to admission he experienced dizziness, vomiting and ____________

6. Physical Examination DATE (Lifted From the Chart) Head-HEENT: pale palpebral conjunctiva Chest Lungs:-----------------------------------------Cardiovascular:-----------------------------Abdomen: flat, soft, non tender abdomen Musculo Skeletal: pedal edema Aug 7, 2011 (Lifted from the chart) Abdominal Pain (+) Lymphnodes Icteric sclera pedal edema DATE (First student nurse patient interaction) THE INTEGUMENT Skin - uniform, when pinched the skin goes back to previous state immediately, good skin turgor, with normal temperature, absence of jaundice Hair - His hair is a bit of long and oily, evenly distributed, with no presence of pediculitis. Nails - dirty fingernails and toenails, smooth. The student nurse checked for the capillary refill test and the result is normal because it returns to its usual color in less than 3 seconds. Capillary Refill - Capillary refill less than 3 seconds THE HEAD Skull - normocephalic size of skull, symmetrical, no tenderness palpated, no masses, absence of nodules.

Face - The facial movement is symmetrical and facial features are also symmetrical, hair evenly distributed

EYES AND VISION Eyebrows - hair evenly distributed, equal movement and are symmetrically aligned skin intact, no discoloration and bilaterally blinking Eyelashes - curled slightly outward and evenly distributed Eyelids - skin intact, no discoloration and bilaterally blinking Bulbar Conjunctiva/ Sclera Palpebral Conjunctiva - Smooth and color pale. Lacrimal Gland, Lacrimal Sac, Nasolacrimal Duct - absence of edema/ tenderness Cornea - Transparent, shiny and smooth, normal blinking reflex. The client was able to blinks when the cornea is touched. Pupils - black in color, PERRLA (Pupil Equally Round and Reactive to Light Accommodation), the iris is flat and round. The pupils are react accordingly to light, it constricts as the light passes. THE EARS AND HEARING Auricles - Same as facial skin; symmetrical; auricle is aligned with the outer canthus of the eye; firm; non tender; External Ear Canal - Same colors as facial skin, symmetrical, with dry cerumen, and grayish tan color. GROSS HEARING ACUITY TEST Watch Tick Test - Able to hear ticking in both ears

THE NOSE AND SINUSES Nose - Symmetrical to face, no discharge, no bleeding Sinuses - Air moves freely as the client breathes through the nares. MOUTH AND OROPHARYNX Lips and Buccal Mucosa - uniform pink color, soft, and able to purse lips. Teeth and Gums - Have incomplete set of teeth Tongue and Floor of the Mouth - Was able to move freely, central position, no tenderness and pinkish in color. Palates - Light pink, smooth soft palate; lighter pink hard palate; more irregular texture Uvula - Position midline of soft palate Oropharynx and Tonsils - Pink, smooth; no discharge THE NECK Neck - Muscles equal in size; head centered; coordinated, smooth movement with no discomfort. Lymph Nodes - Are not palpable Trachea - Central placement in midline of neck; spaces are equal on both sides Thyroid Gland - Not visible on inspection; gland ascends during swallowing but is not visible THORAX AND LUNGS Posterior Thorax- Spinal column is straight; left and right shoulders and hips are at the same height Chest wall intact- no tenderness; no masses Anterior Thorax - Quiet, rhythmic, and effortless respiration THE HEART Carotid Artery - Symmetric pulse volumes, Full pulsations; Jugular Veins- Veins are not visible

AXILLA - No tenderness, masses, or nodules upon palpation of lymph nodes ABDOMEN - The abdomen of the client is uniform in color, flat and audible bowel sounds. Absence of pain upon the release of pressure MUSCLES - Equal size on both sides of the body. No fracture, equal in size, no deformities, and no tenderness and tremors. BONES - no swelling and deformities JOINTS - No swelling and tenderness, or nodules; joints move smoothly Cranial Nerves (First student nurse patient interaction) Cranial Nerve Cranial Nerve I: Olfactory Function Smell Test Expected Result must to Actual Findings

Ask the client to Client smell identify aromatic, nonirritating nostrils separately with the closed. and eyes and able an

be Mr. X was able scent alcohol

identify to identify the like like cologne

an different scent of different object asked cologne, alcohol and smell it.

odor with each when

to prepared by the student nurses.

Cranial Nerve II: Optic

Vision and Vision fields

Snellens chart or Clint must be able Mr. X was able newspaper/ma gazine to read to read newspaper at 14 newspaper at 9 inches distances inches distance

Cranial Nerve III: Movemen Oculomotor t of pupil sphincter

Test

for

Pupils Eyes must follow Pupil

constrict

of equally and

round the movement of when looking at dim environment, dilate the pupils of the looking when at a

reactive to light ball pen. In light a near object, accommodatio n (PERRLA)

eyes are dilated, distance object,

upon introduction converge when of light to the near object is eyes, constricted. pupils moved towards the nose.

Cranial

Nerve Extra ocular eye t

Ask the client to Eyes must follow Left follow movement his eyes. the the of and object difficulty.

eye

are the eye

IV: Trochlear

downward able to move as lateral necessary of Right test due

movemen the penlight with movement

without cannot able to to intact dressing.

Cranial Nerve V: Sensation Trigeminal of cornea, masticati on

Ask the client to Client must blink look then upward and should be lightly able to identify lateral the sharp and dull blink a

Mr. X was able to elicit corneal reflex, identified and sharp. and the

muscle of touch to elicit

sclera of the eye sensation. reflex using

sensation of dull

small pieces of cotton ball. Cranial Nerve Extra ocular eye Ask the client to The follow movement client must Able to follow; the both eyes move VI: Abducens the follow

of movement of the in coordination.

movemen the penlight with penlight laterally. t, eyeball his eyes. moves laterally.

Cranial VII: Facial

Nerve Facial expressio

Make the patient smile,

Clients muscle of facial expression

Mr. X was able to smile, puffed

n; taste (anterior two third of tongue)

puff cheeks and raise his eyebrows and other facial expressions. Ask client to identify various tastes placed on tip and sides of tongue with eyes closed (sugar and vinegar).

should work. The client should also be able to candy

his cheeks and raises eyebrows able distinguish his and to the

distinguish taste of was

taste of candy

Cranial VIII:

Nerve Hearing And balance

The client will listen to and report on a whispered voice. Ask the client to walk in a straight manner to assess for gait and balance.

Must be able to hear and understand whispered words. Must be able to walk with steady balance.

Client was able to repeat what has whispered was walk balance. able been and to with

Vestibulocochle ar

Cranial IX:

Nerve Taste (Posterior Tongue), gag reflex

Ask the client to identify some foods or condiments. Ask the client to say ah and

Must be able to Able to identify distinguish from and reflex the should one various tastes other, like coffee and be sugar and was to elicit and gag reflex and without able to swallow

Glossopharynge al

able to elicit gag able

have the patient swallow

yawn to observe upward movement of the soft palate. Elicit gag response. Note ability to swallow.

difficulty.

without difficulty.

Cranial Nerve X: Swallowin Vagus g, vocal cord movemen t

Ask the client to Must be able to Able to swallow cough, swallow speak clearly. and to speak. without difficulty and can speak clearly.

Cranial

Nerve Head t, shrugging of shoulders

Ask the client to Would rotate and Able to move move neck head from side to side with can resistance, shoulders overcome resistance. shoulders, turn without difficulty.

XI: Accessory

movemen elevate the head side to side, and push the resistance. head forward against

Cranial

Nerve Protrusion of tongue, moves tongue up, down and side

Ask the client to Tongue protrude tongue move at midline and difficulty. then move it side to side.

should Was

able

to

XII: Hypoglossal

without move tongue in different directions.

to side

DATE (Second student nurse patient interaction) THE INTEGUMENT Skin - uniform, when pinched, the skin goes back to previous state immediately, good skin turgor, with normal temperature, absence of jaundice Hair - His hair is a bit of long and oily, evenly distributed, with no presence of infection. Nails - dirty fingernails and toenails, smooth. The student nurse checked for the capillary refill test and the result is normal because it returns to its usual color in less than 3 seconds. Capillary Refill - Capillary refill less than 3 seconds THE HEAD Skull - normocephalic size of skull, symmetrical, no tenderness palpated, no masses, absence of nodules. Face - The facial movement is symmetrical and facial features are also symmetrical, hair evenly distributed

EYES AND VISION Eyebrows - hair evenly distributed, equal movement and are symmetrically aligned skin intact, no discoloration and bilaterally blinking Eyelashes - curled slightly outward and evenly distributed

Eyelids - skin intact, no discoloration and bilaterally blinking Bulbar Conjunctiva/ Sclera Palpebral Conjunctiva - Smooth and color pale Lacrimal Gland, Lacrimal Sac, Nasolacrimal Duct - absence of edema/ tenderness Cornea - Transparent, shiny and smooth, normal blinking reflex. The client was able to blinks when the cornea is touched. Pupils - black in color, PERRLA (Pupil Equally Round and Reactive to Light Accommodation), the iris is flat and round. The pupils are react accordingly to light, it constricts as the light passes. THE EARS AND HEARING Auricles - Same as facial skin; symmetrical; auricle is aligned with the outer canthus of the eye; firm; non tender; External Ear Canal - Same colors as facial skin, symmetrical, with dry cerumen, and grayish tan color. GROSS HEARING ACUITY TEST Watch Tick Test - Able to hear ticking in both ears THE NOSE AND SINUSES Nose - Symmetrical to face, no discharge, no bleeding Sinuses - Air moves freely as the client breathes through the nares. MOUTH AND OROPHARYNX Lips and Buccal Mucosa - uniform pink color, soft, and able to purse lips. Teeth and Gums - Have incomplete set of teeth

Tongue and Floor of the Mouth - Was able to move freely, central position, no tenderness and pinkish in color. Palates - Light pink, smooth soft palate; lighter pink hard palate; more irregular texture Uvula - Position midline of soft palate Oropharynx and Tonsils - Pink, smooth; no discharge THE NECK Neck - Muscles equal in size; head centered; coordinated, smooth movement with no discomfort. Lymph Nodes - Are not palpable Trachea - Central placement in midline of neck; spaces are equal on both sides Thyroid Gland - Not visible on inspection; gland ascends during swallowing but is not visible THORAX AND LUNGS Posterior Thorax- Spinal column is straight; left and right shoulders and hips are at the same height Chest wall intact; no tenderness; no masses Anterior Thorax - Quiet, rhythmic, and effortless respiration THE HEART Carotid Artery - Symmetric pulse volumes, Full pulsations; Jugular Veins- Veins are not visible AXILLA - No tenderness, masses, or nodules upon palpation of lymph nodes ABDOMEN - The abdomen of the client is uniform in color, flat and audible bowel sounds. Absence of pain upon the release of pressure MUSCLES - Equal size on both sides of the body. No fracture, equal in size, no deformities, and no tenderness and tremors. BONES - no swelling and deformities JOINTS - No swelling and tenderness, or nodules; joints move smoothly

Cranial Nerves (second student nurse patient interaction) Cranial Nerve Cranial Nerve I: Olfactory Function Smell Test Expected Result must to Actual Findings

Ask the client to Client smell identify aromatic, nonirritating nostrils separately with the closed. and eyes and able an

be Mr. X was able scent alcohol

identify to identify the like like cologne

an different scent of different object asked cologne, alcohol and smell it.

odor with each when

to prepared by the student nurses.

Cranial Nerve II: Optic

Vision and Vision fields

Snellens chart or Clint must be able Mr. X was able newspaper/ma gazine to read to read newspaper at 14 newspaper at 9 inches distances inches distance

Cranial Nerve III: Movemen Oculomotor t of pupil sphincter

Test

for

Pupils Eyes must follow Pupil

constrict

of equally and

round the movement of when looking at dim environment, dilate the pupils of the looking when at a

reactive to light ball pen. In light a near object, accommodatio n (PERRLA)

eyes are dilated, distance object, upon introduction converge when of light to the near object is eyes, constricted. pupils moved towards the nose.

Cranial

Nerve Extra ocular

Ask the client to Eyes must follow Left follow the the

eye

are

IV: Trochlear

downward able to move as

eye t

movement his eyes.

of and object difficulty.

lateral necessary of Right test due

the eye to

movemen the penlight with movement

without cannot able to intact dressing.

Cranial Nerve V: Sensation Trigeminal of cornea, masticati on

Ask the client to Client must blink look then upward and should be lightly able to identify lateral the sharp and dull blink a

Mr. X was able to elicit corneal reflex, identified and sharp. and the

muscle of touch to elicit

sclera of the eye sensation. reflex using

sensation of dull

small pieces of cotton ball. Cranial Nerve Extra ocular eye Ask the client to The follow movement client must Able to follow; the both eyes move VI: Abducens the follow

of movement of the in coordination.

movemen the penlight with penlight laterally. t, eyeball his eyes. moves laterally.

Cranial VII: Facial

Nerve Facial expressio n; taste (anterior two third of tongue)

Make the patient smile, puff cheeks and raise his eyebrows and other facial expressions. Ask client to identify various tastes

Clients muscle of facial expression should work. The client should also be able to candy

Mr. X was able to smile, puffed his cheeks and raises eyebrows able distinguish his and to the

distinguish taste of was

taste of candy

placed on tip and sides of tongue with eyes closed (sugar and vinegar). Cranial VIII: Vestibulocochle ar Nerve Hearing And balance The client will listen to and report on a whispered voice. Ask the client to walk in a straight manner to assess for gait and balance. Must be able to walk with steady balance. Must be able to hear and understand whispered words. Client was able to repeat what has whispered was walk balance. able been and to with

Cranial IX:

Nerve Taste (Posterior Tongue), gag reflex

Ask the client to identify some foods or condiments. Ask the client to say ah and yawn to observe upward movement of the soft palate. Elicit gag response. Note ability to

Must be able to Able to identify distinguish from and reflex difficulty. the should one various tastes other, like coffee and be sugar and was to elicit and gag reflex and without able to swallow without difficulty.

Glossopharynge al

able to elicit gag able

have the patient swallow

swallow.

Cranial Nerve X: Swallowin Vagus g, vocal cord movemen t

Ask the client to Must be able to Able to swallow cough, swallow speak clearly. and to speak. without difficulty and can speak clearly.

Cranial

Nerve Head t, shrugging of shoulders

Ask the client to Would rotate and Able to move move neck head from side to side with can resistance, shoulders overcome resistance. shoulders, turn without difficulty.

XI: Accessory

movemen elevate the head side to side, and push the resistance. head forward against

Cranial

Nerve Protrusion of tongue, moves tongue up, down and side to side

Ask the client to Tongue protrude tongue move at midline and difficulty. then move it side to side.

should Was

able

to

XII: Hypoglossal

without move tongue in different directions.

http://www.intelihealth.com/IH/ihtIH/WSIHW000/9339/9935.html http://emedicine.medscape.com/article/799431-overview http://emedicine.medscape.com/article/799431-overview#a0199 http://www.medscape.org/viewarticle/729714_6 http://www.ncbi.nlm.nih.gov/pubmed/22108106