PRESENTED BY:

CLAIDE B. ARCENO BSN IV B

DATA BASE AND NURSING HISTORY

Patient M, 8 years old, male, child, Roman Catholic from Brgy. San Cruz, Camotes, Cebu was admitted for the first time at Vicente Sotto Memorial Medical Center last January 23, 2012 at 11:59PM due to trauma to the right eye. 3 days prior to admission on January 21, 2012 at 12 noon, patient was playing with his neighbor when his playmate accidentally hit his yes with a rusty nail about 3 meters long. Later that night, patient was having a high grade fever of T- 38.7 and was self-medicated with biogesic. On the following day around 9:00AM they sought consultation to a private doctor and they were advised to go to Ricardo L. Maningo Hospital in Camotes for further medical management. On the same day, they were referred to seek consultation at Vicente Sotto Memorial Medical Center. On January 23, 2012, the patients right eye can no longer see/ loss of vision, (+) periorbital edema, eye pain, watery discharges and had fever thus prompted patients SO to admit patient at VSMMC.

The patient is the 6th among eight siblings and a grade II student. His father was a painter assigned here in Cebu while his mother was a plain housewife. They owned a semi-concrete house in Camotes with three rooms and eight persons staying in the house. He usually takes his breakfast at exactly 7:00AM, lunch at 12:30PM and dinner at 7:30PM. He likes to eat junk foods, chicken and meat and dislikes vegetables especially ampalaya. He usually every morning with a semi-formed and brown color of stool and urinate 4-5 times a day. He usually takes a bath everyday and brushes his teeth twice a day. They stored their water in a jar and their mode of human disposal is a flushed type. He likes to collect playing cards and rubber band and likes to play ball with his playmate. The heredofamilial disease of the family is hypertension in the father side. No previous illness or surgery and present illness is traumatic endophthalmitis with cellulitis OD.

ANATOMY AND PHYSIOLOGY OF THE EYE

CONJUNCTIVA is the mucous membrane that lines the inner surface of the eyelids and sclera on the front of the eyeball. It helps lubricate the eye by producing mucus and tears, although a smaller volume of tears than the lacrimal gland. It also contributes to immune surveillance and helps to prevent the entrance of microbes into the eye. CILIARY BODY is the circumferential tissue inside the eye composed of the ciliary muscle and ciliary processes. It is triangular in horizontal section and is coated by a double layer, the ciliary epithelium. This epithelium produces the aqueous humor. It has three functions: accommodation, aqueous humor production and the production and maintenance of the lens zonules. It also anchors the lens in place. IRIS the opaque muscular contractile diaphragm that is suspended in the aqueous humor in front of the lens of the eye; perforated by the pupil and continuous peripherally with the ciliary body: possesses with a deeply pigmented posterior surface, which excludes the passage of light except through the pupil, and a colored anterior surface which determines the color of the eye.

AQUEOUS HUMOR is the transparent fluid occupying the anterior compartment (the space between the cornea and the crystalline lens) of the eye. PUPIL the contractile, usually round aperture in the iris of the eye which allows light to pass into the crystalline lens. ANTERIOR CHAMBER the space in the eye bounded in front by the cornea and in back by the iris and middle part of the lens; contains the aqueous humor. CRYSTALLINE LENS the highly transparent biconvex, lens shaped or nearly spherical body in the eye, situated immediately behind the pupil, which focuses light rays entering the eye typically onto the retina. CORNEA the transparent, anterior, dome-shaped portion of the eyeball that covers the iris and the pupil, acting like a window which admits light into the eye. EXTRAOCULAR MUSCLES six muscles (medial rectus, lateral rectus, inferior rectus, superior oblique, and inferior oblique) which serve to move an eye by rotating it about its vertical, horizontal and antero-posterior axis. SCLERA the dense fibrous opaque white outer coat enclosing the eyeball, except the part covered by the cornea. CHOROID a vascular membrane containing large branched pigment cells that lies between the retina and the sclera of the eye which absorbs light and prevents internal reflection. MACULA the small yellowish area, lying slightly lateral to the center of the retina, that constitutes the region of maximum visual acuity and is made up of almost wholly of retinal cones. OPTIC NERVE the sensory nerve which carries electrical impulses from the visual stimuli in the retina out of the eye, across the optic chiasm and to the ventral part of the diencephalon, on their way to the visual cortex in the occipital cortex of the brain for interpretation. RETINA layer of the nervous tissue, covering the back two-thirds of the eyeball, in which the stimulation by light initiates an electrochemical reaction in which the electrical impulses are transmitted to the brain, producing the sensation of vision VITREOUS HUMOR the transparent gelatinous mass occupying the posterior compartment of the eye.

PATHOPHYSIOLOGY
DIAGNOSIS AND DEFINITION
>TRAUMATIC ENDOPHTHALMITIS -- is an inflammatory condition of the intraocular cavities usually caused by infection. It results from direct inoculation of an organism from the outside as a complication of ocular surgery, foreign bodies and/or trauma. > CELLULITIS OD -- is a bacterial infection that affects the dermal layer of the skin and the soft tissues surrounding the eye.

DISCUSSION OF SIGNS AND SYMPTOMS

Loss of vision Eye pain Redness of the conjunctiva

It is due to the injury that causes trauma

due to the injury that affects the small

Due to the impact of the object that hits

OUTLINE OF NURSING MANAGEMENT

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ACHIEVING OPTIMAL FUNCTIONING WITHIN LIMITS OF VISUAL IMPAIRMENT Assess eye and lid for inflammation, edema, positional defects and deviation. Evaluate the patients ability to function within limits of visual impairment Introduce self to patient and acknowledge visual impairment Do not make unnecessary change in environment Place tray, tissues, water and call light within patients range of vision or reach. Remove environmental barriers to ensure safety Maintain bed in low position with side rails up if appropriate Involve caregiver in patients care and instruction Teach general eye care PREVENTING INJURY OR FALL Assess mood and coping abilities of the patient Monitor vital signs and health condition of the patient Assist the client and provide patients SO the information regarding present eye condition and risk that accompany it. Advise the client and the SO to set or make safety precautionary measures Raise the side rails to prevent fall Dont let the patient alone in his bed. REDUCING ANXIETY Assess anxiety level, degree of pain experience/suddenness of onset of symptoms and current knowledge of the condition. Provide accurate, honest information. Discuss probability that careful monitoring and treatment can prevent additional vision loss. Maintain frequent contact with the patient, talk and touch the patient. Encourage patient and his SO to acknowledge concerns and express feelings PREVENTING/ AVOIDING FURTHER INFCTION Asses skin for severity of skin integrity compromise Apply topical antibiotics/ eye ointment. Encourage the patient to use appropriate hygiene. If the infection is not treated with the first line therapy which is the antibiotic therapy, advised for E enucleation of the eye to prevent further spread of infection to the left eye.

DISCHARGE PLANNING

MEDICATIONS Make a list of medication that the patient should religiously take with the
guidance of his family. Incorporate there the dose, time, frequency in order to be sure that the patients SO will not forget to give the medication specifically optic medications at the right time.

EXERCISE Encourage to avoid activities that will increase the IOP of the patient like
straining, lifting heavy objects or blowing of nose.

TREATMENT Reinforce the patient and his SO that having the surgery which is the removal of
the eye that is already infected is important to prevent further spread of infection.

HEALTH TEACHING Teach the mother on how to apply the eye ointment or eye drops properly.
Instruct her to always do hand washing before doing the procedure to prevent spread of microorganisms that will result to some complications.

OUT-PATIENT Encourage to have a follow up check up after discharge to monitor the condition
of the patients right eye and for the replacement of artificial eye.

DIET Instruct the patient to resume normal eating habits. Advised to eat plenty of fruits
and vegetables that is rich in vitamin A and C which is good for the eye and promotes healing of the soft tissues due to surgery. Example: squash, carrots, broccoli and citrus fruits.

SPIRITUAL Encourage patient and family to have faith in our Almighty Father and ask for
help and guidance in every trial that will come in their lives.