16.6 Conjunctivitis

Conjunctivitis refers to inflammation of the conjunctiva of the eye and is commonly known as pink eye. The conjunctiva is the clear mucous membrane that covers the eye and provides lubrication. Conjunctivitis can be an infectious or noninfectious process. The most common type is conjunctivitis caused by a viral infection, usually adenovirus. However, infectious conjunctivitis can also be caused by bacteria, fungi, or parasites. Bacterial conjunctivitis can occur at any age but is more commonly seen in children than adults. Noninfectious conjunctivitis can be caused by allergies or exposure to toxins. Conjunctivitis may be an acute or chronic process, with acute cases lasting up to four weeks and chronic cases lasting over four weeks.^[1]

Pathophysiology

When the conjunctiva comes into contact with an infectious microorganism or an irritant, inflammation occurs. The blood vessels in this area then dilate, leading to redness and swelling. Based on the cause of the conjunctivitis, eye discharge may also result.^[2]

Assessment (Recognizing Cues)

Physical Exam

The signs and symptoms of conjunctivitis can vary based on the causative factor. Common signs and symptoms are eye redness, discharge, pain, watering, itching, sensitivity to light, sticky-feeling eyes, and the sensation that something foreign is in the eye. With conjunctivitis, the entire surface of the eye is reddened, not just a specific area. One or both eyes can be affected. With viral conjunctivitis, symptoms of an upper respiratory tract infection are typically present, as well as tender preauricular lymphadenopathy.^[3] See Figure 16.11^[4] for an image of an eye with conjunctivitis.

Examination of the eye discharge, if present, can provide a clue regarding the cause of conjunctivitis. With a bacterial cause, discharge is purulent and may stick to the eyelashes. Viral and allergic forms of conjunctivitis have a watery discharge.^[5]

Complications of conjunctivitis are rare but can occur. When conjunctivitis is caused by Chlamydia trachomatis in the newborn, it can lead to pneumonia and ear infections. When conjunctivitis is caused by Neisseria gonorrhoeae, clients can develop sepsis, meningitis, or perforation of the cornea. Other types of conjunctivitis can lead to scarring of the cornea and vision loss if not treated appropriately.^[6]

Common Laboratory and Diagnostic Tests

Conjunctivitis is usually a clinical diagnosis, but further testing may be performed for recurrent or resistant infections, if infectious conjunctivitis occurs in a newborn or when sexually transmitted bacteria are suspected. In these cases, eyelid secretions can be cultured or undergo rapid antigen testing. Cytology testing may also be done on the affected area as different types of white blood cells predominate with viral, bacterial, and allergic conjunctivitis.^[7]

Nursing Diagnosis (Analyzing Cues)

Nursing priorities for clients with conjunctivitis include symptom management, preventing spread to others, and avoiding the development of complications.

Nursing diagnoses for clients with conjunctivitis are created based on the specific needs of the client, their signs and symptoms, and the etiology of the disorder. These nursing diagnoses guide the creation of client-specific care plans that encompass client outcomes and nursing interventions, as well the evaluation of those outcomes. These individualized care plans then serve as a guide for client treatment. Possible nursing diagnoses for clients with conjunctivitis are as follows^[8]:

• Disturbed sensory perception r/t disease process
• Risk for infection r/t cross-contamination risk
• Acute pain r/t disease process

Outcome Identification (Generate Solutions)

Outcome identification encompasses the creation of short- and long-term goals for the client. These goals are used to create expected outcome statements that are based on the specific needs of the client. Expected outcomes should be specific, measurable, achievable, relevant, and timebound (SMART) within a set time frame based on the application of appropriate nursing interventions. Sample expected outcomes for clients with conjunctivitis include the following:

• The client will exhibit a reduction in irritative eye symptoms within 24 hours of treatment.
• The client will avoid contamination of their other eye if only one eye is affected during the course of the illness.
• The client will exhibit a reduction in pain using a numeric scale, FACES, or FLACC, within 24 hours of treatment.

Interventions (Generate Solutions & Take Action)

Medical Interventions

Medical treatment varies based on the etiology of conjunctivitis. Bacterial conjunctivitis is treated with antibiotic ointment or drops that are applied to the affected eye(s). Systemic antibiotics are prescribed for conjunctivitis caused by gonorrhea or chlamydia. Supportive care is recommended for most types of viral conjunctivitis with application of cold compresses and administration of artificial tears. However, conjunctivitis caused by herpes simplex or herpes zoster requires consultation with an ophthalmologist and prescriptions for antiviral medications and potentially topical steroids. Conjunctivitis that is linked to allergies can be treated by avoiding allergens and application of cold compresses, as well as artificial tears. Topical or oral antihistamines may also be used. Referral to an ophthalmologist should also be considered for those who wear contact lenses or have recurrent conjunctivitis, severe pain, or conjunctivitis linked to herpes simplex virus.^[9]

Nursing Interventions

Registered nurses develop interventions based on the expected outcomes of the client. Prior to implementation, the nurse must determine if all previously planned interventions are still suitable based on the current situation of the client. When caring for a client with conjunctivitis, nursing interventions can be divided into nursing assessments, nursing actions, and client teaching, as described in the following subsections.^[10],[11]

Nursing Assessments

• Assess the visual acuity of the client using an age-appropriate eye chart, as some types of conjunctivitis can lead to loss of vision.
• Assess the client’s eye pain using an age-appropriate scale. Worsening eye pain could signal the development of a complication.

Nursing Actions

• Encourage the use of cold compresses for symptomatic relief.
• Administer antibiotic or antiviral medications, as ordered by the provider.
• Encourage the use of sunglasses outside to protect eyes that might be sensitive to light.

Client Teaching

• Educate the client and their caregivers about the various etiologies of conjunctivitis and their treatment regimens.
• To prevent the spread of this highly contagious infection, clients and caregivers should be taught the importance of effective handwashing, avoiding touching the eye to prevent spreading the infection to the other eye, and not sharing personal items like makeup. Pediatric clients should remain home from school until symptoms are under control. Additionally, linens should be washed, and any eye makeup should be replaced.
• Teach clients who wear contact lenses to not insert them during an active infection.
• Teach the client and their caregivers on proper eye drop or ointment administration. To prevent contamination of the medication, the tip of the medication should not touch the surface of the eye.

Evaluation (Evaluate Outcomes)

Evaluation of client outcomes refers to the process of determining whether or not client outcomes were met by the indicated time frame. This is done by reevaluating the client as a whole and determining if their outcomes have been met, partially met, or not met. If the client outcomes were not met in their entirety, the care plan should be revised and reimplemented. Evaluation of outcomes should occur each time the nurse assesses the client, examines new laboratory or diagnostic data, or interacts with another member of the client’s interdisciplinary team.