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CLIENT
TEACHING GUIDE
WOUND CARE: PRESSURE INJURIES/ULCERS
PROBLEM
CAUSE
PREVENTION/CARE
A.
Keep the area clean and free of foreign debris.
B.
You may be prescribed dressing changes.
1.
Remove dressing.
2.
Clean the ulcer with normal saline.
3.
Apply prescribed medication (see below as recommended by your provider).
4.
Cover with dry dressing, change as ordered.
C.
You may be prescribed antibiotics; if so, take all antibiotics until they are completely gone.
TREATMENT
Activity:
Diet:
Eat a well-balanced diet. Drink 8 to 10 glasses of water per day. Increase protein intake.
Medications:
ulcer on the body that lies over a bony surface.
Prolonged
periods of pressure to the area of the ulcer causing a breakdown of skin integrity.
PLAN
Do not apply direct pressure to the site of the ulcer.
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
A reaction or cannot tolerate any of the prescribed medications.
B.
A fever and a general ill feeling.
C.
Any new or unexplained symptoms:
1.
Increase in size.
2.
New odor.
3.
Increased drainage.
4.
Change in color of the drainage.
5.
Increased pain at the site.
D.
Any questions or concerns.
Phone:
RESOURCE
National
Pressure Injury Advisory Panel, 4 Lan Drive, Suite 310, Westford, MA 01886, United States, Phone: 978-364-
5130, www.npiap.org
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
139
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CLIENT
TEACHING GUIDE
WOUND CARE: WOUNDS
PROBLEM
CAUSE
of the site.
PREVENTION/CARE
A.
Prevent accidental or intentional injury.
B.
Immediately after injury, cleanse the wound well with soap and water.
C.
Remove all dirt and foreign material.
D.
You may be prescribed antibiotics; if so, take all antibiotics until they are completely gone.
E.
You may need a tetanus shot.
TREATMENT
Activity:
Diet:
Eat a well-balanced diet. Drink 8 to 10 glasses of water per day.
Medications:
You
Have Been Prescribed:
wound is a break in the external surface of the body.
Wounds
are often due to an accidental or intentional injury. Wound infection is usually caused by bacterial contamination
PLAN
No restrictions. If infection is present, you may need to increase rest.
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
A reaction or cannot tolerate any of the prescribed medications.
B.
A fever and a general ill feeling.
C.
A wound/infection that seems to worsen.
D.
Any new or unexplained symptoms.
E.
Any questions or concerns.
Phone:
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
140
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CLIENT
TEACHING GUIDE
XEROSIS (WINTER ITCH)
PROBLEM
but it is seen most commonly on the legs.
CAUSE
decreases with aging, excessive bathing, and excessive rubbing of the skin. An environment with low humidity also promotes dryness of the skin.
PREVENTION/CARE
A.
Reduce water loss from the skin.
1.
2.
3.
4.
5.
6.
7.
8.
9.
B.
Apply hand cream four to eight times a day to the hands and twice daily on the trunk and extremities.
Xerosis
is a severely chapped skin that becomes cracked, ssured, and inamed. It can appear anywhere on the body,
Xerosis
is caused by insufcient oil on the skin’s surface, which allows water to evaporate through the skin. Oil in the skin
Decrease the frequency and duration of baths or showers; use tepid water.
Use soap sparingly.
Avoid detergent soaps.
Pat skin dry rather than rubbing.
Apply skin lubricants (Lac-Hydrin, Eucerin, etc.) to dry the skin before chapped areas become inamed.
Use ultrasonic, cool-mist humidiers if the air is very dry.
Clean the humidier daily.
Oil (such as Nivea) in the bath water may be helpful.
Apply lubricants after bathing when possible to trap additional moisture before evaporation occurs.
TREATMENT
Activity:
Diet:
Medications:
You
Have Been Prescribed:
You
Need to Take:
You
Need to Notify the Office If You Have:
A.
Severely chapped skin and self-care does not relieve the symptoms in 1 week.
B.
Chapped skin that becomes inamed or if you see any oozing.
C.
Any questions or concerns.
Phone:
RESOURCE
PLAN
No restrictions. Avoid long-term exposure to drying environments.
Eat a well-balanced diet; drink 8 to 10 glasses of water per day.
American
Academy of Dermatology, 9500 W Bryn Mawr Avenue, Ste 500, Rosemont, IL 60018-5216, United States,
Phone: (888) 462-DERM (3376), www.aad.org
From FAMILY PRACTICE GUIDELINES, Sixth Edition. Copyright Springer Publishing Company, LLC. All Rights Reserved.
C H A P T E R
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EYE GUIDELINES
Jill C. Cash and Nancy Pesta Walsh
AMBLYOPIA
DEFINITION
A. Amblyopia is a decrease in the visual acuity of one eye. It
is commonly diagnosed in younger adults and children and is
often referred to as “lazy eye.”
B. It cannot be corrected with either glasses or contact lenses.
INCIDENCE
A. Amblyopia is most commonly diagnosed in children and
occurs in approximately 1.75% to 3% of the population.
B. Effective return of vision occurs with approximately 75%
of children who have experienced occlusion therapy. Of these
children, 50% had mild visual acuity loss over time, which
emphasizes the importance of referring clients early in life.
C. Amblyopia is the most common cause of childhood vision
loss.
PATHOGENESIS
A. Amblyopia has numerous causes, including the following:
1. Congenital defect.
2. Develops from a corneal scar or cataract.
3. Occurs from an uncorrected high refractive error,
which causes visual blurring.
4. Develops when each eye has a different refractive error,
which leads to blurred vision.
5. Strabismic amblyopia may also occur due to loss of
vision in the eye that turns inward or outward.
PREDISPOSING FACTORS
A. One parent with amblyopia.
B. Prematurity.
C. Small for gestational dates.
D. Maternal smoking or alcohol use.
COMMON COMPLAINTS
A. Decreased vision: complains of sitting close to the televi-
sion, sitting in the front row of a classroom, having trouble
seeing the ball in sports, and so forth.
B. Vision that is not corrected with either glasses or contact
lenses.
C. Wandering eye and frequent eye squinting.
D. Distorted or confused vision.
OTHER SIGNS AND SYMPTOMS
A. Frequent rubbing of the eyes.
B. Tired eyes.
SUBJECTIVE DATA
A. Elicit the onset of visual changes, noting course of symp-
toms and severity.
B. Assess for pain or any new injury or trauma to the eye.
C. Inquire about new events or changes in health history,
including contact lenses, glasses, illnesses, and cataracts.
D. Review client and family history of amblyopia.
PHYSICAL EXAMINATION
A. Inspect:
1. Note extraocular movements of eyes.
2. Examine sclera, pupil, iris, and fundus.
3. Examine eyes for red reex.
4. Intraocular pressure testing should be done if the client
can tolerate it. It may be deferred to a specialist if needed,
due to age, for example.
5. Assess vision based on age, using LEA SYMBOLS®,
Sloan letters, Sloan numerals, tumbling E, and the HOTV.
The Kindergarten Eye Chart and the Snellen Chart are
less preferred methods as they do not meet the World
Health Organization (WHO)/Committee on Vision
Standards.
6. Visual elds may be assessed with a parent holding the
child on their lap.
DIAGNOSTIC TEST
A. None.
DIFFERENTIAL DIAGNOSES
A. Amblyopia.
B. Organic brain lesion.
PLAN
A. General interventions:
1. All children need to have a visual examination prior to
starting school.
2. Recommend examination by an ophthalmologist for
children with strabismus and for those with a family history of amblyopia.
3. Measures for refractive correction or patching of the
stronger eye are usually performed to encourage the weak
eye to develop.
4. Surgery may be required for abnormal positioning of
the eye.
FOLLOW-UP
A. Follow up with an ophthalmologist.
The contributions of Jenny Mullen to this chapter in prior editions are acknowledged here.
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CONSULTATION/REFERRAL
A. Refer the client to an ophthalmologist for evaluation and
treatment.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Closely monitor children postsurgery to ensure they
do not peek from under the bandages. Establish a reward
system to assist their adherence with eye patch.
BIBLIOGRAPHY
Blair, K., Cibis, G., & Gulani, A. (2021). Amblyopia. StatPearls NCBI
Resources. https://www.ncbi.nlm.nih.gov/books/NBK430890/
BLEPHARITIS
DEFINITION
A. Blepharitis is dryness and aking of the eyelashes, result-
ing from an inammatory response of the eyelid.
INCIDENCE
A. A survey of U.S. ophthalmologists and optometrists dis-
covered up to 47% of clients had signs of blepharitis.
B. Blepharitis affects all age and ethnic groups. Current stud-
ies indicate the mean age of clients affected with blepharitis
is 50 years, and clients with staphylococcal blepharitis were
approximately 42 years old and primarily female.
SUBJECTIVE DATA
A. Elicit onset and duration of signs and symptoms.
B. Note sensations of itching, burning, or pain in the eye.
C. Ask what makes signs and symptoms worse and what
makes signs and symptoms better.
D. Any change in soaps, creams, lotions, or shampoos?
E. Has the client had similar signs and symptoms in the
past?
F. Note any visual change or pain since the last eye
examination.
G. Note contributing factors involved if present.
PHYSICAL EXAMINATION
A. Inspect:
1. Inspect eyes, noting extraocular movements.
2. Examine sclera, pupil, iris, and fundus.
3. Examine eyes for red reex.
4. Note erythema or edema on lid margin; note dryness,
scaling, and akes.
5. Assess vision based on age, using the Snellen Chart for
children older than 3 years.
6. Visual elds may be assessed with a parent holding the
child on their lap.
DIAGNOSTIC TEST
A. None; however, cultures of eyelid margins may be war-
ranted if signs/symptoms indicate.
PATHOGENESIS
A. Seborrheic: excessive shedding of skin cells and blockage
of glands.
B. Staphylococcus: the most common bacteria found and
responsible for bacterial infection of the lid margin.
C. Commonly seen with inadequate ow of oil and mucus
into the tear duct.
PREDISPOSING FACTORS
A. Diabetes.
B. Candida.
C. Seborrheic dermatitis.
D. Acne rosacea.
E. Demodicosis (Demodex mites).
F. Isotretinoin oral medication used to treat cystic acne.
G. Clients who wear contact lens and have acquired giant
papillary conjunctivitis.
COMMON COMPLAINTS
A. Burning and itching.
B. Lacrimal tearing.
C. Photophobia.
D. Recurrent eye infections, styes, or chalazions.
E. Dry, aky secretions on lid margins and eyelashes.
F. Dry eyes.
OTHER SIGNS AND SYMPTOMS
A. Seborrheic blepharitis: lid margin swelling and erythema,
aking, nasolabial erythema, and scaling.
B. Staphylococcus aureus blepharitis: erythema/edema, scal-
ing, burning, tearing, itching, and recurrent stye or chalazia.
C. Meibomian gland dysfunction: prominent blood vessels
crossing the mucocutaneous junction, frothy discharge along
eyelid margin, thick discharge, and chalazion; may have rosacea or seborrheic dermatitis.
D. May have dandruff on scalp and eyebrows.
DIFFERENTIAL DIAGNOSES
A. Blepharitis:
1. S. aureus.
2. Seborrheic.
3. Meibomian gland dysfunction.
B. Conjunctivitis.
C. Squamous cell carcinoma.
D. Stye.
E. Upper respiratory infection.
F. Sinusitis.
PLAN
A. General interventions:
1. Assess client and rule out bacterial infection and vision
changes.
2. When examining a child, notify the parent of diagnosis
and educate them on the ndings.
3. Clients with recurrent blepharitis need further
follow-up.
B. Client teaching:
1. Wash the eye with antibacterial soap and water. A gen-
tle baby shampoo may be used.
2. Apply warm compress to the eye for comfort daily for
approximately 10 to 20 minutes.
3. Stop use of contacts until the eye is healed.
4. Encourage good hygiene to prevent recurrent episodes.
C. Pharmaceutical therapy:
1. Apply bacitracin or erythromycin ophthalmic oint-
ment to the margin of the eye at bedtime, taking care not
to contaminate the medication bottle.
2. Oral antibiotics include tetracycline 250 mg PO QID,
or doxycycline 100 mg PO BID, tapering after clinical
improvement, for a total of 2 to 6 weeks. An alternative is
erythromycin 250 to 500mg daily or azithromycin 250 to
500mg one to three times a week for 3 weeks.
CATARACTS
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3. Consider long-term treatment with doxycycline if
infections reoccur.
FOLLOW-UP
A. Recommend follow-up with a primary provider in 1 to 2
weeks.
B. Consider referral to an eye specialist for recurrent episodes
of blepharitis and for slit-lamp examination.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. Tetracycline is not recommended for children younger
than 8 years.
B. Pregnant or lactating individuals:
1. Tetracycline is not recommended.
2. Azithromycin may lead to abnormalities of heart elec-
trical rhythm; use with caution in clients at high risk of cardiovascular disease.
BIBLIOGRAPHY
Amescua, G., Akpek, E. K., Farid, M., Garcia-Ferrer, F. J., Lin, A., Rhee,
M. K., Varu, D. M., Musch, D. C., Dunn, S. P., Mah, F. S., &American
Academy of Ophthalmology Preferred Practice Pattern Cornea and
External Disease Panel. (2019). Blepharitis preferred practice pattern.
Ophthalmology, 126(1), 56–93. https://doi.org/10.1016/j.ophtha.2018.
10.019
Eberthardt, M., & Rammohan, G. (2021). Blepharitis. StatPearls NCBI
Resources. https://www.ncbi.nlm.nih.gov/books/NBK459305/
Tonk, R., & Hossain, K. (2019). Blepharitis: Disease entity. American Academy
of Ophthalmology, e1–e7. https://eyewiki.aao.org/Blepharitis
CATARACTS
DEFINITION
A. A cataract, or opacity of the crystalline lens of the eye,
causes progressive, painless loss of vision (functional impairment). Presenile and senile cataract formation is painless
and progresses through months and years. Cataracts are
frequently associated with intraocular inammation and
glaucoma.
INCIDENCE
A. Cataracts are the most common cause of blindness and are
responsible for >51% of vision loss in the world.
B. Of people older than 60 years, 95% have cataract without
visual disturbance.
C. Of people older than 40 years, 50% have signicant visual
loss due to cataract.
D. Prevalent cases in the United States are 61% female and
39% male.
E. The National Institutes of Health projected that by year
2030 approximately 40 million U.S. citizens are expected to suffer from cataract and approximately 50 million people by 2050.
PATHOGENESIS
A. Age-related changes of the lens of the eye result from pro-
tein accumulation, which produces a brous thickened lens
that obscures vision.
PREDISPOSING FACTORS
A. Age.
B. Trauma.
C. Medications (e.g., topical or systemic steroids, major tran-
quilizers, or some diuretics).
D. Medical diseases (e.g., diabetes mellitus, Wilson disease,
hypoparathyroidism, glaucoma, congenital rubella syndrome,
and chronic anterior uveitis).
E. Chronic exposure to UVB light.
F. Alcohol use.
G. Family history.
H. Prior intraocular surgery.
I. Obesity.
J. Smoking.
COMMON COMPLAINTS
A. Decreased vision.
B. Blurred or foggy vision and “ghost” images.
C. Inability to drive at night.
OTHER SIGNS AND SYMPTOMS
A. Initial visual event can be a shift toward nearsightedness.
B. Visual impairment can be more marked at distances, with
abnormal visual acuity examinations.
C. Severe difculty with glare can occur.
D. Altered color perception may be noticed.
E. Frequent falls or injuries may occur.
SUBJECTIVE DATA
A. Review the onset, course, and duration of visual changes,
including altered day or night vision and nearsighted versus
farsighted vision.
B. Assess whether involvement is in one or both eyes.
C. Determine what improves vision: use of glasses or use of
extra light.
D. Review the client’s medical history and current medications.
E. Review the client’s history for traumatic injury.
F. Discuss the client’s occupation and leisure activities to
determine exposure to UV rays.
PHYSICAL EXAMINATION
A. Inspect:
1. Conduct a funduscopic examination.
a. Check red reex and opacity.
i. A bright red reex is seen in the normal eye.
ii. Cataract formation is seen by disruption of the
red reex.
iii. Lens opacities appear as dark areas against the
background of the red-orange reex.
b. Examine color of opacity. For brunescent cataracts,
the nucleus acquires a yellow-brown coloration and
becomes progressively more opaque.
c. Check retinal abnormalities, hemorrhage, scarring,
and drusen (small yellow deposits).
DIAGNOSTIC TESTS
A. Perform visual acuity examination.
B. Perform peripheral vision examination.
C. Perform slit-lamp examination to determine the exact loca-
tion and type of cataract.
D. Perform dilated eye examination.
DIFFERENTIAL DIAGNOSES
A. Cataracts.
B. Glaucoma.
C. Age-related macular degeneration (macular degeneration
causes vision loss that is symptomatically similar to cataracts).
D. Diabetic retinopathy.
E. Temporal arteritis.
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PLAN
A. General interventions:
1. Monitor the client for increased interference of visual
impairment in their lifestyle.
2. Cataracts do not need to be removed unless there is
impairment of normal, everyday activities.
3. Surgery is the denitive treatment; however, modi-
cation of glasses may improve vision adequately to defer
surgery. Contact lenses are optically superior to glasses.
B. Client teaching:
1. Prevention is important. Teach the client to use protec-
tive eyewear to prevent trauma.
2. Use sunglasses to prevent penetration of UVB rays.
3. Wear a hat with a visor to protect eyes when outdoors.
FOLLOW-UP
A. Surgical removal is indicated if the visual disturbance is
interfering with the client’s life, such as causing falls or prohibiting reading.
CONSULTATION/REFERRAL
A. Refer client for ophthalmologic consultation.
B. Clients should be followed by an ophthalmologist to mon-
itor the cataract for increased size and progressive visual
impairment.
C. Contact a social worker or community resources as needed.
INDIVIDUAL CONSIDERATIONS
A. Adults:
1. In light of advancing intraocular technologies and
new surgical approaches, the American Academy of
Ophthalmology advocates educating clients regarding
the long-standing standard of care in the United States for
cataract surgery: small-incision phacoemulsication with
foldable intraocular lens implantations.
2. Topical nonsteroidal anti-inammatory drugused to treat
ocular inammation and pain was approved by the Food and
Drug Administration (FDA) in 1988; however, it remains controversial for postcataract surgery. Current research indicates
it may be used for clients with diabetic retinopathy and other
high-risk comorbidities to prevent cystic macular edema.
BIBLIOGRAPHY
National Institutes of Health. (2019). Cataracts. Statistics and Data, e1–e4.
https://nei.nih.gov/eyedata/cataract
Nizami, A. A., & Gulani, A. C. (2021). Cataracts. StatPearls NCBI Resources.
https://www.ncbi.nlm.nih.gov/books/NBK539699/
Prall, F. R., Ciulla, T., Talavera, F., Charles, S., Dahl, A., Phillpotts, B.,
Criswell, M., & Harris, A. (2021). Exudative (wet) age-related macular
degeneration (AMD). Macular degeneration: Ophthalmology. MedScape,
e1–e24. https://emedicine.medscape.com/article/1226030-overview
CHALAZION
DEFINITION
A. Chalazion is a chronic lipogranulomatous inammation of
a meibomian gland located in the eyelid margin. It differs from
a hordeola in that it is a result of gland obstruction rather than
an infection. Inammation occurs from occlusion of the ducts.
INCIDENCE
A. Commonly seen, although the incidence is unknown.
B. More prominent in adults aged 30 to 50 years than in chil-
dren secondary to androgenic hormones inuencing sebaceous secretion and viscosity.
C. Affects males and females equally.
PATHOGENESIS
A. Meibomian glands secrete the oil layer of the tear lm that
covers the eye. When the glands become blocked, the oil or
lipid extrudes into the surrounding tissue, causing the formation of a nodule.
PREDISPOSING FACTOR
A. Chalazion may occur as a secondary infection of the sur-
rounding tissues.
COMMON COMPLAINTS
A. Swelling, nontender palpable nodule, usually pea-sized,
inside lid margin or eye.
B. Discomfort or irritation due to swelling.
OTHER SIGNS AND SYMPTOMS
A. Tearing.
B. Feeling of a foreign body in the eye.
C. If infection is present, the entire lid becomes painfully
swollen.
SUBJECTIVE DATA
A. Review the onset of symptoms, their course and duration,
and any concurrent visual disturbance.
B. Question the client regarding possible foreign body or
trauma to the eye.
C. Elicit the quality of pain or tenderness of the eyelid.
D. Review past eye problems and the treatment received.
PHYSICAL EXAMINATION
A. Check temperature.
B. Inspect:
1. Inspect the eye, sclera, and conjunctiva for a foreign
body.
2. Check for red- or gray-colored subconjunctival mass.
C. Palpate:
1. Palpate the eyelid for masses and tenderness. Usually
a hard, nontender nodule is found on the middle portion
of the tarsus, away from the lid border; it may develop on
the lid margin if the opening of the duct is involved. Some
chalazia continue to increase in size and can cause astigmatism by putting pressure on the eye globe.
2. Chalazia may become acutely tender; however, note
the difference between chalazia and stye, which is found
on the lid margin.
3. Check for preauricular adenopathy.
DIAGNOSTIC TEST
A. Perform visual acuity examination.
DIFFERENTIAL DIAGNOSES
A. Chronic dacryocystitis.
B. Hordeolum (stye).
C. Blepharitis.
D. Xanthelasma.
E. Cellulitis of the eyelid.
PLAN
A. General interventions:
1. Small chalazia usually do not require treatment.
B. Client teaching:
1. Instruct client regarding warm, moist compress applied
for 15 minutes four times a day.
2. Use of baby shampoo and lid massage may be helpful.
3. Educate client regarding the importance of good
handwashing to prevent spreading infection.
C. Pharmaceutical therapy:
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1. If infected, doxycycline 100mg PO BID for 10 days, OR
minocycline 50mg daily for 10 minutes. If unable to take
tetracycline, metronidazole is recommended.
2. Intrachalazion corticosteroid injection is performed by
an ophthalmologist.
FOLLOW-UP
A. For large infected chalazia, follow up with client in 1 week
and then evaluate the client every 2 to 4 weeks.
CONSULTATION/REFERRAL
A. If the chalazion does not resolve spontaneously, incision
and curettage by an ophthalmologist may be necessary.
B. Consider referral to an ophthalmologist for chalazions
larger than 5 mm.
FIGURE 5.1 Bacterial conjunctivitis.
CONJUNCTIVITIS
145
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. If a chalazion recurs in a child or young adult, eval-
uate further for viral conjunctivitis or Job syndrome
(hyper-immunoglobulin E (IgE)).
B. Geriatrics:
1. If a chalazion recurs in an older adults client, consider
conditions that charade as a chalazion: sebaceous carcinoma, squamous cell, and other cancers.
BIBLIOGRAPHY
Deschênes, J., You, J., Y, Y., Talavera, F., Dahl, A., Fansler, J., Plouzinkoff,
A., Brenner, B., Brown, D. F. M., Camara, J. G., Law, S. K., Santen, S.,
Schraga, E. D., & Talavera, F. (2019). Chalazion: Ophthalmology. MedScape,
e1–e17. https://emedicine.medscape.com/article/1212709-overview
Jordan, G., & Beier, K. (2021). Chalazion. StatPearls NCBI Resources. https://
www.ncbi.nlm.nih.gov/books/NBK499889/
CONJUNCTIVITIS
DEFINITION
A. Conjunctivitis is inammation of the conjunctiva.
INCIDENCE
A. Viral conjunctivitis is the most common type; conjunctivi-
tis occurs in 1% to 12% of newborns.
B. Every year, approximately 135 bacterial conjunctivitis cases
per 10,000 population occur in the United States and constitute 1% of primary care consultations. Internationally, isolated
epidemics have reported newborn-blinding infections, which
have caused blindness in almost 8% of the affected region’s
population.
C. An estimated 6 million new cases of viral conjunctivitis
occur in the United States annually, often presenting as an
epidemic in schools, ofces, athletic teams, military organizations, shipyards, and residential communities.
D. Most common viral conjunctivitis affect young children
and infants (herpes simplex and varicella zoster), 20 to 40
years (adenovirus), young adults and children in lower socioeconomic regions (picornavirus), and all ages (latent varicella
zoster).
Source: Image courtesy of Tanalai.
2. Viral (adenovirus, coxsackievirus, and enteric cyto-
pathic human orphan viruses; see Figure 5.2).
FIGURE 5.2 Viral conjunctivitis.
Source: Image courtesy of Joyhill09.
3. Allergic (seasonal pollens or allergic exposure; see
Figure 5.3).
PATHOGENESIS
A. Primarily three types of conjunctivitis are seen:
1. Bacterial (Staphylococcus aureus, Streptocuccus pneumo-
nia, Haemophilus inuenzae, Moraxella catarrhalis, chlamydia,
Neisseria gonorrhoeae; see Figure 5.1).
FIGURE 5.3 Allergic conjunctivitis.
Source: Image courtesy of James Heilman, MD.
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5: EYE GUIDELINES
PREDISPOSING FACTORS
A. Contact with another person with a diagnosis of
conjunctivitis.
B. Exposure to sexually transmitted infection.
C. Other atopic conditions (allergies).
COMMON COMPLAINTS
A. Red eyes.
B. Eye drainage.
C. Itching (with allergic conjunctivitis).
OTHER SIGNS AND SYMPTOMS
A. Bacterial:
1. Fast onset, 12 to 24 hours of copious purulent or muco-
purulent discharge.
2. Burning, stinging, or gritty sensation in eyes.
3. Crusted eyelids upon awakening, with swelling of eyelid.
4. Usually starts out unilaterally; may progress to bacte-
rial infection.
5. Bacterial conjunctivitis may present as beefy red
conjunctiva.
B. Viral:
1. May begin in one eye and progress to both eyes.
2. Tearing of eyes.
3. Sensation of foreign body.
4. Systemic symptoms of upper respiratory infection
(runny nose, sore throat, sneezing, fever).
5. Preauricular or submandibular lymphadenopathy.
6. Photophobia andimpaired vision.
7. Primary herpetic infection: vesicular skin lesion, cor-
neal epithelial defect in form of dendrite, and uveitis.
C. Allergic:
1. Itchy, watery eyes, bilateral.
2. Seasonal symptoms.
3. Edema of eyelids without visual change.
4. With allergic conjunctivitis, hyperemia of eyes is
always bilateral and giant papillae on tarsal may be seen.
5. May also see eczema, urticaria, and asthma are.
SUBJECTIVE DATA
A. Elicit the onset, duration, and course of symptoms.
B. Question client regarding the presence of discharge upon
awakening.
C. Elicit changes in vision since symptoms began.
D. Determine whether there has been any injury or trauma to
the eye.
E. Assess whether these symptoms have appeared before.
F. Rule out exposure to anyone with conjunctivitis.
G. Ask the client about any new events, such as use of contact
lenses or change in contact lenses or solutions.
H. Review client and family history of allergies.
PHYSICAL EXAMINATION
A. Check temperature.
B. Inspect:
1. Observe eyes for color and foreign objects. Perform
complete eye examination.
2. Note lid edema.
3. Assess pupillary reexes.
4. Examine skin.
5. Inspect ears, nose, and throat.
C. Auscultate:
1. Auscultate heart and lungs.
D. Palpate:
1. Palpate the preauricular lymph nodes and anterior and
posterior cervical chain lymph nodes.
DIAGNOSTIC TESTS
A. Perform gram stain testing of the discharge/exudate
extracted from eyes if gonococcal infection is suspected and/
or in all neonates.
B. Culture if gonococcal or chlamydial infection is suspected,
if recurrent conjunctivitis, or if treatment-resistant infection.
C. Perform uorescein stain of eye if foreign body or corneal
abrasion/ulceration is suspected.
D. Test visual acuity with an age-appropriate visual acuity
chart. Assess peripheral vision and extraocular movements.
DIFFERENTIAL DIAGNOSES
A. Conjunctivitis.
B. Blepharitis.
C. Drug-related conjunctivitis.
D. Herpetic keratoconjunctivitis.
E. Iritis.
F. Gonococcal or chlamydial conjunctivitis.
G. Corneal abrasion.
PLAN
A. General interventions:
1. Distinguish among bacterial, allergic, and viral infections.
2. Consider other diagnoses if eye pain is noted.
B. Client teaching: See Client Teaching Guides for this chapter,
“Eye Medication Administration” and “Conjunctivitis.”
1. Cool compress to the affected eye should be applied
several times a day.
2. Clean eyes with warm, moist cloth from inner to outer
canthus to prevent spreading infection.
3. Encourage good handwashing technique with antibac-
terial soap.
4. Instruct on the proper method of instilling medication
into eye. Give client the teaching guide on how to administer eye medications.
5. Instruct the client to discard all eye makeup, including
mascara, eyeliner, and eye shadow, worn at the time of the
infection.
6. Teach the client/parent the difference among bacterial,
allergic, and viral infections. Educate according to appropriate diagnosis.
7. If using aminoglycoside or neomycin ointments
or drops, use caution and monitor closely for reactive
keratoconjunctivitis.
8. Contact lens wearers should be prescribed a uoroqui-
nolone to cover for Pseudomonas.
9. Bacterial conjunctivitis is contagious until 24 hours
after starting medication.
10. Viral conjunctivitis is contagious for 48 to 72 hours, but
may last up to 2 weeks. This is typically self-limiting and
does not require antibiotic treatment.
C. Pharmaceutical therapy:
1. Bacterial:
a. Aminoglycosides: should be avoided due to risk of
reactive keratoconjunctivitis.
b. Tobramycin 0.3%: for severe infections, 2 drops
(gtts) every hour on day 1, then 1 to 2 gtts QID for 5 to
7 days; for mild to moderate infections, 1 to 2 gtts QID
for 5 to 7 days.
CORNEAL ABRASION
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147
c. Polymyxin B: trimethoprim/polymyxin B sulfate
(Polytrim) ophthalmic ointment in each eye QID for 7
days;polymyxin B/bacitracin (Polysporin) drops may
also be used, 1 gtt Q3H for 7 to 10 days.
d. Macrolides: erythromycin (Ilotycin) ophthalmic
ointment 0.5% in each eye QID for 7 days.
e. Fluoroquinolones: ciprooxacin 0.3%, 1 to 2 gtts
Q2H for 2 days, then Q4H for 5 days; moxioxacin
(Vigamox) 0.5%, 1 gtt TID for 7 days.
2. Viral:
a. Triuridine 1% drops: one drop Q2H while awake,
no more than nine drops per day, use for 10 to 14 days;
not recommended for children younger than 6 years.
Clients suspected with ocular herpes should benet from a same-day referral to an ophthalmologist
as permanent vision loss can be a sequela of herpes
conjunctivitis.
b. Ganciclovir 0.15% gel: one drop ve times a day until
epithelial heals and then TID for 1 week.
c. Oral antiviral medications (triuridine, valacyclovir)
may be used for herpes simplex keratitis. Herpes zoster ophthalmicus is often treated with acyclovir, famciclovir, or valacyclovir and lessens symptoms if started
within 72 hours of onset.
3. Allergic:
a. Topical antihistamines/mast cell stabilizer:
i. Azelastine HCl (Optivar) 0.05%: not recom-
mended for children younger than 3 years; for those
older than 3 years, one drop to the affected eye BID.
ii. Olopatadine HCl (Pataday) 0.2%: not recom-
mended for children younger than 2 years; for those
older than 2 years, one drop to the affected eye daily.
iii. Olopatadine HCl (Patanol) 0.1%: not recom-
mended for children younger than 3 years; for those
older than 3 years, one to two drops BID to the
affected eye.
b. Mast cell stabilizer:
i. Cromolyn sodium (Crolom) ophthalmic solu-
tion for children older than 4 years, one to two
drops four to six times daily.
c. Topical nonsteroidal anti-inammatory drug:
i. Ketorolac tromethamine (Acular) 0.5%: not
for use in children younger than 2 years; one
drop QID; used for severe symptoms of atopic
keratoconjunctivitis.
d. Articial tears four to ve times daily.
e. Oral antihistamines may be used in severe cases
(loratadine or diphenhydramine HCl).
4. Concurrent conjunctivitis and otitis media should be
treated with a systemic antibiotic; no topical eye antibiotic
is needed.
C. Refer to an eye specialist if client has vision change or
eye pain or is not responding to treatment or if red ags are
present.
1. Reduced visual acuity with onset of symptoms.
2. Observation of a ciliary ush.
3. Photophobia.
4. Severe foreign-body sensation.
5. Corneal opacity.
6. Fixed pupil.
7. Severe headache associated with nausea.
INDIVIDUAL CONSIDERATIONS
A. Pediatrics:
1. In neonates, consider gonococcal and chlamydial con-
junctivitis. Perform culture if suspected.
B. Partners:
1. Check partners for gonorrhea and chlamydia when an
adolescent or an adult presents with gonococcal or chlamydial conjunctivitis.
C. Geriatrics:
1. Avoid diphenhydramine secondary to risks of confu-
sion, constipation, blurred vision, delirium, dry mouth,
and other anticholinergic symptoms. This may be considered only for acute treatment of a severe allergic reaction.
BIBLIOGRAPHY
Ryder, E. C., & Benson, S. (2021). Conjunctivitis. StatPearls NCBI Resources.
https://www.ncbi.nlm.nih.gov/books/NBK541034/
Varu, D.M., Rhee, M.K., Akpek, E.K., Amescua, G., Farid, F., Garcia-Ferrer,
F. J., Lin, A., Musch, D. C., Mah, F. S., Dunn, S. P., &American Academy
of Ophthalmology Preferred Practice Pattern Cornea and External
Disease Panel. (2018). Conjunctivitis preferred practice pattern.
Ophthalmology, 126(1), 94–169. https://doi.org/10.1016/j.ophtha.201
8.10.020
Yeung, K., Weissman, B. F., Talavera, A., & Dahl, A. (2019). Bacterial conjunc-
tivitis (pink eye). MedScape, e1–e8. https://emedicine.medscape.com/
article/1191730-overview#a6
CORNEAL ABRASION
DEFINITION
A. Corneal abrasion is the loss of epithelial tissue, either
supercial or deep, from trauma to the eye (see Figure 5.4).
FOLLOW-UP
A. If resolution occurs within 5 to 7 days after proper treat-
ment, follow-up is not needed.
B. If client continues to have symptoms or if different
symptoms appear, follow-up with the primary provider is
recommended.
C. If herpes infection is suspected, follow up with ophthal-
mology within 2 to 5 days.
CONSULTATION/REFERRAL
A. Consult or refer client to a physician if they are not
responding to treatment within 48 to 72 hours.
B. Refer if client is suspected of having periorbital cellulitis.
FIGURE 5.4 Corneal abrasion with fluorescein staining.
Source: Image courtesy of James Heilman, MD.
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