Case Study of Chalazion Management

Introduction

This essay is meant to demonstrate a nurse’s ability to make critical decisions during clinical testing, as well as the most appropriate prescribing behaviour when presented with a patient. The essay will be based on a case study characterised by a patient complaining of chalazion. So, the essay will use Driscoll’s Reflection Model to reflect on various aspects of assessment and treatment of the patient based on a detailed analysis of each clinical action and their justification.

A Description of the Event (WHAT)

Diana (not her real name) visited the hospital’s ophthalmic incident department with a lump on her upper eyelid. She had experienced the lump for the past two days and had not sought any medication. She mentioned the local pharmacist’s advice to visit an ophthalmologist and this triggered her to visit the hospital. By the time she was visiting the hospital, the lid was extremely painful, swollen and red.

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While providing details for history taking, Diana mentioned that she was not pleased by the fact that her eye had a lump yet she was supposed to travel to Kenya for holidays in the next few days. She therefore wanted the lamp to be removed before she could travel. In the spirit of professional clinical practice, I informed Diana that I was about to subject her to a medical examination which would yield an elaborate treatment plan to ensure that she would be okay long before she travels for holiday.

My assessment began by examining her left eye, which appeared to be normal. However, upon examining her right eye, I realised a mobile lump and her lid had a mild swelling. Besides, her right eye had a mild conjunctival injection, even though she had a deep Anterior Chamber with a clear cornea.

Patient’s Demographic Information

Gender: Male Color: White/Caucasian Age: 30 years old Profession: University Lecturer

Right upper lid lump (RUL) with a history of 2/7 Red and painful right eye with no visual acuity affected Patient not on any medication The patient does not wear contact lens

During my examination of the patient, I asked her some questions regarding the characteristics of the lesion, the speed with which it emerged, any associated symptoms, her travel history and any history of similar lesions on the exact place; because according to Wu et al (2018), reoccurrence of lesions on the exact place would need a thorough examination to exclude carcinoma. Besides, I felt that her travel history was important so as to determine whether she had visited areas prone to leishmaniasis or tuberculosis. Ideally, existing pieces of evidence reveal that ophthalmologists have mistaken such etiologies for chalazion (Fukuoka et al, 2017). Also, while examining Diana, I was keen to eliminate other causes of her eyelid condition. In doing so, I focused on symptoms such as eye pain reoccurring at the same position, acute visual changes, facial swelling and fever, and diffuse eyelid. These symptoms were absent and therefore I diagnosed her with RUL chalazion.

In addition, Diana’s body temperatures were within a normal range and her normal visual acuity was material did not necessitate any special management of her ocular disorder. Also, Diana’s skin was on a normal medical condition, she was not on any medication, neither did she have any allergies.

Upon completing the medical examination, we agreed on a treatment plan which could help manage her pains. Using an elaborate prescription plan highlighted in Appendix 1, I advised Diana to take chloramphenicol antibiotic ointment 1% at every night for seven days so as to prevent any further infection on her RUL.

I also had concerns over the possibilities of Diana developing preseptal cellulitis and the fact that she might not be able to get any appropriate medical attention if her condition deteriorated while she is abroad. Therefore, to respond to these concerns and in discussion with my DMP, I prescribed for her some CO-amoxiclav 625 mg to be taken three times a day for one week.

I informed Diana of all the possible side effects of the drugs and whereas oral therapy is not freely prescribed under normal circumstances (of which I informed her), it was important for her to know the signs of these side effects as well as the most appropriate time to take these antibiotics. I particularly emphasized to her that she should not take alcohol while on these medications.

I also completed a health promotion with Diana, informing her about her medical condition so as to equip her with the relevant information that could help her make an informed decision regarding her treatment plan and any changes she would like to make on it. Ideally, the plan was to educate her on a non-medical treatment of heat and massage to lid, on a long-term basis. Particularly, the heat and massage to the lid was to be applied in the direction of her eyelashes and over the lesion.

I also gave chalazion information leaflets to Diana, which contained instructions on how to apply the heat and massage on the lid. I advised Diana to read the leaflet before leaving the hospital, and showed her the emergency department’s contacts on the leaflet – for use in case of any medical emergency. Moreover, the leaflet contained information regarding the incision procedure for her chalazion. Ultimately, before discharging her, I gave her an opportunity to ask any question regarding chalazion or the treatment plan. This was aimed at ensuring that she had a good understanding of how she could use the oral therapy, and to ensure that she had realistic expectations of the therapy outcomes.

Analysis of the Event (SO WHAT)

According to Hanafi & Oubaaz (2018), a chalazion is a lipogranulomatosis, sterile and chronic inflammatory lesion that occurs when meibomian gland orifices are blocked and when sebaceous secretions develop some sluggishness. Chalazion is considered one of the most common eyelids lumps even though it is important to exclude some differential pathology to ensure that the condition is properly managed for purposes of obtaining a good treatment outcome. Besides, Jin et al (2017) argue that ophthalmologists should be aware of any suspicious reoccurrence and presentation of the problem on the same eyelid position, as well as the occurrence of eyelashes loss, the shape of the lesion, as well as its colour because these symptoms might represent a different malignancy.

When there is a proper exclusion of differential diagnoses, the practitioner is able to determine whether there is a need for further referral for purposes of getting a specialist (ophthalmologist) opinion or procedures such as incision or biopsy of lesion, as well as for purposes of referring the patient to a different clinician to treat any underlying secondary conditions such as meibomitis, blepharitis, eczema or rosacea.

Because Diana had a slightly injected conjunctiva, I recommended her to undergo a chloramphenicol ointment therapy that she could only take at night. Particularly, I recommended the chloramphenicol therapy due to its broad spectrum action (Chang et al, 2017) that could help reduce Diana’s possibility of contacting secondary bacterial conjunctivitis that could emanate from the chalazion discharge (Ozer et al, 2016).

I also assessed Diana’s swollen eyelid to establish whether there she had preseptal or orbital cellulitis as I felt that this was an important differential diagnosis worth contemplating when handling a swollen eyelid. Ideally, according to Carlisle & Digiovanni (2015), preseptal cellulitis is less severe and most common and their main causative organisms are staphylococci. Hence, streptococci treatment which includes antibiotic therapy is the most appropriate for them. Contrariwise, according to Aycinena et al (2016), the occurrence of orbital cellulitis might be as a result of faults in the structures of the eye and could lead to blindness if not properly detected and managed. Nonetheless, after establishing that Diana had no raised temperatures, no chemosis to the lids and no tenderness, I diagnosed her with mildly swollen lid, which was secondary to chalazion as opposed to preseptal cellulitis (Park & Lee, 2014).

Part of my reassurance to Diana was that although it might take weeks or months to resolve, the meibomian cyst is a self-limiting condition and 80% of such conditions resolve spontaneously (Mittal et al, 2013). Also, I reassured Diana that applying heat and massage at least twice a day to the lid was the best management technique for chalazion as this would enhance the drainage of from the glands (Mirjana et al, 2013).

However, it is important to acknowledge the professional responsibility of considering the patient’s needs and preferences when managing such patients, especially for purposes of enhancing informed decision-making and to achieve concordance during the treatment process (Department of Health, 2008). Against this backdrop, I was keen to holistically consider Diana’s situation by following the prescribing pyramid and local protocols. This was based on the Department of Health’s (2015) argument that such considerations enable the development of effective treatment and assure the patient of safety, accountability, and result -oriented treatment plans.

During my session with Diana, I was determined to explain to her that under normal circumstances, I would not prescribe oral therapy due to the fact that we had not established signs of prespetal cellulitis (Parveen et al, 2015). Besides, I considered her intention to travel abroad and the fact that she might not be able to access quick medical attention in case her condition deteriorated. Therefore, antibiotics were the best option, and this is supported by Department of Health’s (2008) assertions that oral medication would only be needed in cases where preseptal cellulitis is present so as to prevent the occurrence of further complications.

To address the possibilities of preseptal cellulitis, we discussed with my DMP and prescribed for her amoxiclav 625 mg, which she could take three times a day for 7 days based on local protocol prescriptions. Noteworthy though, this treatment would only begin if chalazion became infected, with signs of higher temperature and tenderness around the lump. Part of my emphasis to Diana was that she had to take all the prescribed antibiotics for purposes of taking a full treatment. This is beside my advice to her that she needed to adhere to the prescriptions so as to prevent her from developing antibiotic resistance (Department of Health, 2015).

In respect to drug side effects, I was keen to explain to her the need to avoid any alcoholic substance while taking the antibiotics Nursing and Midwifery Council (NMC, 2006). But again, this was challenging considering the fact that she was going on a holiday with friends and that she could possibly be influenced by friends to take alcohol. Nevertheless, Diana agreed to take my advice on using oral therapy only when her lid got more swollen. She was also advised that in case the lid got redder, more painful and swollen, she could cold massage the swollen area for a few days so as to reduce inflammation. She could, however, continue with the warm massage after realizing a reduced swelling.

As part of the clinical procedure, I advised Diana to seek medical review by a general practitioner in 1-2 months in case chalazion persisted, a situation which could call for Incision and Curettage (I+C). I was keen to inform her that she needed the warm massage throughout until emergence of the need to have I+C, and also informed her that having I+C would not be a guarantee that chalazion would not reoccur.

The information I provided to Diana was detailed enough to inform her that in order to prevent the reoccurrence of chalazion and achieve good treatment outcomes, she needed to strictly and conservatively adhere to the treatment plan. This was in the spirit of achieving concordance, which although has been a familiar concept in clinical practice, has not been understood by many practitioners as a concept that could help obtain the best patient outcome during a treatment plan/procedure.

Ideally, the works of Cox & Amro (2012) indicate that concordance as a negotiation between the patient and the prescriber during a consultation session, whose aim is to develop a therapeutic alliance between them. It is based on giving utmost respect to the patient’s agenda in order to develop a relationship between the prescriber and the patient that is anchored on reality as opposed to concealment, distrust, and misunderstanding.

Against this background, I support the idea by NMC (2006) that when patients are involved and engaged in their own care, they are more able to acknowledge and prevent medication errors by staying committed to the treatment plan whether the plans are medical or non-medical. When an elaborate framework is adopted while prescribing medications, it gives a more holistic approach to patient care and the prescribing practitioner gains a certain sense of satisfaction and autonomy out of it. Besides, Department of Health (2015) points out that when the patient is involved in making various decisions regarding their care, it becomes easier to diagnose and manage the illness because they gain a better understanding of the treatment procedures and why they are conducted. Also, adopting a proper drug prescription framework gives creates an opportunity to improve patient satisfaction, reduce patient waiting times and creates more access to medication, all which contribute to quality care (Department of Health, 2008).

To my realization, there is an emerging trend in nursing and a non-medical prescription called evidence-based practice (EBP) which is particularly gaining popularity in the current medical landscape of changing patient needs and demands. According to NMC (2006), the concept of EBP basically entails applying the use of scientific evidence in making clinical decisions and in general practice of medication prescription. Ideally, proponents of EBP claim that it entails a combination of clinical experience and skills held by the practitioner and the use of the most current information in managing the patient’s condition (Department of Health, 2008).

Non-medical prescribers, like any medical practitioners, have the professional responsibility of delivering quality care to patients (NMC, 2006). However, to uphold this high professional standard of practice, it is necessary to rely on EBP and engage in continuous improvement of skills and knowledge, which in turn enhances the practitioner’s confidence in practice. This argument corroborates with those of Bradle & Nolan (2007) that it is only when practitioners are able to develop an efficacy in searching for clinical evidence and integrate these pieces of evidence into practice that they can be able to achieve the best management of patients’ illness conditions through safe medication prescription. Hence, the integration of evidence-based into practice, especially during the consultation process, in conjunction with an improved relationship with the patient enables the achievement of prescription excellence. Moreover, Bradle & Milan (2007) argue that this process also allows for a cost-effective prescription process thereby enhancing an efficient patient care process.

When consulting with Diana as a nurse prescriber, I managed to shorten the duration of her stay in the department and effectively manage her condition while adhering to the department’s standards of practice. Also, I was able to apply EBP together with my skills in providing her with the best management plan for chalazion. This is evidenced by the way I considered her traveling schedules in developing an antibiotic prescription for her while taking into consideration that her condition might worsen while he is on holiday, within an environment that she might not get adequate medical attention in case her condition deteriorates. I was also able to give her the best information regarding the treatment plan, the prescribed drugs, and their side effects. Hopefully, the medical leaflet containing information on chalazion proved useful in guiding her without having to visit the hospital. The leaflet will also hopefully guide her in making decisions regarding how to prevent the reoccurrence of chalazion.

To conclude, this reflective essay has evidenced the important nature of independent prescription within the ophthalmic setting. The reflection has demonstrated how supplementary prescribers can only work with the clinical plan as a guide to drug prescription. However, it is important to note that this aspect limits their role in a clinical prescription because they cannot conduct any prescription outside the established clinical management plan. Nonetheless, it is also important to note the fact that they are capable of amending the prescriptions when a need arises.

This reflection has also helped me realize my role as a nurse prescriber, which is to use my knowledge and skills in helping my patients while adhering to evidence-based practice. This not only improves the quality of care but also ensures patient satisfaction with the clinical outcome of the treatment. Also, I have learned the importance of developing and following an elaborate protocol of prescription, basing all the decisions on the available information. All in all, I believe that for purposes of a holistic and effective prescription, there is a need to make both legal and ethical considerations, thereby developing a safe and effective drug prescription which focuses on the patients’ needs.

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References

  • Aycinena AR, Achiron A, Paul M, Burgansky-Eliash Z. Incision and Curettage Versus Steroid Injection for the Treatment of Chalazia: A Meta-Analysis. Ophthalmic Plast Reconstr Surg. 2016 May-Jun;32(3):220-4.
  • Bradle & Nolan. Impact of nurse prescribing: a qualitative study. Jounal of ophthalmic practice, 2007; 6 (2), p. 260-264.
  • Carlisle RT, Digiovanni J. Differential Diagnosis of the Swollen Red Eyelid. Am Fam Physician. 2015 Jul 15;92(2):106-12.
  • Chang M, Park J, Kyung SE. Extratarsal presentation of chalazion. Int Ophthalmol. 2017 Dec;37(6):1365-1367.
  • Cox, C. & Amro R. Adherence: Compliance, persistence and conocordance in the management of glaucoma. Part 1. International Journal of ophthalmic practice,. 2012; 6, (2) , p. 2060-264.
  • Department of health High Quality care for all. London: 2008’ The stationary Office
  • Department of health Antibiotics Awareness resources: Key messages on antibiotic use. London: 2015; Public Health England.
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  • Hanafi Y, Oubaaz A. [Leishmaniasis of the eyelid masquerading as a chalazion: Case report]. J Fr Ophtalmol. 2018 Jan;41(1):e31-e33.
  • Jin KW, Shin YJ, Hyon JY. Effects of chalazia on corneal astigmatism : Large-sized chalazia in middle upper eyelids compress the cornea and induce the corneal astigmatism. BMC Ophthalmol. 2017 Mar 31;17(1):36.
  • Mittal R, Tripathy D, Sharma S, Balne PK. Tuberculosis of eyelid presenting as a chalazion. Ophthalmology. 2013 May;120(5):1103.e1-4.
  • Mirjana A. Janicijevic-Petrovic, Snezana Jancic, Katarina Janicijevic & Andrijana Popovic. ‘Treatment of Multiple Chalazions with Intralesional Kenalog-40 Injections in Juvenile Patient: A Case Report’, Open Access Macedonian Journal of Medical Sciences, 2013; Vol 1, Iss 1, Pp 83-86, no. 1, p. 83.
  • Nursing and Midwifery Council (2006) Standards of proficiency for nurse and Prescribers. London: NMC
  • Ozer PA, Gurkan A, Kurtul BE, Kabatas EU, Beken S. Comparative Clinical Outcomes of Pediatric Patients Presenting With Eyelid Nodules of Idiopathic Facial Aseptic Granuloma, Hordeola, and Chalazia. J Pediatr Ophthalmol Strabismus. 2016 Jul 01;53(4):206-11.
  • Park YM, Lee JS. The effects of chalazion excision on corneal surface aberrations. Cont Lens Anterior Eye. 2014 Oct;37(5):342-5.
  • Parveen, S. et al. Comparison of Subcutaneous Extralesional and Intralesional Triamcinolone Injection for the Treatment of Chalazion’, Pakistan Armed Forces Medical Journal, 2015; 65(4), p. 502.
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