sCASE 20-2016: A 50-Year-Old Man with Cloudy Vision, Hearing Loss

and Unsteadiness
Patients Profile
A. Demographic
Name: M. M. M.
Address: Boston, Massachusetts
Age: 50 year old
Gender: Male
Civil Status: Married
Occupation:
Nationality:
Religion:
Admitting diagnosis:
Date of Admission:
Time of Admission:
B. Chief Complaint
Cloudy vision
C. History of the Present Illness
Cloudy vision that gradually developed in both eyes last 3 days.
o with resports of fatigue and worsening of rash, joint pain
o

and stiffness associated with his psoriatic arthritis.

Topical opthalmic prednisolone was prescribed for

presumed psoriatic arthritis associated iritis.

After 5 days, cloudy vision persisted and that decreased hearing
and difficulty balancing had developed.
o A diffuse rash characterized by erythematous plaques and
overlying white scales was present in his face, abdomen,
o

back, arms, legs, palms and soles.

Topical opthalmic Prednisolone was continued, and

opthalmic cyclopentolate was prescribed.

11 days after initial evaluation, hearing loss and unsteadiness
worsened and patient was seen by an otolaryngologist.
o Patient returned to the eye and ear infirmary because of
worsened visual cloudness and a new floater in the right

eye.
D. History of the Past Illness
Laser surgery for retinal tear in left eye 16 years ago.
Pneumocystis jirovecii (10 months ago) and was diagnosed of HIV
infection

Started antiretroviral medications 2 months before this

consultation
6 weeks before consultation, patient was admitted to another
hospital.
o Adrenal insufficiency, disseminated infection with
mycobacterium avium-intracellulare, and the immune
o

reconstitution inflammatory syndrome were suspected.

Anti retrovirals were stopped and azithromycin, rifambutin,
ethambutol, hydrocortisone and fludrocortisone were given

as was trimetroprim-selfamethoxazole 3 times a week.

2 weeks before consultation, anti retrovirals were again initiated.

E.

Social History
Lives with husband
Non smoker and no history of use of illicit drugs
Social drinker

F. Allergies
No known allergies noted.
G. ASSESSMENT
Date: Initial evaluation
Vital Signs:
Pulse Rate: 91 bpm
Respiratory Rate: 20 bpm
Blood Pressure: 121/77 mm Hg
Oxygen Saturation: 100%
1. Physical Assessment (Initial evaluation)
1. General

-alert and oriented to person, place and

2. Eyes

time.
-pupils equal and reactive to light; no
relative afferent papillary defect.
-Visual fields full in response to

3. Skin

confrontation.
A diffuse rash characterized by
erythematous plaques and overlying
white scale was present and involved
face, abdomen, back, arms, legs, palms
and soles.

DIAGNOSTIC AND LABORATORY TESTS

INITIAL EXAMINATION:
-

Visual Acuity (Snellens Chart)

o OD 20/25
o OS 20/30
Extraocular Motility (Six Cardinal Positions of Gaze)
o OU - Full motility
Intraocular Pressure (Tonometry)
o OD 8mmHg
o OS 7mmHg
Hypotony
Slit Lamp Examination
o 1+ injection of the conjuctiva
Red eyes
o 2+ cells Right anterior chamber
16-25 cells in field
o 4+ cells Left anterior chamber
50+ cells in field
White blood cells (leukocytes)
o

o
o
-

No Hypopyon
Inflammatory cells in the anterior chamber of the eye. It is
a leukocytic exudate, seen in the anterior chamber,
usually accompanied by redness of the conjunctiva and
the underlying episclera.
Diffuse fine
Large keratic precipitates on the cornea

Indirect Opthalmoscopy
o 1+ virteous cells
11-20 cells
Inflammatory process
o Normal fundi with cup to disk ratios of 0.3 bilaterally
cup-to-disc ratio compares the diameter of the "cup"
portion of the optic disc with the total diameter of the
optic disc
normal cup-to-disc ratio is 0.3

Laboratory Data:
Variable
Hemoglobin (g/dl)
Hematocrit (%)
White-cell count (per

Reference Range, Adults

14.0-18.0
41.0-53.0
4800 10,800

On
Presentation
10.8
31.7
4400

HIV

mm3)
Monocytes (%)
Erythrocyte
sedimenatation rate
(mm/hr)
Chloride (mmol/liter)
Alkaline phosphatase
(U/liter)

C-reactive protein
(mg/liter)

4-11
20

15
105

Bacterial Infection
Inflammation assoc
infection

100-108
45-115

98
124

98
Liver damage
Abnormal liver func
are common among
infected persons.
Syphilitic hepatitis i
common occurring
(12/32) of HIV-posit
patients with early
syphilis infection

0.0 8.0

18.6

Inflammation / Infec

5 DAYS FOLLOWING:
-

Visual Acuity (Snellens Chart)

o OD 20/30
o OS 20/40
Pupil Examination (Pen Light)
o Anisocoria present in both bright and dim lighting conditions
o Subtle relative afferent papillary defect
Intraocular Pressure (Tonometry)
o OD 12mmHg
o OS 11mmHg
Slit Lamp Examination
o OS
Trace injection of the superior conjuctiva
Extensive posterior synechiae
o OD
1+ injection of the anterior chambers
Posterior synechiae at the 3 o clock position OD
o OU
Diffuse fine and large keratic precipirates on the corneas
OS more abundant
Indirect Opthalmoscopy
o OD 1+ virteous cells
o OS 2+ virteous cells
Serologic Testing
o Angiotensin-converting-enzyme level
Reference range 9-67

80 U per liter
ACE has been found in moderately increased levels with
HIV
HLA-B37 Present
Psoriatic arthiritis

o
-

Screening Test for antibodies to Borrelia burgdorferi

o (+)
o Lyme Disease
o Patients with syphilis can have a false positive test for Lyme
disease because of cross reactivity
Eleven days after initial presentation:

Audiogram
o Moderate sensorineural hearing loss
Worse on the left side than right

Visual Acuity (Snellens Chart)

o OD 20/100
o OS 20/375
Pupil Examination (Pen Light)
o Anisocoria present

Intraocular Pressure (Tonometry)

o OD 8 mmHg
o OS 8 mmHg
Slit Lamp Examination
o OS
3+ anterior chamber
o OD
4+ anterior chamber
o OU
Extensive keratic precipirates on the corneas
Indirect Opthalmoscopy
o OD
3+ virteous cells
2+ virteous haze
o OS
2+ virteous cells
4+ virteous haze
o Many small, yellow bilateral inferotemporal preretinal infiltrates
Optical Coherence Tomography
o Shadowing form virteous opacities
o OD - Normal foveal contour
o OS - Poor view of the retina

Image of macula could not be contained

Fluoresceinangiography
o OD
Hazy view
Staining of the peripheral retina
o OS
Very hazy view
Some leakage
Staining of the retina nasally and temporally

Screening Test for antibodies to Borrelia burgdorferi

o (-)

THE DIAGNOSTIC TESTS (SCREENING FOR SYPHILLIS)

-

Fluorescent Treponemal Antibody Absorption Test

o Reactive
Rapid Plasma Reagin Test
o Reactive at a titer of 1:128
o (+) T. pallidum passive particle agglutination assay
Lumbar Puncture Cerbrosinal Fluid Analysis
o Total Protein level: 142 mg per deciliter
(Referance range: 15 45)
Increase commonly seen in Syphillis
o White-Cell Count: 75 per cubic millimeter
(Reference Range: 0 8)
Infection or inflammation of the central nervous system
Venereal Disease Research Laboratory Test
o (+)
o Titer of 1:4

DRUG
NAME

MECHANISM

Generic:

Interferes with
cell wall
replication

penicillin G

OF ACTION

Brand:

of susceptible
organisms;
osmotically
unstable

Pfizerpen

cell wall swells

INDICATION
AND
CONTRAINDICA
TION
otitis media, skin
and soft tissue
infections; any
stages of syphilis

Contraindicatio

SIDE EFFECTS
AND ADVERSE
REACTIONS
CNS: Lethargy,
anxiety, depression,
hyperreflexia
GI: Nausea,
vomiting, diarrhea,
increased
AST, ALT, abdominal

NURS

Monitor vita
treatment.
Verify docto
Assess patie
penicillins o
Assess patie
infection inc
sputum, uri
earache, fev

and bursts from

osmotic

Functional
class:

pressure,
resulting in cell
death

ns:

pain

Hypersensitivity
to penicillins,
corn

GU: Oliguria,
proteinuria,
hematuria,
HEMA: Anemia,
increased bleeding
time,

Broadspectrum
antiinfective

bone marrow
depression
META: alkalosis,

Dose:

hypernatremia

4 million
Units IV
every 4hrs
for 14 days

DRUG
NAME
Generic:
prednisone

Brand:
Rayos

Functional
class:
Intermediate
-acting

MISC: Local pain,

tenderness and
fever

MECHANISM
OF ACTION
Decreases
inflammation
by increasing
capillary
permeability
and lysosomal
stabilization,
minimal
mineralocortico
id activity

INDICATION
AND
CONTRAINDI
CATION
Severe
inflammation,
dermatologic
disorders

SIDE EFFECTS AND

ADVERSE
REACTIONS
CNS: Depression,
flushing, sweating,
headache, mood
changes
CV: Hypertension,
thrombophlebitis,
tachycardia, fluid
retention

Contraindica
tions:

EENT: increased
intraocular pressure,
blurred vision
GI: Diarrhea, nausea,
abdominal distention,

during treat
Obtain C&S
identify if co
Obtain skin
starting the
Check IV lin
complicatio
phlebitis.
Monitor bloo
bilirubin, LD
Monitor elec
chloride.
Assess bow
occurs, prod
Monitor for
gums, hema
colitis).
Assess for o
itching, feve
drainage, ra
Check for d
heparin, tet
May give fa
protein.
For treatme
maintain air
aminophylli

NURSIN

Monitor vita
treatment;
discontinued
Verify doctor
Monitor pota
while on lon
hyperglycem
Monitor weig
for decreasin
edema.
Notify presc
Monitor plas
therapy (nor
measured at
Assess adren

glucocorticoi
d

Hypersensitivi
ty

GI hemorrhage,
increased appetite
INTEG:, poor wound
healing, ecchymosis,
petechiae

Dose:

META: Hyperglycemia

80 mg PO
daily

MS: Fractures,
osteoporosis,
weakness

hypothalami
Assess infec
after withdra
infection sym
Assess for p
fatigue, nau
dysrhythmia
cardiac sym
Assess ment
changes, ag
Give with fo

PAST MEDICATIONS OF CASE 20

DRUG
NAME
Generic:
azithromycin

MECHANISM
OF ACTION
Binds to 50S
ribosomal
subunits
of susceptible
bacteria and
suppresses
protein

Brand:
Zithromax

Functional
class:
Macrolide

INDICATION
AND
CONTRAINDICA
TION
prophylaxis of
disseminated
Borrelia
burgdorferi,
Mycobacterium
intracellulare

synthesis;
much greater
spectrum of
activity than
erythromycin;
more effective
against gramnegative
organisms

SIDE EFFECTS
AND ADVERSE
REACTIONS
CNS: Dizziness,
headache, vertigo,
somnolence,
fatigue
CV: Palpitations,
chest pain, QT
prolongation,
EENT: Hearing loss,
tinnitus, loss of
smell
(anosmia)

Contraindicatio
ns:
Hypersensitivity
to azithromycin,
erythromycin,
or any
macrolide,
hepatitis,
jaundice

GI: Nausea,
diarrhea,
hepatotoxicity,
abdominal
pain, stomatitis,
heartburn,
dyspepsia,
flatulence, melena,
cholestatic jaundice,
pseudomembranous
colitis, tongue
discoloration

NURSIN

Monitor vita
treatment.
Verify doctor
Assess patie
penicillins or
Assess for a
in elderly th
Assess for si
drainage, fe
urine culture
culture posit
Monitor resp
wheezing, ti
product if th
Monitor aller
each medica
all people gi
Monitor I&O
hematuria, o
urinalysis, p
Check for dr
with pharma
Monitor liver
alkaline pho
Monitor C&S
may be take
Caution pati
aluminum/m
food simulta

HEMA: Anemia
INTEG: Rash,
urticaria, pruritus,
photosensitivity,

levels of azit
Provide adeq
diarrhea epi
Give with a f
Store at room

pain at injection site

SYST: Angioedema

DRUG
NAME
Generic:
Rifabutin

MECHANISM
OF ACTION

INDICATION
AND
CONTRAINDICA
TION

Inhibits DNAdependent RNA

Prevention of M.
avium complex

polymerase in
susceptible
strains.

(MAC) in patients
with advanced
HIV infection.

Brand:

Contraindicatio
ns:

Rifamycin Sderivative

CNS: Headache,
fatigue, anxiety,
confusion,
insomnia
GI: Nausea,
vomiting, anorexia,
diarrhea,
heartburn, hepatitis,
discolored saliva,
pseudomembranous

Mycobutin

Functional
class:

SIDE EFFECTS
AND ADVERSE
REACTIONS

Hypersensitivity,
active TB,
WBC<1000/mm3
,
Platelets
<50,000/mm3

colitis
GU: Discolored urine
HEMA: Hemolytic
anemia,
eosinophilia,
thrombocytopenia,
leukopenia
INTEG: Rash
MISC: Flulike
syndrome,
shortness of breath,
chest pressure
MS: Asthenia,

NURSIN

Monitor vita
treatment.
Verify doctor
Assess for a
culture, bloo
obtain PPD t
MAC and ne
Monitor CBC
eosinophilia
Assess for p
abdominal p
possible ane
albumin); st
vancomycin
Advise patie
sweat, tears
Give with m
better to tak
hr after mea
may take in
and mix with
whole
Give antiem
Check for dr
with pharma

arthralgia, myalgia

DRUG
NAME

MECHANISM

Generic:

Inhibits RNA
synthesis,
decreases
tubercle bacilli
replication.

ethambutol

OF ACTION

INDICATION
AND
CONTRAINDICA
TION
other
mycobacterial
infections: M.
intracellulare

Brand:
Myambutol
Contraindicatio
ns:
Hypersensitivity;
optic neuritis
Functional
class:
Antitubercul
ar;
Diisopropyle
thylene
diamide
derivative

SIDE EFFECTS
AND ADVERSE
REACTIONS
CNS: Headache,
confusion, fever,
malaise, dizziness,
disorientation,
peripheral
neuropathy
EENT: Blurred
vision, optic neuritis,
photophobia,
decreased visual
acuity
GI: Abdominal
distress, anorexia,
nausea, vomiting
INTEG: Dermatitis,
pruritus, erythema
multiforme
META: Elevated uric
acid, acute gout,
liver function
impairment
MISC:Thrombocytop
enia, joint pain

NURSIN

Monitor vita
treatment.
Verify doctor
Check for dr
with pharma
Obtain C&S
initiating tre
resistance
Monitor liver
Monitor rena
specific grav
appetite, jau
Assess patie
mood, behav
Assess patie
indicate opti
color percep
Caution pati
of appetite,
or eyes, ting
gain, or decr
Instruct pati
rash; hot, sw
tingling of ex
Give with m
same time e
Give 2 hr be
Give antiem

DRUG
NAME
Generic:
hydrocortiso
ne

MECHANISM
OF ACTION
Decreases
inflammation
by
suppressing
migration of
polymorphonuc
lear

Brand:
Colocort

Short-acting
glucocorticoi
d

Severe
inflammation,
adrenal
insufficiency

stabilization
(systemic).

SIDE EFFECTS
AND ADVERSE
REACTIONS
CNS: Depression,
flushing, sweating,
headache,mood
changes,
euphoria, insomnia,
seizures
CV: Hypertension,
circulatory collapse,

leukocytes and
fibroblasts and
reversing
increased
capillary
permeability
and lysosomal

Functional
class:

INDICATION
AND
CONTRAINDICA
TION

Contraindicatio
ns:
Hypersensitivity,
fungal infections

thrombophlebitis, ,
tachycardia, edema,
heart failure
EENT: Fungal
infections, increased
intraocular
pressure, blurred
vision, cataracts,
glaucoma
GI: Diarrhea,
nausea, abdominal
distention, GI
hemorrhage,
increased appetite,
pancreatitis,
vomiting
HEMA:
Thrombocytopenia
INTEG:poor wound
healing,
ecchymosis,
petechiae
MISC: Adrenal
insufficiency (after
stress/

NURSIN

Monitor vita
treatment.
Verify doctor
Check for dr
with pharma
Assess adren
symptoms):
breath, moo
joint pain be
plasma corti
(normal leve
at 8 am); ch
hypothalami
Monitor pota
hypokalemia
Monitor I&O
output and i
Assess for in
after withdra
infection sym
should be di
Assess ment
changes, ag
Teach patien
hyperglycem
Teach patien
pain, black t
bleeding/per
Give with fo

withdrawal)
MS: Fractures,
osteoporosis,
weakness

DRUG
NAME

MECHANISM

Generic:

Promotes
increased
reabsorption of
sodium and
loss of
potassium,
water,
hydrogen from
distal tubules

fludrocortiso
ne

OF ACTION

INDICATION
AND
CONTRAINDICA
TION
Adrenal
insufficiency

Synthetic
corticosteroi
d

CV: Hypertension,
circulatory collapse,
thrombophlebitis,
tachycardia, CHF,
edema
CNS: Flushing,
sweating, headache,
paralysis, dizziness,
seizure

Contraindicatio
ns:
Functional
class:

SIDE EFFECTS
AND ADVERSE
REACTIONS

hypersensitivity,
acute
glomerulonephrit
is, amebiasis,
psychosis,
Cushings
syndrome,
fungal infection

ENDO: Weight gain,

adrenal suppression,
hyperglycemia
META: Hypokalemia
MISC:
Hypersensitivity,
cataracts, GI ulcers
MS: Fractures,
osteoporosis,
weakness

NURSIN

Monitor vita
treatment.
Verify doctor
Check for dr
with pharma
Assess weig
gain .5 lb.
Monitor I&O
increasing e
Assess for p
paresthesia,
dysrhythmia
Monitor sodi
hypokalemia
Give with fo

DRUG
NAME

MECHANISM

Generic:

Synthetic
nucleoside
analog of
cytosine;
inhibits
replication of
HIV virus by
competing with
the natural
substrate and
then becoming
incorporated
into cellular
DNA by viral
reverse
transcriptase,
thereby
terminating
cellular DNA
chain

emtricitabin
e

Brand:
Emtriva

Functional
class:
Antiretroviral
;

OF ACTION

INDICATION
AND
CONTRAINDICA
TION
HIV-1 infection
with other
antiretrovirals

SIDE EFFECTS
AND ADVERSE
REACTIONS
CNS: Headache,
dizziness, insomnia,
neuropathy,
paresthesia,
asthenia
GI: Nausea,
vomiting, diarrhea,
anorexia, abdominal
pain, dyspepsia

Contraindicatio
ns:

INTEG: Rash, skin

discoloration

Hypersensitivity.

MS: Arthralgia,
myalgia
RESP: Cough
SYST: Change in
body fat
distribution, lactic
acidosis

NURSIN

Monitor vita
treatment.
Verify doctor
Check for dr
with pharma
Wear necess
Monitor liver
bilirubin, am
periodically
Teach that G
treatment
Instruct that
time of day
Advise that p
not a cure fo
pass HIV viru
Instruct that
prevent othe
Advise that c
occur.
Give without
Store at 25

Nucleoside
reverse
transcriptase
inhibitor
(NRTI)

DRUG
NAME
Generic:
Tenofovir

MECHANISM
OF ACTION
Inhibits
replication of
HIV-1 virus

INDICATION
AND
CONTRAINDICA
TION
HIV-1 infection
with at least 2
other

SIDE EFFECTS
AND ADVERSE
REACTIONS
CNS: Headache,
asthenia
GI: Nausea,

NURSIN

Monitor vita
treatment.
Verify doctor
Check for dr

by competing
with the natural
substrate and
then
Brand:
Viread

Functional
class:
Antiretroviral
;

incorporating
into cellular
DNA by viral
reverse

antiretrovirals,

flatulence,
abdominal pain,
pancreatitis
Contraindicatio
ns:

transcriptase,
thereby
terminating
cellular DNA

vomiting, diarrhea,
anorexia,

Hypersensitivity.

chain

GU: Renal failure,

renal tubular
acidosis/Necrosis
HEMA: Neutropenia,
osteopenia
INTEG: Rash,
angioedema
META: Lactic
acidosis,
hypokalemia,

Nucleoside
reverse
transcriptase
inhibitor
(NRTI)

hypophosphatemia
MS: Myopathy,
rhabdomyolysis
SYST:
Lipodystrophy

DRUG
NAME

Generic:
Ritonavir

Brand:
Norvir

MECHANI
SM
OF
ACTION
Inhibits
HIV-1
protease
and
prevents
maturation
of the
infectious
virus

INDICAT
ION
AND
CONTRA
INDICAT
ION
HIV-1
infection
with at
least 2
other
antiretro
virals,

SIDE EFFECTS AND

ADVERSE REACTIONS

CNS: Paresthesia, headache,

seizures, dizziness,
insomnia, fever, asthenia
CV: QT, PR interval
prolongation
GI: Diarrhea, buccal mucosa
ulceration,
abdominal pain, nausea, taste
perversion, dry

with pharma
Wear necess
Monitor vira
RNA, serum
Resistance t
treatment fa
Assess liver
amylase, lip
treatment
Assess for b
abnormalitie
phosphorus,
Teach that G
treatment
Instruct that
time of day
Advise that p
not a cure fo
pass HIV viru
Advise patie
serious toxic
done q2wk
Advise that c
occur.
Give without
Store at 25

NURSIN

Monitor vital si
treatment.
Verify doctors
Check for drug
pharmacists.
Wear necessar
Assess signs o
Monitor viral lo
HIV RNA, serum
throughout the
Resistance tes
after treatmen

mouth, vomiting, anorexia

Functional
class:
Antiretroviral
;
Protease
inhibitor

Contrai
ndicatio
ns:
Hyperse
nsitivity.

INTEG: Rash
MISC: Asthenia, angioedema,
anaphylaxis,
increased lipids,
lipodystrophy, toxic epidermal
necrolysis
MS: Pain, rhabdomyolysis,
myalgia

Monitor C&S be
be taken as so
after treatmen
STDs
Assess bowel p
severe abdomi
product should
Teach patient t
missed, take a
before next do
Teach patient t
intervals aroun
for duration of
Teach patient t
opportunistic in
acquired, and o
from the patien
Inform that red
accumulation o
Store caps in re

DRUG
NAME

MECHANISM

Generic:

Inhibits
human
immunodeficie
ncy virus (HIV1) protease;
this prevents
maturation of
virus

Darunavir

Brand:

OF ACTION

INDICATION
AND
CONTRAINDIC
ATION
HIV-1 in
combination
with ritonavir
and other
antiretrovirals

CNS: Headache,
insomnia, dizziness,
somnolence
GI: Diarrhea,
abdominal pain,
nausea, vomiting,
anorexia, dry
mouth, hepatitis,
hepatotoxicity

Prezista

Contraindicati
ons:
Functional
class:

SIDE EFFECTS
AND ADVERSE
REACTIONS

INTEG: Rash,
angioedema, toxic
epidermal
necrolysis,
exanthematous
pustulosis

Hypersensitivity
MS: Pain
.

OTHER: Asthenia,
insulin-resistant
hyperglycemia,
hyperlipidemia,
ketoacidosis,
lipodystrophy

Antiretroviral
;
Protease
inhibitor

NURSING CONSID

Monitor vital sig

treatment.
Verify doctors o
Check for drugpharmacists.
Wear necessary
Assess for comp
indicates kidney
Assess for signs
of other STDs.
Monitor viral loa
HIV RNA, serum
throughout ther
Assess bowel pa
severe abdomin
product should
Teach patient to
missed, take as
before next dos
Advise patient t
time of day to m
therapy.
Teach patient to
stones; if stone
need to be inte
Teach patient th
controls sympto
share, notify all
use with any ot
approval.
Give with food a
Tab should be s

NURSING CARE PLANS

Assessment
Subjective:
Complains of worsening
of cloudy/blurry vision
and floater in the right
eye

Diagnosis
Disturbed
sensory
perception
related to
altered status of
sense organ

Nursing Interven

Independent:
1. Introduce self to patient, and acknowledg
2. Assess ability to speak, hear, interpret an
commands.
3. Monitor VS and Determine visual acuity
4. Provide means of communication and pro

Objective:
-(+) HIV infection
-MSM (Men who have sex
with men)
-(+) keratic precipitates
on the corneas
-(+) granulomatous
panuveitis
-(+) iritis
-visual acuity 20/100 in
the right eye and 20/375
in the left
-Anisocoria
-(+) small yellow bilateral
inferotemporal preretinal
infiltrates

(eyes)
secondary to
syphilis

Assessment
Subjective:
The patient also reported that
decreased hearing and
difficulty balancing had
developed same time with his
ocular symptoms.
Objective:
50 years old female
Visual acuity: 20/100 in right
eye and 20/375 in left eye
Hearing difficulties
Unsteadiness/

with continuity of care by same personnel a

5. Explain sounds and any unusual stimuli in
6. Provide tactile stimulation as care is given
7. Provide safety measures as needed
8. Remove environmental barriers to ensure
9. Avoid isolation of client physically and em
10. Inform patient about the importance of p
treatment to prevent vision loss
11. inform patient that a lumbar puncture is
whether there is a involvement of his CNS
12. Watch out for further deterioration of vis
perception

Collaborative:
1. Administer prescribed antibiotics (IV penic
2. Administer prescribed Glucocorticoid (pre
4. Assist in procedures
3. Collaborate with other involved health ca

Diagnosis
Risk for injury
related to impaired
vision secondary to
cataract

Interventio
1. Introduce rapport

2. Perform thorough assessment

when planning for client care.

3. Note clients age, gender, dev

cognition/ competence.

4. Assess clients muscle, gross,

5. Observe for signs of injury (cu

such as old or new bruises.)

6. Maintain bed or chair in lowes

locked and use the side rails.
bathroom is unobstructed and

7. Move items used by the patie

as call light, urinal, water, and

8. Inform patient the advantage

and hearing aids and to have

9. Ask family to stay with the pa

10.Consider physical and occupa

assist with gait techniques an
assistive devices for transfer
home safety evaluation as ne
Assessment
Subjective:

Objective:
- (+) HIV
infection
- Rash
characterized
by
erythematous
plaques and
overlying
white scale
involving the
face,
abdomen,
arms, legs,
feet, and
hands,
including
palms

Assessment
Subjective:

Objective:
- (+) HIV
infection

Diagnosis
Impaired skin
integrity evident by
skin rashes
secondary to syphillis

Nursing Interventi

Independent:
1. Assess skin daily. Note color, turgor, circulat
and measure lesions and observe changes. Tak
2. Assess bony prominences, perineum, and de
for pallor, redness, and breakdown.
3. Maintain and instruct in good skin hygiene:
carefully, and gently massage with lotion or ap
4. Maintain clean, dry, wrinkle-free linen, prefe
5. Position client properly; use pressure-reduci
devices
6. Instruct or assist client to shift weight at lea
7. Encourage ambulation as tolerated.
8. File nails regularly.
9. Apply and administer medications as indicat
10. If tissue breakdown occurs notify appropria

Collaborative:
1. Administer prescribed antibiotics (IV penicill
2. Administer prescribed Glucocorticoid (predn
4. Assist in procedures
3. Collaborate with other involved health care

Diagnosis
Disturbed body
image related to
illness

Nursing Interventi
Independent:

1. Assess for signs and symptoms of a self

2. Determine the meaning of changes in a

functioning to the client by encouraging

Rash
characterized
by
erythematous
plaques and
overlying
white scale
involving the
face,
abdomen,
arms, legs,
feet, and
hands,
including
palms
-sensorineural
hearing loss
Decreased
vision

and by noting nonverbal responses to th

3. Be aware that client may grieve the loss

elimination and change in appearance. P
grieving process.

4. Emphasize the positive effects of the su

5. Promote activities that require client to
that have occurred.

6. Demonstrate acceptance of client using

and frequent visits. Encourage significan

7. Support behaviors suggesting positive a

have occurred.

8. Encourage significant others to allow cli

so that independence can be re-establis
redeveloped.

9. Assist client's and significant others' adj

facilitating communication, and providin

10.Encourage visits and support from signi

11.Encourage client to pursue usual roles a

involvement in social activities.

12.Provide information about and encourag

agencies and support groups.

Collaborative:
1. Consult appropriate health care provide
clinician) if client seems unwilling or una
resulting from the bowel diversion.

Assessment

Diagnosis

Nursing Inte

Objective:
- (+) HIV infection
- Gait instability
-(+) keratic
precipitates on the
corneas
-(+) granulomatous
panuveitis
-(+) iritis
-visual acuity 20/100
in the right eye and
20/375 in the left
-Anisocoria
-(+) small yellow
bilateral
inferotemporal
preretinal infiltrates

Risk for Trauma: falls

related to visual, and
spatial-perceptual
impairments secondary
to syphilis infection

Independent:
1. Keep bed in low posi

client is in bed
2. keep needed items w
3. Encourage client to r
needed; have call sig
4. Instruct client to wea
with nonslip soles an
5. Keep floor free of clu
promptly
6. Accompany client du
transfer safety belt i
7. Provide ambulatory a
unsteady on feet
8. Instruct client to am
utilize handrails if ne
9. Do not rush client; a
ambulation to the ba
10. Instruct and assist c
positions slowly in or
associated with post
11. Make sure that show
surface and that sho
12. Signal, grab bars, an
13. Administer central ne
judiciously
14. Reorient frequently t
of adhering to safety
15. Provide appropriate
16. Include client and sig
implementing measu
17. If client falls, initiate
appropriate and noti

Collaborative:
1. Consult physician about the
2.

or jacket or wrist restraints

Administer prescribed antia
medications if indicated.