NU 641 Discussion: Ophthalmic Disorders

Sample Answer for NU 641 Discussion: Ophthalmic Disorders Included After Question

Initial Post

In your initial post, answer all the questions and provide rationales for your answers with supporting evidence using APA formatting. Integrate two evidence-based resources to include clinical practice guidelines as well as the course textbook.

Read the scenario and answer the following questions:

Ophthalmic Disorders

V.S., age 12 Hispanic male, presents with a feeling that there is sand in his eye. He had a cold a week ago and woke up this morning with his left eye crusted with yellowish drainage. On physical examination, he has injected conjunctiva on the left side, no adenopathy, and no vision changes. His vision is 20/20. Fluorescein staining reveals no abrasion. He is allergic to sulfa.

Diagnosis: Conjunctivitis

  1. List specific goals of treatment for V.S.
  2. What drug therapy would you prescribe? Why?
  3. What are the parameters for monitoring the success of the therapy?
  4. Discuss the education you would give to the parents regarding drug therapy.
  5. List one or two adverse reactions for the selected agent that would cause you to change therapy.
  6. What would be the choice for second-line therapy?
  7. What over-the-counter or alternative medications would be appropriate for V.S.?
  8. What dietary and lifestyle changes should be recommended for V.S.?
  9. Describe one or two drug–drug or drug–food interactions for the selected agent.

A Sample Answer For the Assignment: NU 641 Discussion: Ophthalmic Disorders

Title: NU 641 Discussion: Ophthalmic Disorders

List specific goals of treatment for V.S.

The major goal for the treatment of bacterial conjunctivitis is for V.S.’ symptoms to resolve. For example, the feeling of sand in his eye should go away and there should be no more discharge from his eye. 

What drug therapy would you prescribe? Why?

Although most cases of bacterial conjunctivitis clear up on their own, topical antibiotic treatment can speed the recovery process (Woo & Robinson, 2020, p.843). However, the recent systematic review of clinical practice guidelines for infectious and non-infectious conjunctivitis revealed that initial observation without treatment is highly recommended for bacterial conjunctivitis that is not chlamydial or gonorrhoeal for the first three days (Chan et al., 2021).

Therefore, if V.S.’ symptoms did not resolve after three days, I would prescribe him erythromycin ointment to use, with the instructions of instilling a 1-cm ribbon of ointment in his affected eye four times a day for one week (Azari & Arabi, 2020; Epocrates, 2018). Erythromycin ointment is an FDA-approved topical antibiotic used to treat conjunctivitis (Viriya & Mah, 2021, p.372). It is a bacteriostatic macrolide that binds to the 50S ribosomal subunit which prevents bacterial protein synthesis (Woo & Robinson, 2020, p. 840).

This drug is mainly effective against gram-positive organisms, including S. aureus, S. pyogenes, S. pneumoniae, S. viridans, C. diptheriae (Woo & Robinson, 2020, p. 840). It is more limited in its gram-negative coverage but is active against C. trachomatis (Woo & Robinson, 2020, p. 840). Erythromycin is generally one of the least expensive ophthalmic preparations for conjunctivitis (Woo & Robinson, 2020, p. 845). 

According to Azari and Arabi (2020), it is not likely that there is a significant difference in the effectiveness of one broad-spectrum antibiotic eye drop as compared to another when treating bacterial conjunctivitis. The major factors in the consideration of which antibiotic to choose should be the local resistance patterns and availability, cost, and individual patient needs, such as allergies (Azari & Arabi, 2020). Since V.S. is allergic to sulfa drugs, that class of antibiotics would not be considered.

Even though systemic absorption is minimal with most ophthalmic antibiotics, there may be some systemic absorption (Woo & Robinson, 2020, p. 840). Therefore, since V.S. is a 12-year-old boy and may be very active, I would avoid fluoroquinolones due to the potential risk of tendon rupture (Vallerand & Sanoski, 2020, p. 587). Aminoglycosides are not recommended as first-line treatment due to their potential to cause damage to the cornea and conjunctiva (Woo & Robinson, 2020, p. 843). Below is my prescription for V.S.:

Downey Family Practice

1234 Health Road

Richmond, VA 23223

(555) 555-5555

Nicole Downey, BSN, DNP, FNP-C Date: March 28, 2022 

Patient: V.S. DOB: 03/08/2010 Weight: 45 kg Phone: (231) 818-5090

Erythromycin ophthalmic ointment 0.5%

Disp: One tube

Sig: Administer 1-cm ribbon of ointment to the affected eye four times a day for seven days to treat bacterial conjunctivitis. 

No refills.

What are the parameters for monitoring the success of the therapy?

Parameters involved with monitoring the success of therapy have to do with the resolution of his symptoms. As stated above, the resolution of the feeling of sand in his eye and no more eye discharge would be indications of successful treatment. In addition, it would be important to ensure that V.S. is not experiencing severe or prolonged burning of his eyes or any other unusual symptoms associated with his treatment (Woo & Robinson, 2020, p. 846). If his symptoms did not seem to be resolving, I would explore how he is taking the medication and his technique for instilling the eye drops to ensure that he is taking the medication correctly. It would also be important to monitor any adverse reactions to the medication, which would affect the success of treatment. 

Discuss the education you would give to the parents regarding drug therapy.

I would let V.S. know that the ointment he is being prescribed is given to fight the bacteria that is causing his eye infection, and that it should be stored at room temperature away from heat or moisture-prone environments (Epocrates, 2018). Further, V.S. needs to be aware that this medication should not be shared with anyone else (Woo & Robinson, 2020, p. 846). In addition, I would use the teach-back method to educate him on the proper way to instill the ointment. For example, I would tell him to begin by washing his hands (Epocrates, 2018). The first time he opens the tube of medication, I would tell him to squeeze out and discard the first quarter of an inch of the drug (Woo & Robinson, 2020, p. 846).

Then, I would tell him to tilt his head back and pull his lower eyelid down while looking away from the tip of the tube (Epocrates, 2018). Then, he should squeeze out a ribbon of the medication into the pocket in his lower eyelid without touching the tube to his skin and then close his eye for one to two minutes (Epocrates, 2018). I would let him know that he may wipe excess ointment off of his eyelash or surrounding area with a clean tissue and that he may experience short-term blurry vision directly after medication application (Epocrates, 2018). I would also make sure to answer any questions that he has about the procedure or the medication in general. 

List one or two adverse reactions for the selected agent that would cause you to change therapy.

Mild eye redness or irritation are common side effects of erythromycin ointment (Epocrates, 2018). However, I would stop this treatment and change therapy if he experienced any signs of an allergic reaction, such as hives, difficulty breathing, or facial, tongue, or throat swelling (Epocrates, 2018). In addition, I would change his therapy if his symptoms were not improving after a few days or his condition was worsening, such as if he were experiencing severe pain or discomfort, increased swelling, crusting, or drainage, or sensitivity to light (Epocrates, 2018). 

What would be the choice for second-line therapy?

If erythromycin was not effective for V.S., my choice for second-line therapy would be the combination product of trimethoprim/polymixin B (Polytrim), with one drop given every three hours while awake for a maximum of six doses per day for seven days (Epocrates, 2022). This product is active against many of the organisms that often cause bacterial conjunctivitis (Woo & Robinson, 2020, p. 845). In addition, it is safe to give to patients with a sulfa allergy, since this drug lacks the SO2NH moiety that is linked directly to a benzene ring, which is a vital characteristic in order to be considered a sulfa drug (Shah et al., 2018). Below is my second-line prescription for V.S.:

Downey Family Practice

1234 Health Road

Richmond, VA 23223

(555) 555-5555

Nicole Downey, BSN, DNP, FNP-C Date: March 28, 2022 

Patient: V.S. DOB: 03/08/2010 Weight: 45 kg Phone: (231) 818-5090

Polymixin B/trimethoprim ophthalmic solution 10,000 units/1mg per mL

Disp: One bottle

Sig: Administer one drog to the affected eye every three hours while awake for seven days to treat bacterial conjunctivitis. Do not take more than six doses each day. 

No refills.

What over-the-counter or alternative medications would be appropriate for V.S.?

Using artificial tears or lubricating ointments may assist in relieving the symptoms related to bacterial conjunctivitis (Chan et al., 2021). In addition, the use of the over-the-counter povidone-iodine ophthalmic solution 1.25% may assist in the treatment of bacterial conjunctivitis (Sahdev et al., 2018). I would make sure to let V.S. know to wait at least ten minutes before instilling any other adjunctive medications into his eye after applying his prescribed ophthalmic antibiotic ointment (Woo & Robinson, 2020, p. 846).

What dietary and lifestyle changes should be recommended for V.S.?

An important piece of information to discuss with V.S. is for him and his family members to engage in frequent and effective hand washing, especially when the infected eyes are touched and before administering eye drops, to decrease the risk of spreading the infection (Woo & Robinson, 2020, p. 846). In addition, he needs to be informed to not share towels with anyone else while he has an eye infection (Woo & Robinson, 2020, p. 846).

Further, I would let V.S. know that he may remove any purulent eye discharge with warm water-moistened cotton balls that are wiped from the interior to the exterior canthus (Woo & Robinson, 2020, p. 846). He should be instructed to use a clean cotton ball with each wipe and each eye (Woo & Robinson, 2020, p. 846). In addition, I would advise V.S. to use a cold compress to relieve his symptoms of discomfort (Chan et al., 2021). 

Describe one or two drug–drug or drug–food interactions for the selected agent.

There are no common drug interactions noted with the ophthalmic preparation of erythromycin ointment (Woo & Robinson, 2020, p. 841). There are also no common interactions associated with the use of Polytrim (Epocrates, 2022). However, it would be important to reinforce to V.S. to wait at least ten minutes before instilling two different types of treatments, such as artificial tears and ophthalmic antibiotics, to ensure both act in the way they are intended (Woo & Robinson, 2020, p.846). 

References

Azari, A. A., & Arabi, A. (2020). Conjunctivitis: A systematic review. Journal of Ophthalmic & Vision Research, 15(3), 372.

Chan, V. F., Yong, A. C., Azuara-Blanco, A., Gordon, I., Safi, S., Lingham, G., Evans, J., & Keel, S. (2021). A systematic review of clinical practice guidelines for infectious and non-infectious conjunctivitis. Ophthalmic Epidemiology, 1-10.

Epocrates (2018). Erythromycin ophthalmic. Retrieved March 28, 2022, from https://online.epocrates.com/drugs/2408/erythromycin-ophthalmic/Patient-Education

Epocrates (2022). Polytrim. Retrieved March 28, 2022, from https://online.epocrates.com/drugs/238302/Polytrim/Peds-Dosing

Sahdev, A. K., Sethi, B., Singh, A., Sharma, N., & Purwar, S. (2018). Conjunctivitis: Types, diagnosis and treatment under different therapies. Asian Journal of Pharmacy and Pharmacology, 4, 421-428.

Shah, T. J., Moshirfar, M., & Hoopes, P. C. (2018). “Doctor, I have a sulfa allergy”: Clarifying the myths of cross-reactivity. Ophthalmology and Therapy, 7(2), 211-215.

Vallerand, A., & Sanoski, C. (2020). Davis’s drug guide for nurses (Seventeenth ed.). F.A. Davis Company.

Viriya, E. T., & Mah, F. (2021). Bacterial conjunctivitis. Cornea, E-Book, 370.

Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th edition). FA Davis.