Eye Infections: Patient Assessment and Care Plan

  • Patient Initials: JB Age: 68
  • Gender: F

Subjective Data

Chief Complaint (CC): “Yellow secretions from eyes.”

History of Present Illness (HPI): A 68-year-old Caucasian female presents to the office with complaints of yellow discharge from her eyes. The symptoms occurred quickly about 3 days ago, and they continue to progress in severity. Accompanying symptoms are itching and burning in both eyes. JB did not try any treatments; eye cleaning does not stop the discharge from reappearing. The patient reports no relieving or aggravating factors and rates the severity of pain as 2/10.

Medications:

  • Coumadin 5 mg for atrial fibrillation
  • Metoprolol 25 mg daily for hypertension
  • Plavix 75 mg once daily for coronary artery disease
  • Keppra 500 mg twice daily for seizures
  • Dilantin 100 mg three times a day for seizures

According to the American Geriatrics Society 2015 Beers Criteria Update Expert Panel ([AGS], 2015), the majority of these medications are safe to use in geriatric patients. Coumadin (warfarin) may react to other drugs and increase the risk of bleeding for the patient (AGS, 2015). JB does not use the main interacting drugs, making the use of warfarin acceptable. Keppra (levetiracetam) may cause central nervous system issues, but the patient’s dose is minimal, significantly reducing its potential danger.

Allergies: NKA.

Past Medical History (PMH): The patient has a history of hypertension, epilepsy, and atrial fibrillation.

Past Surgical History (PSH): No major surgeries.

Sexual/Reproductive History: Gravida II, Para 2-0-0-2. LMP about 15 years ago, last mammogram 2017, last PAP smear last year. The patient is sexually active with her husband; she does not use any contraceptive methods.

Personal/Social History: The patient does not smoke, drink alcohol, or use drugs. JB performs light exercises and avoids caffeinated drinks, stating that her diet is mostly healthy.

Immunization History: Last Tdp 2017, flu shot October 2018.

Significant Family History: The patient’s mother passed at 84 from cardiovascular disease; the father passed at 79 from myocardial infarction. JB has no siblings. The patient’s children – daughter (40) and son (38) – are healthy.

Lifestyle: The patient lives with her husband (70). Her house is equipped to assist her with her seizures. She carries some information about her epilepsy in her purse.

Review of Systems

General: No weight change, weakness, fatigue, or fever.

HEENT: Head: no trauma, dizziness, headaches. Eyes: no changes in vision, yellowish discharge from both eyes, burning, itchiness, irritation. Ears: no hearing loss, no vertigo. Nose: no sneezing or runny nose. Throat: no sore throat.

Neck: No pain, masses, or goiter.

Respiratory: No cough, rales, wheezing, sputum, or dyspnea.

Cardiovascular/Peripheral Vascular: No chest pain or tightness.

Gastrointestinal: No nausea, vomiting, pain, constipation, or diarrhea.

Genitourinary: No dysuria or polyuria, no changes in frequency, no pain or burning on urination.

Musculoskeletal: No injuries.

Psychiatric: No anxiety, nightmares, depression, mood changes, memory problems.

Neurological: Last seizure on July 14. No tremors, numbness, history of stroke.

Hematologic: No bleeding disorders, no bruises or injuries.

Endocrine: No polydipsia, no changes in heat/cold tolerance.

Allergic/Immunologic: No known allergies.

Objective Data

Physical Exam

Vital signs: BP 135/84, P 60, R 16, Weight 149 lbs., Height 5’7”, BMI 23.3

General: The patient is neatly dressed, calm, alert, and oriented. There are no hygiene issues, no odors, no problems with motor activity and gait.

HEENT: Head: atraumatic, no lesions. Eyes: visual acuity 20/20 bilaterally, sclerae pink, no foreign body, conjunctivae edematous. No subconjunctival hemorrhages or photophobia. Purulent exudate. Ears: good hearing, no redness. Nose: no discharge, flaring, swelling, drainage, tenderness. Mucosa pink. Throat: no redness, membranes pink.

Neck: Lymph nodes are non-tender, not enlarged, neck supple.

Chest/Lungs: No wheezing, rhonchi, crackles; breathing vesicular.

Heart/Peripheral Vascular: S1 and S2 regular, no gallops, murmurs, or rubs, no S3 or S4.

Abdomen: Normoactive bowel sounds x4, abdomen non-tender, soft, no masses, no pain.

Genital/Rectal: Deferred at the patient’s request.

Musculoskeletal: Normal gait, no swelling, full motion range.

Neurological: AAAOX3, cranial nerves intact (II-XII).

Skin: Warm, soft, dry to touch. No bruising, inflammation, edema, or lesions.

Assessment

  1. Conjunctivitis. It is an inflammation of the conjunctiva that can occur as a result of a bacterial or viral infection, allergy, or a foreign object in one’s eye (Alfonso, Fawley, & Lu, 2015). The main symptoms are the redness of the sclerae in one or both eyes, irritation, itchiness, and discharge (Alfonso et al., 2015). The patient’s symptoms and description of previous days align with the diagnosis of bacterial conjunctivitis. During the eye exam, no foreign body was detected, excluding this cause of the irritation. A culture test can be completed to identify the cause of the infection.
  2. Keratitis. It is an inflammation of the cornea with such symptoms as eye redness, pain, discharge, blurred vision, photophobia, and irritation (Azher, Yin, Tajfirouz, Huang, & Stuart, 2017). Keratitis can be caused by bacteria, viruses, and various injuries. The patient does not show signs of photophobia, and her vision is not decreased. Moreover, keratitis is usually linked to eye pain, and the patient does not report feeling any pain.
  3. Corneal ulcer. Corneal ulcers are open sores on the cornea caused by an infection (Pflipsen, Massaquoi, & Wolf, 2016). The signs of the ulcer’s occurrence are itchiness, purulent discharge, redness, photophobia, blurred or decreased vision, edematous eyelids, and foreign body sensation (Pflipsen et al., 2016). The patient does not have photophobia, there is no sign of cornea damage found, and her vision did not change recently. A fluorescein eye stain can eliminate this diagnosis if the previous tests are unhelpful.

Plan

Treatment Plan

The patient can continue her medications (Coumadin, Metoprolol, Plavix, Keppra, and Dilantin) as usual since they do not need adjusting or replacing. The prescription is Ilotycin with the dosage of approximately 1 cm of ointment ribbon applied to the infected structure up to 6 times daily (“Ilotycin,” 2019). It is vital to teaching the patient how to use the drug correctly. If the patient’s condition does not improve, she should be referred to an ophthalmologist for further consultation. A follow-up appointment can be scheduled in one week from the first one.

Health Promotion

The patient has to learn about proper hygiene since bacterial conjunctivitis is highly contagious. JB has to use hand sanitizer and wash her hands regularly before and after touching her eyes (Alfonso et al., 2015). She should avoid sharing any hygiene products and swimming (Resnick, 2016). The patient’s exercise plan seems to include walking and light physical activity, which is in line with her diagnoses and age. JB’s diet appears to be healthy, and she avoids foods that may trigger a seizure or raise her blood pressure. Her risk of cardiovascular complications is high, meaning that she should be attentive to her overall state and monitor her blood pressure regularly.

Disease Prevention

JB should pay attention to any changes in her wellbeing and follow an active and healthy routine. Her family history suggests an increased risk of cardiovascular issues, meaning that she should manage her blood pressure as well as lipid levels (Resnick, 2016). The patient is due for a breast check-up and mammography. Furthermore, since the patient is sexually active, sexual education is a vital part of the disease prevention plan. JB needs to use a condom with her partner to prevent sexually transmitted infections.

Reflection

This clinical experience helped me to further my understanding of infectious conditions. It also allowed me to test my knowledge and communicative skills during patient-nurse conversations. Geriatric patients with comorbidities and complex medication plans require increased attention since their symptoms and complaints are often reliant on their health history, advanced age, and drug interactions. Thus, this assignment was crucial to my education and my experience as a practicing nurse.

If I were to complete this activity again, I would inquire about the patient’s daily life to understand the cause of the infection better. Overall, the patient’s history is the main source of information for such diseases. However, this would also help me to see whether any similar symptoms were present in other patients, increasing my awareness of the population’s health. Based on the presented data and evidence, I agree with the preceptor about the clinical experience.

References

Alfonso, S. A., Fawley, J. D., & Lu, X. A. (2015). Conjunctivitis. Primary Care: Clinics in Office Practice, 42(3), 325-345.

American Geriatrics Society 2015 Beers Criteria Update Expert Panel. (2015). American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 63(11), 2227-2246.

Azher, T. N., Yin, X. T., Tajfirouz, D., Huang, A. J., & Stuart, P. M. (2017). Herpes simplex keratitis: Challenges in diagnosis and clinical management. Clinical Ophthalmology, 11, 185-191.

Ilotycin. (2019). Web.

Pflipsen, M., Massaquoi, M., & Wolf, S. (2016). Evaluation of the painful eye. American family physician, 93(12), 991-998.

Resnick, B. (Ed.). (2016). Geriatric nursing review syllabus: A core curriculum in advanced practice geriatric nursing (5th ed.). New York, NY: American Geriatrics Society.