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Case Study - Conjunctivitis

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The case study

John (85 years old) is a resident at a high dependency aged care facility (nursing home). He has developed infectious conjunctivitis in his right eye. On examination, his eye was found to be a red and swollen with a purulent and sticky discharge. His vision was unaffected; however he did complain that his eye was painful. The doctor prescribed Chloramphenicol eye drops which were to be administered to both eyes.


Q1. What is infectious conjunctivitis?

Conjunctivitis is identified by irritation and redness of the conjunctiva. Except in obvious pyogenic or toxic/chemical conjunctivitis, slit lamp will be needed to have any confidence in the diagnosis. Examination of the tarsal conjunctiva is usually more diagnostic than the bulbar conjunctiva. Infectious conjunctivitis refers to an inflammation of the conjunctiva usually caused by viruses or bacteria that can infect the human conjunctiva of a person. Conjunctiva, membrane that lines the eyelids and covers the exposed surface of the human eyeball, can be caused by allergies, bacteria, viruses, chemicals, or underlying health conditions. There can be redness; irritation, tearing or discharge, and sensitivity to light are common, hygiene helps prevent the infection from spreading.


Q2. Of the four micro-organism listed below, justify which one is more likely to be the cause of John's eye infection. Explain why the other micro-organisms from the list are least likely to cause the infection.

The likely to cause John's eye infection is the Adenovirus, group of viruses that infect the membranes (tissue linings) of the respiratory tract, the eyes, intestines, and the urinary tract account for about 10 percent of acute respiratory infections in kids and frequent cause of diarrhea. Adenoviral infections affect infants and young children much more frequently than adults however, conjunctivitis and pharyngoconjunctival fever caused by adenovirus tend to affect older kids mostly in the summer. There lead to John’s conjunctivitis, inflammation of conjunctiva (membranes that cover the eye and inner surfaces of the eyelids). The other micro organisms does not contribute to John’s case as for instance, Legionella pheumophila are categorized as a Gram-negative organism, it stains poorly due to its unique lipopolysaccharide content in the outer leaflet of the outer cell membrane which does not relate to an eye infection case. Meanwhile, plasmodium ovale involve species of parasite protozoan which cause tertian malaria in humans, responsible for most malaria and not an eye related problem or issue. Furthermore, Haemophilus influenza does not also contribute to the case because it has been responsible for wide range of clinical diseases and John’s situation does not directly mean a clinical process. There can also deal with un-encapsulated strains that are almost less invasive, however they can produce an inflammatory response in human which can lead to symptoms that refer to a certain Hib infection and not on eye related case on conjunctivitis.


Q3.Provise a scientific rationale for why Chloramphenicol was prescribed by the doctor before taking a swab sample

Chloramphenicol was prescribed by the doctor before taking in swab sample due to the fact that John’s case of conjunctivitis is ideally caused by bacteria which adhere to adenovirus organism wherein chloramphenicol is bacteriocidal antimicrobial and being considered prototypical spectrum based antibiotic, alongside the tetracyclines which in turn can be used to control further infection to the eyes and possibly prevent the other eye from getting infected with infectious conjunctivitis as well. Chloramphenicol is effective against bacteria, including most anaerobic organisms. Due to resistance and safety concerns, it is no longer a first-line agent for any indication in developed nations, although it is sometimes used topically for eye infections. For instance, in the West chloramphenicol is still widely used in topical preparations (ointments and eye drops) for the treatment of bacterial conjunctivitis. Isolated cases report of aplastic anaemia following chloramphenicol eyedrops exist but the risk is estimated to be less than 1 in thousand prescription base.

Q4. Identify and discuss the various chemical and cellular mediators which are responsible for the signs and symptoms of John's condition.

 The various chemical and cellular mediators which are responsible for signs and symptoms of John's condition can relate to pathogenesis of ocular allergy that involve multiple mechanisms, which lead to mast cell degranulation and release of chemical mediators. Mast cell mediators that have been implicated in allergic ocular disease include histamine, eosinophil chemotactic factors, eosinophil granule major basic protein, platelet-activating factor, prostaglandin D2, and several other less well-defined preformed or newly synthesized mediators. Release of these chemical mediators ultimately results in conjunctival vasodilation, increased vascular permeability, leukocyte chemotaxis, ocular surface destruction. Current therapy of ocular allergy involves elimination of the offending allergen, modulation of the immune system, and pharmacologic inhibition of the chemical mediators. There provide better understanding of the pathogenesis and current therapy of ocular allergic disorders and to review the central role of the mast cell and chemical mediators involved in ocular allergy. Bacterial conjunctivitis due to the common pyogenic bacteria causes marked grittiness/irritation and a stringy, opaque, grey or yellowish mucopurulent discharge that may cause the lids to stick together, after sleeping. Another symptom that could be caused by bacterial conjunctivitis is severe crusting of the infected eye and the surrounding skin. However discharge is not essential to the diagnosis, contrary to popular belief. Bacteria such as Chlamydia trachomatis or Moraxella can cause a non-exudative but persistent conjunctivitis without much redness. The gritty and/or scratchy feeling is sometimes localized enough for patients to insist they must have foreign body in the eye. The more acute pyogenic infections can be painful. Like viral conjunctivitis, it usually affects only one eye but may spread easily to the other eye. However, it is dormant in the eye for three days before the patient shows signs of symptoms. In addition, conjunctivitis is irritable or painful when the infected eye is pointed far down or far up. Discharge and itch are usually absent. This is the only group in which severe pain and uncomfort may occur. Irritant or toxic conjunctivitis show primarily marked redness. If due to splash injury, it is often present only in the lower conjunctival sac. With some chemicals, with caustic alkalis such as sodium hydroxide, as there may be necrosis of the conjunctiva with deceptively white eye due to vascular closure, followed by sloughing of the dead epithelium and associated with slit-lamp evidence of anterior uveitis.

Q5. Explain the role of tears as natural first line of defense produced by the body

The role of tears as natural first line of defense produced by the body can serve to the external eye being exposed to an environment containing pathogenic microorganisms. There can be about a certain mechanism which protects the eye from infection due to tears as a form of defense. There can be knowledge of antimicrobial substance known to be present in tears and role tears play in preventing infection, there can be about the substance of lysozyme, lactoferrin, beta-lysine and the antibody balance system of protein. However, tears collected from allergic subjects contain bioactivity capable of up regulating eosinophil adhesion by treatment of subject of cellular target in adhesion.


Q6. Identify and discuss two infection control issues associated with high dependency aged care facility that can contribute to the spread of conjunctivitis.


The infection control issue on not using clean and sterile pads on taking eye swabs on the affected eye, this can also be failure of the care provider to put gloves and alcohol prior to the actual taking of eye swab sample. Thus, leading to bacteria or viruses that can cause infective conjunctivitis and clear whether the infection is bacterial or viral, the provider failed to take eye swabs carefully and with proper application and infection control posed an issue due to being inattentive and less responsible on the situation. Another, the infection control issue on the missed hand washing by the care provider which is a no-no in serving quality health care to infected patients. Although it is quite a common practice still, frequent and constant hand washing of the care providers at the high dependency aged-care facility will serve as the most important factor to avoid infection that spread conjunctivitis in an instance. The virus causing conjunctivitis spreads very easily. It can be spread both by touching the water or pus that comes out of the eye and by coughing or sneezing if there is cold at the same time. Conjunctivitis from bacteria can be spread by hands touching the pus from the eye and moving it to other eyes, and trachoma can also be spread by flies. Conjunctivitis from allergies is not infectious. Careful hand washing is very important to prevent spreading, particularly before and after touching the eyes or face.

Q7. Suggest two procedures nurses will need to undertake to prevent the infection from John's eye being transmitted to other individual. Explain how each procedure will effectively break the chain of infection.

The two procedures that nurses need to undertake in order to prevent the infection from John's eye being transmitted to other individual is first by gentle cleaning John’s eyes by the careful procedure on hand washing, an imperative action in stopping the spread of John’s infectious conjunctivitis, this can be possible by means of alcohol (70 percent solution) hand washing and or if not through frequent soap hand washing before and after touching John’s affected eyes. Everyday hand washing should be performed to prevent spread of conjunctivitis from hands that have by accident touched John’s infected eyes.

Another is cleaning of John’s eye area by using sterile gloves into the hands of the care provider in order to achieve a regular cleaning away of pus is useful to help John feel better thus, helping the eye infection clear up quickly. Nurses can clean the eyes either towards the nose from the outside in and or from the inside out, whichever is easier. Thus, important to use separate cotton wool ball or tissue for each eye, and to use warm but not hot water.  Wipe the closed eye gently but firmly to remove the excess pus do not clean inside the eyelids as this may cause damage to the conjunctiva or the cornea.

-          Nurses must complete course of any drops and ointment prescribed by the physician and only use the latter on the person as prescribed

-          Nurses need to use and have separate towels and flannels

-          General nursing care rule: always wash thy hands before and after applying treatment and or cleansing the eyes of the patient


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