Republic of the Philippines MARINDUQUE STATE COLLEGE Tanza, Boac, Marinduque

A CASE STUDY ACUTE BACTERIAL CONJUNCTIVITIS LESLIE ANNE F. FLORES BSN II MARCH 2011

Acute Bacterial Conjunctivitis

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TABLE OF CONTENTS
I. Introduction. 1-3 II. Anatomy of the Eye. 4 III. Physiology of the Eye.. 5-8 IV. Pathophysiology of Acute Bacterial Conjunctivitis. 9 V. Patient Profile.. 10 VI. Nursing History... 10 VII. Nursing Care Plan.. 11 VIII. Course in Ward... 12 IX. Daily Progress Chart.. 13 X. Laboratory Diagnosis 14 XI. Drug Study. 15 XII. Discharge Planning 16 XIII. Bibliography 17

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Introduction: Conjunctivitis- is a general term because there are many causes if inflammation of the conjunctiva. In lay terms it is known as pink eye. This inflammation is said to be the most common ophthalmic problem that prompts to seek medical treatment. Acute Bacterial Conjunctivitis- is often called pink eye. Common in school children, pink eye is highly infectious. Conjunctival redness and crusting discharge deposited on the lashes and corners of the eye are the characteristics findings. Treatment includes cleansing of the lids and lashes, use of topical antibiotics, and precautions to prevent the spread to others. Firm adherent crusts may be softened by use of hot moist compresses. Because the material is infectious it should be disposed of in a sanitary way. Fortunately, acute bacterial conjunctivitis is usually self-limited, leaving no permanent scars.

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Etiology/ Clinical Manifestation:

Causes of conjunctivitis include viruses, bacteria, fungi, parasites, toxins, chemical, allergy, & foreign bodies. Conjunctivitis: Causes & Manifestation TYPE Bacterial infection CAUSES Causes include staphyloccus aureus (most common), haemophilus (Kochweeks bacillus), streptococcus pneumonae, moraxella, and neisseria gonorrhea (ophthalmia neonatorum) CHARACTERISTIC Can be unilateral or bilateral Purulent discharge from eye(s) Difficulty opening eyes when walking (caused by lashes & lids crusting, sticking from drainage) Blepharitis (infection of lid margin) may be present. Preauricular lymphadenopathy usually not present Edema of the eyelids.

The onset is usually sudden w/ symptoms noticeable on walking. Symptoms include a reddened conjunctiva (hyperemia), serous of mucous discharge from the eye (eyes attempt to wash the irritant out), crusting the eye discharge on lashes & lids causing difficulty in opening eyes such as is felt w/ foreign body (caused by drying out of the conjunctiva), eye discomfort (often described as a burning sensation), enlarged and tender particular lymph nodes & itching of the eye when the cause is allergy.

Acute Bacterial Conjunctivitis

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Therapeutic Management: Any person suspected of having conjunctivitis should be considered highly contagious & equipment used to examine & treat the disease eyes should be carefully sterilized. A smear (treat the eyes) culture should be obtained before initiating antibiotic therapy. Antibiotic eye drops are usually administered 4 times a day. Drug commonly used are erythromycin derivatives, neomycin or chloramphenicol. When purulent discharge is present, saline eye irrigation/application of warm compresses may be necessary before instillation of medication. Systematic antibiotic & corticosteroids are sometimes also administered. I doxuridine- IDO (stoxil), adenine, arabinoside, &influridine may be prescribed for viral infection cause by herpes simplex. Ophthalmic analgesic ointment/ drops may be instilled for discomfort, esp. at bedtime because discomfort becomes more noticeable when the eyelids are closed. Vasoconstristor eye medications are sometime stilled allergic types of conjunctivitis. Visual acuity should be checked to rule out other disorder.

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Anatomy of the Eye

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Physiology of the Eye

The eye has many functions. Unless an organism lives in total darkness, the eye has its use. In broad categories, it can either distinguish: light & dark, shape, colour, brightness and distance or can do all of the above.

nervous response ---a brief introduction to the terms used in explaining about the nervous system Light perception and adaptation --- the involvement of photopigments in vision Image formation --- our interpretation of the sensation of light Accommodation --- how the eye see objects at different distances from us Colour vision --- recognition of different colours Light intensity control --- pupil reflex controlling the amount of light entry into eye Binocular & Stereoscopic vision --- how we can see 3D

The following is what people mean when they talk about the physiology of the mammalian eye:

The human eye is the organ which gives us the sense of sight, allowing us to observe and learn more about the surrounding world than we do with any of the other four senses. We use our eyes in almost every activity we perform, whether reading, working, watching television, writing a letter, driving a car, and in countless other ways. Most people probably would agree that sight is the sense they value more than all the rest. The eye allows us to see and interpret the shapes, colors, and dimensions of objects in the world by processing the light they reflect or emit. The eye is able to detect bright light or dim light, but it cannot sense objects when light is absent.

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Process of vision Light waves from an object (such as a tree) enter the eye first through the cornea, which is the clear dome at the front of the eye. The light then progresses through the pupil, the circular opening in the center of the colored iris.

Fluctuations in incoming light change the size of the eyes pupil. When the light entering the eye is bright enough, the pupil will constrict (get smaller), due to the pupillary light response. Initially, the light waves are bent or converged first by the cornea, and then further by the crystalline lens (located immediately behind the iris and the pupil), to a nodal point (N) located immediately behind the back surface of the lens. At that point, the image becomes reversed (turned backwards) and inverted (turned upside-down). The light continues through the vitreous humor, the clear gel that makes up about 80% of the eyes volume, and then, ideally, back to a clear focus on the retina, behind the vitreous. The small central area of the retina is the macula, which provides the best vision of any location in the retina. If the eye is considered to be a type of camera (albeit, an extremely complex one), the retina is equivalent to the film inside of the camera, registering the tiny photons of light interacting with it. Within the layers of the retina, light impulses are changed into electrical signals. Then they are sent through the optic nerve, along the visual pathway, to the occipital cortex at the posterior (back) of the brain. Here, the electrical signals are interpreted or seen by the brain as a visual image. Actually, then, we do not see with our eyes but, rather, with our brains. Our eyes merely are the beginnings of the visual process. Myopia, hyperopia, astigmatism If the incoming light from a far away object focuses before it gets to the back of the eye, that eyes refractive error is called myopia (nearsightedness). If incoming light from something far away has not focused by the time it reaches the back of the eye, that eyes refractive error is hyperopia (farsightedness). Acute Bacterial Conjunctivitis MSC- BSN 2011 6 In the case of astigmatism, one or more surfaces of the cornea or lens (the eye structures which focus incoming light) are not spherical (shaped like the side of a basketball) but, instead, are cylindrical or toric (shaped a bit like the side of a football). As a result, there is no distinct point of focus inside the eye but, rather, a smeared or spread-out focus. Astigmatism is the most common refractive error. Presbyopia (after 40 vision) After age 40, and most noticeably after age 45, the human eye is affected by presbyopia. This natural condition results in greater difficulty maintaining a clear focus at a near distance with an eye which sees clearly far away. Presbyopia is caused by a lessening of flexibility of the crystalline lens, as well as to a weakening of the ciliary muscles which control lens focusing. Both are attributable to the aging process.

An eye can see clearly at a far distance naturally, or it can be made to see clearly artificially, such as with the aid of eyeglasses or contact lenses, or else following a photorefractive procedure such as LASIK (laser-assisted in situ keratomileusis). Nevertheless, presbyopia eventually will affect the near focusing of every human eye. Eye growth The average newborns eyeball is about 18 millimeters in diameter, from front to back (axial length). In an infant, the eye grows slightly to a length of approximately 19 millimeters. The eye continues to grow, gradually, to a length of about 24-25 millimeters, or about 1 inch, in adulthood. A ping-pong ball is about 1 inch in diameter, which makes the average adult eyeball about 2/3 the size of a ping-pong ball. The eyeball is set in a protective cone-shaped cavity in the skull called the orbit or socket. This bony orbit also enlarges as the eye grows. Acute Bacterial Conjunctivitis MSC- BSN 2011 7

Extraocular muscles The orbit is surrounded by layers of soft, fatty tissue. These layers protect the eye and enable it to turn easily. Traversing the fatty tissue are three pairs of extraocular muscles, which regulate the motion of each eye: the medial & lateral rectus muscles, the superior & inferior rectus muscles, and the superior & inferior oblique muscles. Eye structures Several structures compose the human eye. Among the most important anatomical components are the cornea, conjunctiva, iris, crystalline lens, vitreous humor, retina, macula, optic nerve, and extraocular muscles.

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Pathophysiology of Acute Bacterial Conjunctivitis

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Patient Profile:

Name: King James Olores Age: 2 years old Birthdate: March 17, 2009 Fathers Name: Apolinario Olores Mothers Name: Fe Olores Address: Yook, Buenavista Impression: Acute bacterial conjunctivitis Date of Admission: February 20, 2011 Time of Admission: 3:20 a.m

Nursing History
Cc: fever, eye discharge & c Present history: 2 wks.- (+) cold 3 days- note of eye redness & discharge of both eyes Fever- (+) intermittent fever & cough Past history: Urinary Tract Infection

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Nursing Care Plan

CUES

NSG. DX

SCIENTIFIC RATIONALE

EXPECTED OUTCOME After 24 hours the childs eye become whitish. And his eye didnt itch & no purulent discharge from eyes.

NURSING INTERVENTION Administer antibiotic eye drops as prescribed by the doctor. Instruct the parents to wash the child hands esp. when it put in his eyes

RATIONALE

EVALUATION

SHindi naman na sinosore eyes ang anak ko katunayan aalis na kami ngayon, hinihintay ko lang na tangalin ng nurse ang swero ng anak ko. OTemp: 36.5 oC CR: 127/min. RR: 34/min.

Risk for infection r/t acute bacterial conjunctivitis amb discharge from eye, difficulty opening of eye when waking, enlarge & tender of lymph nodes & itching of the eyes.

Bacteria infects conjunctiva Inflammatory respose White blood cells engulfs the bacteria Inflammatory purulent discharge from eyes Pinkish eye difficulty opening of eye when waking Eye discomfort

Individual responses to intervention/ teaching & actions performed.

The parents of the child received the instruction that give by the student. The parents of the put antibiotic eye drops into the eyes of their child.

enlarge & tender of lymph nodes & itching of the eyes Acute Bacterial Conjunctivitis

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Course in the Ward

Febuary 20Temp.= 38.4 oC Wt.= 13.8 kgs. Admit to Pedia Charity Ward - Secure consent for admission & management - Diet for age - Monitor v/s every 4 hours & record - Start IVF D8 0.3 NaCl 12 * 51-52 gtts/mins.

February 21 A febrile An diet for age w/ angoing IVF infusion still for urinalysis instructed still for CXR (PA) v/s taken w/ record needs attended February 22Discharge

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Daily Progress Chart

ADMISSION Feb. 20,2011 3:30 a.m Temp: 38.4 oC Wt.: 13.8 kgs. DIAGNOSTIC LAB./ TEST Secure consent for admission CBC w/ CXR (PA) & urinalysis DIET Diet for age ACTIVITY Admit to pedia charity ward Monitor v/s every 4 hrs. & record Monitor I & O every shift & record Monitor v/s MEDICINE Paracetamol Ampicilin Ambroxal Tobramycin & Dexamethazone TREATMENT IVF D8 0.3 Nacl 12 x 51-52 gtts/min.

Feb. 21,2011 -a febrile

Still for urinalysis instructed Still CBC w/ CXR (PA)

An diet for age

Paracetamol Ampicilin Ambroxal Tobramycin & Dexamethazone

w/ angoing IVF infusing rule

Feb. 22, 2011 9:00 a.m Temp. 36.5 CR: 127/min RR:34/min

DISCHARGE

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Laboratory Diagnosis

PROCEDURE URINALYSIS Color Transparency Ph SPECIFIC GRAVITY Protein Sugar RBC Bacteria HEMATOLOGY Hemoglobin Mass Erythrocyte Volume Leukocyte Lymhocytes

RESULT Pale yellow to amber Clean slightly hazy 5.6 Negative Negative Negative Negative 117 g/ L 0.35 g 7.25 8 10g/L 0.51

NORMAL VALUE Pale yellow to amber Clean slightly hazy 4.5-8.0 Negative Negative Negative Negative 125-155 g/ L 0.36-0.38 g 4.5-11.0 * g/ L 1.25-4.0

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Drug Study
DRUG Tobramycin CLASSIFICA TION 1st generation antibiotic DOSE/ROUTE/ FREQUENCY 1-2 gtts both-3 mg/ 1mg MECHANISM OF CONTRAINDI SIDE ACTION CATION EFFECTS Bacteriostatic, although may be bactericidal in high concentration. Prevents up-take of PABA, ametabolite of bacterial folic acid synthesis An aminopenicillin that inhibits cellwall synthesis during microorganism multiplication Contraindicate d in patient hypersensitive to drug/ other aminoglycoside s EENT- burning / stingling on instillation, lid itching/ swelling, conjunctival erythema, blurred vision w/ ointment, increase lacrimation. Hypersensitivit y reaction over growth of non susceptible organism pain of infection site. NSG. RESPOPNSIBILITY When 2 different ophthalmic solution are used, allow at least 5 minutes between instillation.

Ampicilin

1st generation antibiotic

345 mg/IV every 6 hrs.

Contraindicate d in patients hypersensitive to drug/ other penicillin.

Before giving drug, ask patient about allergic reaction to penicillin. A negative history of penicillin allergy is no guarantee against a

future allergic reaction Obtain specimen for culture & sensitivity test before giving first dose. Therapy may begin pending result. Watch for s/s of hypersensitivity, such as erythematous, maculopapular rash & anaphylaxis. Dexamethazone Antiinflammatory 1-2 gtts both-3 mg/ 1mg Not clearly defined, increase inflammation, mainly by stabilizing leukocyte, lysosomal membrane, suppresses immune response, stimulates bone marrow & influences protein, fat & carbohydrates Contraindicate d in patient hypersensitive to drug/ its ingredients & in those w/ systems fungal infection. Ephedrine: decrease halflife & increase clearance of dexamethazone occur. Determine whether patient is sensitive to other corticosteroid. Monitor patients weight & electrolyte levels Inspect patients skin for petechiae. Drug may mask/ worsen infections. Including latent amoebiasis.

metabolism

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Discharge Planning
Medication: Take medication on time prescribe by the doctor. * Ampicilin 345 mg/IV every 6 hrs. * Ambroxal 15 mg/5ml p.o every 8 hrs. * Dexamethazone & Tobramycin 1-2 gtts both-3 mg/ 1mg Exercise: Encourage patient to maintain the cleanliness of his hands especially his surroundings. Treatment: Continue medicine intake as prescribe by the physician & if symptoms persist consult the doctor. Health Teaching: Maintain healthy lifestyle, good diet & clean surroundings. Put antibiotic eye drops every hour/ when the eye itch.

Proper hand washing technique is important to prevent harmful bacteria who infects the eye . Self cares at home help relieve symptoms. OPD: Patient advised to return for follow up check-up. Diet: Diet as tolerated Acute Bacterial Conjunctivitis 16 MSC- BSN 2011

Bibliography
BOOKS: Pillitteri, A.; Maternal & Child Health Nursing: Care of the Childbearing Family; 2007; A Wolters Kuwer Company. Beare, Patricia & Myers, Judith; Principles & Practice of Adult Health Nursing; 1990; C.V Mosby Company. Noval, Thomas; Pathophysiology, 3rd Edition; 2005; Mc Graw Hill Company Incorporation 1221. Lippincott & Wilkin; Nursing Drug Handbook, 23rd Edition; 2003; A Wolters Kuwer Company.

WEBSITE: http://en.wikipedia.org/wiki/Conjunctivitis

http://kidshealth.org/parent/infections/eye/conjunctivitis.html http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0420.2007.01006.x/full

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