Clinical Treatment Protocols

Walk-in Centre:

Clinical Treatment Protocols

November 2017

Version: 8

Contents

Anaphylactic Reaction – Clinical Treatment Protocol ... 5

Asthma – Clinical Treatment Protocol ... 7

Marine Sting - Clinical Treatment Protocol ... 11

Bites – Clinical Treatment Protocol ... 13

Spider Bite – Clinical Treatment Protocol ... 16

Blood Glucose Level (BGL) – Clinical Treatment Protocol ... 18

Infectious Lactational Mastitis – Clinical Treatment Protocol ... 20

Chaperone – Clinical Treatment Protocol ... 23

Ear Wax – Clinical Treatment Protocol ... 25

Otitis Media – Clinical Treatment Protocol ... 27

Otitis Externa (Swimmer’s Ear) – Clinical Treatment Protocol ... 29

Allergic Conjunctivitis – Clinical Treatment Protocol ... 32

Infective Conjunctivitis – Clinical Treatment Protocol ... 34

Dry Eye Syndrome – Clinical Treatment Protocol ... 37

Corneal Abrasion – Clinical Treatment Protocol ... 39

Stye (Hordeola) – Clinical Treatment Protocol ... 42

Non-Invasive Foreign Body (FB) of the Eye – Clinical Treatment Protocol ... 45

Subconjunctival Haemorrhage – Clinical Treatment Protocol ... 47

Fever – Clinical Treatment Protocol... 50

Diarrhoea – Clinical Treatment Protocol ... 53

Vomiting – Clinical Treatment Protocol ... 56

Primary Dysmenorrhoea – Clinical Treatment Protocol ... 58

Pregnancy Test – Clinical Treatment Protocol ... 60

Vulvovaginal Candidiasis – Clinical Treatment Protocol ... 62

Lower Urinary Tract Infection (Uncomplicated) – Clinical Treatment Protocol ... 64

Headache – Clinical Treatment Protocol ... 66

Migraine – Clinical Treatment Protocol ... 69

Uncomplicated Cellulitis – Clinical Treatment Protocol ... 72

Musculoskeletal Lower Back Pain – Clinical Treatment Protocol ... 75

Knee – Clinical Treatment Protocol ... 77

Pulled Elbow – Clinical Treatment Protocol ... 93

Finger or Toe – Clinical Treatment Protocol ... 95

Subungual Haematoma – Clinical Treatment Protocol ... 99

Foot Injuries– Clinical Treatment Protocol ... 102

Hand – Clinical Treatment Protocol ... 105

Fracture Management – Clinical Treatment Protocol ... 108

Contusion – Clinical Treatment Protocol ... 111

Self-Harm (Cutting) – Clinical Treatment Protocol ... 113

Chlamydia Screening – Clinical Treatment Protocol ... 116

Emergency Contraception – Clinical Treatment Protocol... 118

Boils – Clinical Treatment Protocol ... 120

Paronychia (Acute) – Clinical Treatment Protocol ... 122

Acute Urticaria – Clinical Treatment Protocol ... 124

Contact Dermatitis (Allergen and Irritant) – Clinical Treatment Protocol ... 126

Scabies – Clinical Treatment Protocol ... 128

Dermatophyte (Tinea) Infection – Clinical Treatment Protocol ... 130

Head Lice – Clinical Treatment Protocol ... 133

Impetigo – Clinical Treatment Protocol ... 135

Shingles (Herpes Zoster) – Clinical Treatment Protocol ... 137

Varicella (Chicken Pox) – Clinical Treatment Protocol ... 139

Measles – Clinical Treatment Protocol ... 141

Rubella – Clinical Treatment Protocol ... 143

Coxsackie Virus (Hand Foot and Mouth Disease) – Clinical Treatment Protocol ... 145

Non-Specific Viral Rash – Clinical Treatment Protocol ... 147

Atopic Dermatitis – Clinical Treatment Protocol ... 149

Influenza – Clinical Treatment Protocol ... 152

Common Cold – Clinical Treatment Protocol ... 154

Sinusitis – Clinical Treatment Protocol ... 156

Allergic Rhinitis – Clinical Treatment Protocol ... 158

Sore Throat (Pharyngitis)/Bacterial Strep Throat/Tonsillitis – Clinical Treatment Protocol ... 160

Laceration – Clinical Treatment Protocol... 162

Suture/Staple Removal – Clinical Treatment Protocol ... 167

Abrasion – Clinical Treatment Protocol ... 168

Burns – Clinical Treatment Protocol ... 170

Wound Dressing – Clinical Treatment Protocol ... 173

Cast Removal Protocol ... 175

Croup – Clinical Treatment Protocol ... 177

Anaphylactic Reaction – Clinical Treatment Protocol

Overview:

Condition for treatment - Anaphylaxis is a multi-system severe allergic reaction which affects about one person in 200 and is characterised by:

 At least one respiratory or cardiovascular feature, and

 At least one gastrointestinal or skin feature.

Most reactions occur within 30 minutes of exposure to a trigger. Common causes of anaphylaxis in children include:

 Foods – Peanut, tree nuts, cow’s milk, eggs, soy, shellfish, fish and wheat;

 Bites/stings – Bees, wasps;

 Medications;

 Others.

Inclusion Criteria -

 Difficulty breathing;

 Swelling of the tongue;

 Swelling of the throat;

 Difficulty talking;

 Wheezing with a persistent cough;

 Children who are pale and floppy and/or any of the above;

 Hives, welts and/or skin redness, and

 Persons developing the above symptoms post medication administration or examination.

Differentials:

• Anaphylactoid reaction should be treated the same as an anaphylactic reaction.

Treatment:

• Call for help from other team members.

• External assistance from the ambulance should be summoned immediately upon recognition of the anaphylactic reaction.

• Symptoms affecting the cardiovascular and respiratory systems should be managed with supplemental oxygen and intramuscular adrenaline whilst waiting further assistance.

The following doses of adrenaline are given as per the Walk in Centre Medication Standing Orders:

IMI doses of 1:1000 /1mg in 1 ml adrenaline

epinephrine Repeat after 5 min if no better

Adult and children > 20kg 300mcg/1mg/ml 0.3ml IM

Child 10-20kg 150mcg ampoule/1mg/ml IM (0.15ml)

• Considerations and preparation for BLS should be commenced.

Other treatment to consider:

• Salbutamol is recommended if the client experiences respiratory distress with wheezing.

• Antihistamines may be given for symptomatic relief of pruritus.

Advice:

• Anaphylaxis is an immediate life threatening condition.

• Anaphylactic reactions may occur after the consumption of some food types (e.g. nuts or shellfish), the administration of some medications (including alternative therapies), being bitten by a venomous creature (e.g. bee sting), or from exposure to another substance (e.g.

latex).

• The client should seek GP advice as to the creation of an anaphylaxis action plan, including the prescription and dispensing of an ‘EpiPen’, which they then carry with them at all times, and possible referral to a specialist.

Medication Standing Order:

• Adrenaline References :

• UK National Health Service Institute for innovation and improvement; Clinical Knowledge Summaries 2016.

• Clinical Practice Guidelines 2015

• Better Health Channel 2014

• Therapeutic Guidelines

Asthma – Clinical Treatment Protocol

Overview:

Asthma is a chronic lung disease which can be controlled but not cured. In young children in whom lung function testing is not feasible, asthma is defined by the presence of variable respiratory symptoms. Untreated asthma is usually characterised by chronic inflammation of many calls and cellular elements, airway hyper-responsiveness and intermittent airway narrowing due to bronchoconstriction, congestion or oedema of bronchial mucosa, mucous or a combination of these.

The diagnosis of allergic asthma is more likely when a person also has an allergy and a family history of asthma.

Condition for treatment (1/5):

Severe asthma Inclusion criteria:

 Wheeze, shortness of breath, cough, chest tightness;

 Increased work of breathing, e.g. accessory muscles, tracheal tug, subcostal recession or abdominal breathing;

 Unable to complete sentences in one breath due to dyspnoea and no wheeze audible;

 Tripoding position;

 Physical exhaustion;

 Pulse > 120/min,

 SPO2 < 90% on room air.

Treatment:

 Severe Asthma treatment protocol;

 Salbutamol MSO

 Redirect to ED via ambulance,

 O2 to keep SPO2 > 95%.

Condition for treatment (2/5):

Moderate asthma Inclusion criteria:

 Wheeze, shortness of breath, cough, chest tightness;

 Tracheal tug and accessory muscle use;

 SPO2 < 95%;

 PEF 50-75% predicted, best if known;

 Client talking only in phrases;

 Age-appropriate respiratory rate,

Treatment:

 Redirect to ED via ambulance;

 Salbutamol MSO

 Oxygen therapy to keep O2 > 95%.

 Client Information Sheet - Asthma Condition for treatment (3/5):

Mild asthma – previously diagnosed Inclusion criteria:

 Cough, wheeze, chest tightness, shortness of breath;

 Able to talk in sentences;

 SPO2 > 95%;

 Age-appropriate respiratory rate,

 PEF > 75% predicted, best if known.

Treatment:

 Salbutamol MSO

 Client Information Sheet – Asthma,

 Client is most likely to need a review from a GP and is only likely to attend WiC for exacerbation of condition. Client will need to see GP to discuss use of preventers.

Condition for treatment (4/5):

Mild asthma - undiagnosed Inclusion criteria:

 Wheeze, chest tightness, shortness of breath, cough;

 Able to talk in sentences;

 SPO2 > 95%,

 Age-appropriate respiratory rate.

Treatment:

 Salbutamol MSO

 Redirect to GP within 24 hours.

Condition for treatment (5/5):

Treatment:

 Salbutamol MSO

 Redirect to GP, or

 NP review.

 Client Information Sheet - Asthma Differentials:

• Chest infection, COPD, bronchiectasis, bronchiolitis, vocal cord dysfunction.

• FB aspiration, tracheal lesions, GORD, heart failure, pulmonary embolism, mediastinal masses.

• Chronic sinusitis, Cystic Fibrosis, aspirin or NSAID hypersensitivity.

• Lung cancer, asbestosis, Pertussis, pulmonary embolism.

• Peri tonsillar, retropharyngeal or lung abscess (especially in children).

Management/Treatment:

Severe-Moderate Asthma

• Children < 6yrs:

o Call ambulance and redirect to ED;

o Give 2-6 puffs of Salbutamol (MDI) via spacer and mask. Repeat after 20 min if no response.

• Children > 6yrs/adults:

o Call ambulance and redirect to ED;

o Give 4-12 puffs of 100mcg Salbutamol (MDI) via spacer. Repeat after 20 min if no response.

Mild Asthma

• Children < 6yrs:

o 2-6 puffs of Salbutamol via spacer;

o Symptoms of mild asthma usually resolve with initial dose. Provide Salbutamol (MDI) and spacer. Advise client to use 4 puffs via spacer and repeat as necessary as per asthma action plan.

• Children > 6yrs/adults:

o 4-12 puffs of 100mcg Salbutamol (MDI) via spacer;

o Symptoms of mild asthma usually resolve with initial dose. Provide Salbutamol (MDI)

and spacer. Advise client to use 4 puffs via spacer and repeat as necessary as per

asthma action plan.

Advice:

• Every person with asthma should have their own written asthma management plan that is appropriate for their treatment regime, as per their asthma severity, culture, literacy level and ability to self-manage.

• Any Client with a history of asthma and whose medication regime is not relieving symptoms should be referred back to their GP for investigation and management.

• Use of spacer for MDI to optimise drug absorption – correct technique should be demonstrated if Client is found to be incompetent with the use of a spacer.

• All asthmatics should be advised to carry their asthma medication at all times. They should seek medical advice if they find their medication/s to be ineffective.

• Asthma-triggering factors should be managed appropriately.

• Refer to GP unless Client can follow their asthma management plan to increase dose of preventer.

• Client Information Sheet - Asthma Medication Standing Order:

• Salbutamol

• Oxygen References:

• National Asthma Council Australia, 2016. Retrieved from:

https://www.nationalasthma.org.au

• TGA, 2017. Retrieved from: https://www.tga.gov.au

• Up-to-date, An overview of asthma management

• National institute for clinical excellence. Retrieved from:

https://www.nice.org.uk/guidance/qs25.

Marine Sting - Clinical Treatment Protocol

Overview:

Condition for treatment - Marine stings are unlikely in ACT – however, clients may present on return from coastal areas. First aid needs to be provided onsite to prevent further envenomation.

Inclusion criteria -

 Non-tropical marine stings Redirect to GP/NP if:

 Wound appears infected or foreign body cannot be removed.

Redirect to ED if:

 Any neurological or cardio-respiratory involvement, client febrile.

Differentials:

 Irukandji syndrome with delayed pain may require opioid therapy and hospitalisation.

 Marine wounds that become infected require different management.

Management or Treatment:

• Bluebottle jellyfish first aid:

o Remove adhered stings/tentacles.

o Immerse in hot water, if not available then ice pack.

o Avoid vinegar.

• Stingray/Stonefish first aid:

o Remove any foreign bodies and wash with salt water.

o Immerse the limb in hot water (as hot as can be tolerated without burning the skin).

• Antibiotics should be considered where the skin has been penetrated and there is a possibility of foreign bodies in the wound.

• ADT should be considered for persons that have not had a tetanus immunisation booster in the past 5 years.

Advice:

• Marine bites and stings may become infected and some injuries will require prophylactic antibiotics.

• Symptoms usually spontaneously resolve within 48 hours.

• Stings and bites mostly cause pain at the site of the bite or sting, redness and swelling.

• Do not use alcohol, ammonia or baking soda on sting area.

• Client Information Sheet – Marine Stings Medication Standing Order:

• Paracetamol

• Ibuprofen

• ADT References :

• Therapeutic Guidelines eTG 2017

• CSL Antivenom Handbook 2013

• Australian Medicines Handbook (2017).

• RACGP, Australian Family Physician Vol. 44, No. 1, 2015

• NSW Marine creatures nurse management guidelines 2016

• https://www.healthdirect.gov.au/sea-creature-stings

Bites – Clinical Treatment Protocol

Overview:

Condition for treatment - Animal bites including dog and cat bites - human bites are also included in this protocol.

Inclusion criteria -

 Client presenting complaining of a bite;

 Bleeding is controllable,

 Localised wounds and client in stable condition.

Redirect to GP/NP if:

 Signs of infection or allergy to penicillin prophylaxis.

Redirect to ED if:

 Bites involving deeper structures, e.g. tendons, bones, joints;

 Bites to the face, genital area, or other requiring urgent surgical repair;

 Suspected accompanying crush injury, e.g. large dog bites,

 Foreign bodies that cannot be removed in WiC.

Differentials:

• Consider non-accidental injury and post-exposure prophylaxis for human bites.

• Bat bites require ED review for lyssavirus exposure.

Management or Treatment:

For cat or dog bites:

• Remove any foreign bodies (e.g. teeth) from the wound whilst irrigating it thoroughly with normal saline. Some may need debridement with local anaesthetic and betadine or chlorhexidine irrigation.

• Do not close the wound tightly but some stitches may be needed to oppose the big gaps.

Do Not glue.

• Apply Primapore to the wound.

• Antibiotic therapy is necessary for bites and clenched fist injuries with a high risk of infection. These include:

o wounds with delayed presentation (8 hours or more);

o puncture wounds that cannot be debrided adequately;

o wounds on the hand, feet or face;

o wounds involving deeper tissues (e.g. bones, joints, tendons),

o Wounds in immunocompromised clients, e.g. diabetics, cirrhotic, asplenic, and prosthetic valves or joints.

• Consider tetanus immunisation status.

For human bites:

• Hep B, Hep C and HIV status should be considered for both victim of bite and possibly the perpetrator.

Advice:

• Significant bite or deep puncture wounds to the hands, feet or face should be referred to a Plastic Surgeon through the Registrar Review Clinic.

• The Canberra Hospital Registrar Review Clinic referral process

• Contact, via TCH Switch (02) 6244 2222 and present the case to the appropriate Registrar.

• If, after discussion with the Registrar, the client’s required treatment falls out of the clinical scope of the WiC they will require redirection to the Emergency Department.

• Complete the TCH Registrar Review Clinic front sheet and checklist.

• Complete the client notes and fax them with the completed cover sheet to the Review Clinic (02) 6244 4107.

• Ensure that the client understands that they will be contacted by the Clinic with an appointment time and date.

• If foreign bodies are not able to be removed from the wound then the client should be redirected to the Emergency Department.

• Keep wound area clean and dry for 5-7 days.

• The dressing may be removed after 2 days.

• If the pain associated with the bite becomes worse and/or does not settle down within a day, or if the client notes a rash or swelling away from where the bite is, they should follow up with their GP.

• The client should be made aware of the signs of infection and informed to follow up their care with their GP if they note any infection.

• All Clients on prophylactic antibiotics should have a review with a GP post-course.

• All Clients taking prophylactic antibiotics from WiC need to understand that they are prophylactic and not for treatment of actual infection. If this should develop, GP review is required.

• Client Information Sheet – Dog or Cat Bites.

• Client Information Sheet – Human Bites.

• Amoxicillin with clavulanate

• ADT References:

• Up-to-date (2017). Retrieved from: https://www.uptodate.com

• Therapeutic Guidelines. (2017). Retrieved: https://tgldcdp.tg.org.au

Spider Bite – Clinical Treatment Protocol

Overview:

Condition for treatment - In Australia, there are only 3 insects with venom that is capable of causing death – the Funnel Web spider, the Red Back spider and the Paralysis Tick. The greatest concern from any bite or sting is the risk of allergic reaction leading to anaphylaxis and post-bite infection.

Many skin lesions and effects are blamed on spider bites which are unverified.

Inclusion criteria -

 Client presents complaining of a spider bite;

 If possible, identify type of spider via chart and document,

 Localised pain, swelling and erythema at the site of the bite.

Redirect to GP/NP if:

 Prominent, proximally-spreading pain and localised diaphoresis surrounding the site of the bite.

Redirect to ED if:

 Complaining of Funnel Web, Red Back or Mouse Spider bite;

 Evidence of systemic response up to and including systemic reactions that mimic organophosphate poisoning and include salivation, diaphoresis, muscle spasms, tachycardia, hypertension, muscle fasciculation (tongue fasciculation are typical), paraesthesia’s, catecholamine-induced myocarditis, and pulmonary oedema – Call ACTAS.

Differentials:

• Consider other causes of local skin lesions and reactions, such as infections, bites and stings of other arthropods, and several other more common skin conditions.

Management or Treatment:

• Call ACTAS for suspected envenomation, as discussed above. Support Client as able within the WiC with supplied oxygen.

• If Anaphylaxis – see Anaphylaxis Treatment Protocol.

• If localised allergic reaction, continue with urticaria protocol.

• Clean skin with saline-soaked gauze and apply dressing, monitoring for signs and symptoms of infection.

• ADT if not up to date.

Advice:

• There is often a red and swollen area around the bite.

Common management of symptoms:

• Put a cold pack on the area of the bite.

• Raise the part of the body that has been stung to prevent or reduce swelling.

• Do not scratch the area as it may become infected.

Common medications:

• Ibuprofen is commonly used for pain and swelling.

• Paracetamol may also help with pain.

• Antihistamine to relieve itch.

Medication Standing Order:

• Paracetamol

• Ibuprofen

• ADT

• Antihistamine eg Loratadine, if not effective consider promethazine References :

• http://www.toxinology.com/index.cfm

• https://www.healthdirect.gov.au/spider-bites

• https://www.uptodate.com/contents/approach-to-the-Client-with-a-suspected-spider-

bite-an-overview

Blood Glucose Level (BGL) – Clinical Treatment Protocol

Overview:

Condition for treatment - To identify clients who may have blood glucose levels (BGL) that contribute to their presenting problem.

Inclusion criteria:

 Clients with pre-existing diabetes;

 Wound infections;

 Clients exhibiting signs and symptoms of diabetes, e.g. polydipsia, polyuria, blurred vision, infections, adrenergic symptoms (pale skin, sweating, shaking, palpitations and a feeling of anxiety),

 Reduced level of consciousness, confusion or disorientation.

Redirect to GP/NP if:

 Suspected new-onset diabetes and asymptomatic;

 Delayed wound healing and abnormal BGLs;

 Client had episodes of hyper/hypo-glycaemia, and now asymptomatic and in normal BGL range,

 Requiring script for antihyperglycaemic medications.

Redirect to ED if:

 BGL reading <3mmol/L and symptomatic – redirect to ED post administration of hyperglycaemic agent.

Call Ambulance if:

 BGL reading >15 mmol/L and have altered level of consciousness.

 BGL reading <3 mmol/L and have severely altered level of consciousness (also administer Glucagon).

Differentials:

• Alcohol-associated hypoglycaemia

• Drug-associated hypoglycaemia (most commonly: Quinolones, beta blockers, ACE inhibitors, etc)

• Accidental/deliberate insulin overdose

• Sulfonylurea-induced hypoglycaemia

Management or Treatment:

Administration of Glucagon:

• Adult/child >25kgs – 1mg (SC, IMI).

• Child <25kgs – 0.5mg (SC, IMI).

Administration of hypoglycaemic kit:

• Kits are located in the medication room in the WiC.

• Give 15g of quickly absorbed carbohydrate – either 15g glucose (Glutose-15™) tube OR 1 packet of juice AND 15g of slowly absorbed carbohydrate (6 Jatz biscuits).

• If the client has not left for ED, re-test after 10 minutes.

• If BGL is 3.0mmol/dL, and clinically unwell, repeat the quickly absorbed carbohydrate treatment stat(as above).

Advice:

• This treatment provides immediate short-term treatment for a hypoglycaemic episode prior to redirection to the service deemed suitable by the nurse.

Medication Standing Order:

• Glucagon References :

• ACT Health. (2016). Blood glucose & ketone point-of-care testing (Document No.

CHHS16/083). Canberra, Australia: ACT Government.

• ACT Health. (2012). Management of hypoglycaemia and hyperglycaemia in Diabetes Mellitus Type 1 (T1DM) and Diabetes Mellitus Type 2 (T2DM) Clients in the Exercise Physiology Department (Document No. CHHS13/118). Canberra, Australia: ACT Government.

• Australian Medicines Handbook. (2017). Glucagon (endocrine). Retrieved from https://amhonline.amh.net.au/chapters/chap-10/antidiabetic-drugs/drugs- hypoglycaemia/glucagon

• Service, F. J., Cryer, P. El., & Vella, M. (2017). Hypoglycaemia in adults: Clinical manifestations, definition, and causes. Retrieved

fromhttps://www.uptodate.com/contents/hypoglycemia-in-adults-clinical- manifestations-definition-and-causes

• Therapeutic Guidelines. (2013). Diabetes: Complications. Hypoglycaemia. Retrieved from https://tgldcdp.tg.org.au/viewTopic?topicfile=diabetes-

complications&guidelineName=Endocrinology#toc_d1e47

Infectious Lactational Mastitis – Clinical Treatment Protocol

Overview:

Condition for treatment: Infectious mastitis should be a considered diagnosis for all lactating women presenting with a hard, red, tender, swollen area of one or both breasts and other systemic symptoms including one or more of the following: fever, chills, tachycardia, myalgia, headache, flu-like symptoms and/or axillary lymphadenopathy.

NB: These symptoms are often rapid in onset.

 Infectious mastitis most often occurs following breastfeeding problems which typically result in prolonged engorgement or poor drainage leading to milk stasis.

 A thorough clinical history and physical assessment will identify lactational mastitis risk factors such as: previous history of mastitis, damaged and/or infected nipples, inadequate milk drainage, blocked ducts, blocked nipple pore/white spot, abrupt weaning, fatigue, stress, poor health, change in feeding frequency, abundant milk supply, infection in the household, bacterial contamination from the infants nose/mouth or mothers hands or nipple cream, trauma to the breast, restrictive clothing.

 Symptoms of inflammatory mastitis include, an absence of systemic symptoms, normal breast appearance with a hard area, or a red, hard, tender area. Inflammatory mastitis should be treated using non-pharmacological measures.

Inclusion criteria:

 Lactating women.

Redirect to GP/NP if:

 Recurrent mastitis;

 Suspicion of thrush,

 No improvement after 72 hours of antibiotic treatment.

Redirect to ED if:

 Suspicion of abscess.

Differentials:

 Inflammatory mastitis;

 Nipple trauma;

 Engorgement;

 Candida;

 Blocked duct;

Management or Treatment:

For infectious mastitis –

• Administration of antibiotics as per standing order.

• Provide symptomatic relief - anti-inflammatory agents, i.e. ibuprofen as well as cold compresses or ice packs to reduce local pain and swelling.

• Improve breast feeding techniques. Continued breastfeeding should be encouraged as treatment does not usually require cessation of breastfeeding. Breast emptying is essential during the course of treatment. There is minimal risk of passing any infection on to the infant.

• Refer to GP after 48 hours for follow-up and assessment.

Advice:

Non-pharmacological treatment advice:

• Effective drainage of breast milk to maintain supply and reduce the risk of abscess formation is essential for all forms of lactational mastitis:

o Drain the breast/s often, at least 8-12 times, every 24 hours, either by breastfeeding or expressing.

o Apply warmth prior to, and during, feeding to assist milk ejection.

o Apply cold compress following the feed to decrease swelling and relieve pain.

o Feed from the sore breast first.

o Massage the affected breast gently while feeding and while showering/bathing.

Massage from the affected area towards the nipple.

• Hydration and rest;

• Refer client to MACH services via CHI (02 6207 9977) at the next available day for ongoing breastfeeding support;

• Provide and explain the client information pamphlets (Mastitis information brochure), and WiC specific information sheet.

• Inform the client that if there is no improvement in condition or worsening of condition despite care advice they need to seek medical attention.

• Educate about signs of abscess formation - the presentation of a breast abscess is similar to mastitis, with localised, painful inflammation of the breast associated with fever and malaise, along with a fluctuant, tender, palpable mass.

Medication Standing Order:

• Dicloxacillin

• Cephalexin

• Paracetamol.

• Ibuprofen.

References :

• BMJ Best Practice Guidelines 2016

• Dixon, J. M. (2017). Lactational mastitis. In A. B. Chagpar, E. L. Baron & K. Ecklar (Eds.).

UpToDate. Retrieved from: http://www.uptodate.com/contents/lactational- mastitis?source=search_result&search=mastitis&selectedTitle=1%7E55

• National Health and Medical Research Council. (2012). Infant feeding guidelines:

Information for health workers. Australian Government Publication. Retrieved from:

http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n56_infant_feeding_g uidelines.pdf

• Riordan, J., & Wambach, K. (2010).Breastfeeding and Human Lactation. Fourth Ed. Sudbury:

Jones and Bartlet Publishers.

• Therapeutic Guidelines.

Chaperone – Clinical Treatment Protocol

Overview

A chaperone is a person who accompanies a clinician during a procedure that the clinician or client identifies or request the assistance of.

This document is applicable to all clinicians who provide a service to a Client at the Walk-in Centre:

 All Nurse Practitioners

 All nurses who are working within their scope of practice (Refer to Nursing and Midwifery Continuing Competence Policy)

Procedures:

 Clinician or client identifies the need for a chaperone.

 Chaperone must be a clinician.

 Chaperone joins consultation and is introduced to client.

 Chaperone’s name is documented in client’s medical record.

 Clinician explains to client and chaperone the purpose and likely content of the examination/procedure/tests.

 Clinician undertakes the examination/procedure/tests.

 Clinician clearly documents clinical reasoning for performing procedure along with findings following the examination.

Differentials:

N/A

Management/Treatment:

• Identifying the need for a chaperone

• Male clinicians undertaking anogenital or breast examinations on female clients MUST have a female chaperone present.

• In other situations where a client requires anogenital or breast examination (female clinician examining male or female client, or male clinician examining male client) the clinician may opt to work with a chaperone.

• Clinical judgement is required. Such situations include but are not limited to:

o Clients aged under 16 yrs;

o Clients who are distressed;

o Clients requiring emotional support;

o Clients requiring physical assistance;

o Clients with symptoms of mental illness;

o Clients with a history of sexual assault,

o Clinician discomfort including fear of physical threat or intimidation.

• If the client declines a chaperone, the clinician may decide not to proceed with examination.

• All other Clients should be offered a chaperone but may decline.

• This should be documented in the clinical record.

Evaluation:

Outcome Measures

• Clients and clinicians feel safe and supported whilst participating in clinical consultations.

Method

• Incidents related to chaperones at WiC are reported via the Clinical Incident Reporting System and Staff Accident Incident Reporting (SAIR). Incidents are reviewed and corrective actions are reported via relevant departments in line with continuous quality improvement processes.

Medication Standing Order:

N/A

References:

• Canberra Sexual Health Centre (CSHC) Standard Operating Procedure Chaperone use at CSHC Related Legislation/Policies:

• ACT Health, Consent to Treatment Policy

• ACT health, Consent to Treatment Procedure

• ACT Health, Nursing and Midwifery Continuing Competence Policy

Ear Wax – Clinical Treatment Protocol

Overview:

Condition for treatment: Cerumen/ear wax is a mixture of secretions and sloughed epithelial cells.

A cerumen impaction is an accumulation of ear wax that causes symptoms such as hearing loss, fullness, otorrhoea, tinnitus, dizziness or other symptoms, and/or prevents a required assessment of the ear canal, tympanic membrane or audiovestibular system.

Inclusion criteria:

 Client has presented with blocked ear/s and cerumen impaction is found upon clinical examination;

 Ear wax softening drops used for at least 3 days.

Redirect to GP/NP if:

 Signs of current infection;

 History of recurrent Otitis Externa;

 History of chronic/recurrent Tinnitus ;

 Unilateral deafness or hearing loss not related to the cerumen impaction;

 Failure to expel wax after multiple irrigation attempts preceded by ear wax drops;

 Pain or bleeding upon irrigation;

 History of tympanic membrane perforation, radiation, or surgery;

 Age under 12 years;

 Client with cognitive impairment, and cannot express symptoms;

 Abnormal tissue in the ear,

 Any other concerns.

Differentials:

• Keratosis obturans

• Polyp of ear canal

• Foreign body in ear canal

• Osteoma of ear canal

Management or Treatment:

Ear syringing

• Conduct a history and examine ear and document findings.

• Explain the procedure and risks to the client.

• Obtain verbal consent for procedure.

• Follow instructions for ear irrigation device:

o Use warm water, test with your finger - cold water can cause nystagmus, nausea and vomiting. Hot water can cause considerable damage.

• The procedure should be ceased if any pain, nausea, or dizziness is experienced by the client.

• Examine the ear again post intervention and document findings.

• Advise post-intervention to apply acetic acid drops (available OTC) or “swimmers ear“ alcohol drops, as often some water can become trapped in the canal especially, if it is a narrow canal (which a significant number of people with wax impaction have). This water can lead to Otitis Externa, especially once the wax protection has been removed.

Advice:

Side Effects/Complications:

• Temporary symptoms of nerve irritation e.g. cough;

• Trauma to ear canal and tympanic membrane,

• Infections.

Prevention:

• Routine use of olive oil once a week to prevent wax build-up.

• Client Information sheet – Ear Wax Medication Standing Orders:

N/A

References:

• Dances, E. A. (2017). Cerumen. In D. G. Deschler and H. Libmern (Eds.). UpToDate.

• Poulton, S., Yau, S., Anderson, D., & Bennett, D. (2015). Ear wax management. Australian

family physician, 44(10), 731.

Otitis Media – Clinical Treatment Protocol

Overview:

Condition for treatment: Acute Otitis Media (AOM) refers to all forms of inflammation and infection of the middle ear and/or perforation of the tympanic membrane and is a common complication of viral respiratory illnesses. Acute Otitis Media is indicated with effusion behind the tympanic membrane, plus at least one of the following:

Inclusion criteria:

 Adult and children ≥2 years;

 Bulging tympanic membrane;

 Erythema of the tympanic membrane

 Recent discharge of pus (otorrhoea);

 Fever;

 Ear pain (otalgia),

 Vomiting (children).

Redirect to GP/NP if:

 Chronic Otitis Media – history of recurrent ear infections or inflammation;

 Perforation of tympanic membrane from trauma;

 Complex co-morbidities,

 Systemically unwell with temperature > 38.5°C with vomiting from onset of symptoms or within the first 48 hours.

Redirect to ED if:

 Mastoid tenderness - may indicate mastoiditis.

Differentials:

• Myringitis

• Mastoiditis

• Cholesteatoma Management or Treatment:

Most Acute Otitis Media will resolve within 24-48 hours from first symptoms without the need of antibiotic treatment. Antibiotics will not relieve the earache.

Recommendation

Less than 48 hours from symptom onset:

• Recommended approach is to provide simple over-the-counter analgesia from pharmacist.

Greater than 48 hours from symptom onset

• Antibiotic treatment recommended when systemically unwell with temperature >38.5°C and vomiting.

Advice:

• Recommend for client to have a review of affected ear/ears 5-7 days from onset of symptoms. It is not uncommon for fluid effusion to remain for up to 1 month post AOM.

• The client should be advised to raise their head while sleeping to reduce the discomfort associated with otitis media.

• Client Information Sheet – Middle Ear Infection Medication Standing Order:

• Paracetamol

• Ibuprofen

• Amoxicillin

• Cefuroxime References :

• Armengol, C.E. (2016). Otitis media. In R. Schwartz, O.Yigit & P. Bull (Eds.). British Medical Journal: Best Practice. Retrieved from http://bestpractice.bmj.com/best-

practice/monograph/39/treatment/details.html

• Australian Medicines Handbook. (2017). Retrieved from https://amhonline.amh.net.au/

• Klein, J.O., & Pelton, S. (2017). Acute otitis media in children: treatment. In M.S. Edwards, G.C. Isaacson & M.M. Torchia (Eds.). UpToDate. Retrieved from:

https://www.uptodate.com/contents/acute-otitis-media-in-children-

treatment?source=search_result&search=otitis%20media&selectedTitle=2~150

• Morris, P., Leach, A., Shah, P., Nelson, S., Anand, A., Allnutt, R., ... & Patel, H. (2011).

Recommendations for Clinical Care Guidelines on the Management of Otitis Media: In Aboriginal and Torres Strait Islander Populations 2010.

• The Royal Children’s Hospital Melbourne. (2017). Clinical practice guidelines: acute otitis media. Retrieved from

http://www.rch.org.au/clinicalguide/guideline_index/Acute_otitis_media/

Otitis Externa (Swimmer’s Ear) – Clinical Treatment Protocol

Overview:

Condition for treatment –Acute Otitis Externa (AOE) is defined as diffuse inflammation of the external auditory canal, which may also involve the pinna or tympanic membrane. It is most commonly caused by bacterial and/or fungal infection. The diagnosis of AOE requires the presence of a rapid onset (generally within 48 hours) coupled with signs of ear canal inflammation. Excess moisture in the external canal will elevate the PH level and remove protective cerumen.

Inclusion criteria -

 Adult and children ≥2 years;

 Acute onset of ear pain (otalgia);

 Tragus tenderness;

 External auditory canal is inflamed with erythema;

 Recent or present discharge (otorrhoea);

 Aural fullness;

 Itching,

 Decreased hearing.

Redirect to GP/NP if:

 Chronic Otitis Externa – history of recurrent ear infections or inflammation;

 Perforation of tympanic membrane from trauma or infection;

 Presence of grommet/s in the tympanic membrane;

 If fungal infection is suspected;

 Complex co-morbidities,

 When the auditory canal is occluded from inflammation with inability to instil medication drops effectively – a wick is required to aide in drop application.

Redirect to ED if:

 Mastoid tenderness may indicate mastoiditis.

 Malignant Otitis Externa – a potentially fatal complication of acute bacterial external otitis when the infection spreads from the skin to the skull base.

Differentials:

• Acute Otitis Media

• Otomycosis fungal infection of external canal

• infected hair follicle in canal

• Contact dermatitis of the ear canal

• Viral infections of the external ear

• Cholesteatoma

• Malignant external otitis Management or Treatment:

Recommendation

• Dry aural cleaning of the external ear canal - the removal of cerumen, desquamated skin and purulent material from the ear canal greatly facilitates healing and enhances penetration of ear drops into the site of inflammation. Do not syringe - use tissue spears or similar.

• Simple over-the-counter analgesia as recommended by pharmacist.

• Combination of steroid and antibiotic ear drops.

Advice:

• Recommend having a review of affected ear/s 5-7 days post onset of treatment.

• Earplugs or a shower cap while bathing or swimming should be used to prevent water entering the ear canal, which can cause a recurrence of the infection.

• The Client should be advised to avoid using cotton buds or fingertips to clear wax from the ear canal.

• Keep the ear/s dry for 2 weeks after treatment.

• Client Information Sheet – Swimmers Ear Infection Medication Standing Order:

• Paracetamol

• Ibuprofen

• Dexamethasone + Framycetin + Gramicidin References :

• Australian Medicines Handbook. (2017). https://amhonline.amh.net.au/

• Ghossaini, S., Roland, P.S., Wright, A., & Nunez, D.A. (2017). Otitis externa. British Medical Journal: Best practice.

• http://bestpractice.bmj.com/best-practice/monograph/40/highlights/overview.html

• Gogen, L.A. (2017). External Otitis: treatment. In D.G. Deschler, M.S. Edwards & D.J.

• Morris, P., Leach, A., Shah, P., Nelson, S., Anand, A., Allnutt, R., ... & Patel, H. (2011).

Recommendations for Clinical Care Guidelines on the Management of Otitis Media: In

Aboriginal and Torres Strait Islander Populations 2010.

Allergic Conjunctivitis – Clinical Treatment Protocol

Overview:

Condition for treatment – Allergic conjunctivitis is the inflammation of the conjunctiva, secondary to allergen exposure, and may be acute, seasonal or perennial.

Inclusion criteria -

 Uncomplicated allergic conjunctivitis, Redirect to GP/NP if:

 Condition is resistant to over-the-counter treatment options.

Redirection:

 Moderate to severe eye pain or pronounced photophobia;

 Papillae (cobblestone) found on upper eyelid eversion;

 Yellow-gray infiltrates across the limbus;

 Presence of ciliary injection,

 Reduced visual acuity.

Redirect Client to GP/ED as clinically indicated.

Community Optometrist may be an option.

Differentials:

• Infective conjunctivitis

• Irritant conjunctivitis (e.g. non-invasive foreign body; chlorine from swimming pool)

• Single red eye – beware acute glaucoma/keratitis/iritis

• Vernal or atopic keratoconjunctivitis

• Giant papillary conjunctivitis

• Dry eye syndrome

• Blepharitis

Management or Treatment:

Work-up

• Visual acuity should be assessed on all clients presenting with an eye complaint.

• If indicated by eye pain, the cornea should be examined for abrasions using fluorescein.

Treatment

• Antihistamine tablets, intranasal corticosteroids and/or saline eye drops may be enough to reduce the symptoms of allergic conjunctivitis. Antihistamine eye drops may be required if the other measures do not work.

• Client can place a flannel (soaked in cold water) over closed eyes.

Advice:

• The client should be advised, where possible, to avoid irritants such as pollens, house dust mites, cosmetics, dust or chemical exposure.

• Avoid rubbing eyes as it can make itchiness worse.

• If applicable, discontinue use of contact lenses until condition has resolved.

• Client information sheet – Allergic Conjunctivitis Medication Standing Order:

• Loratadine

• Carmellose 0.5% eye drops References :

• Australian Medicines Handbook https://amhonline.amh.net.au/

• National Institute for Health and Care Excellence: Clinical Knowledge Summary 2012

• Therapeutic Guidelines: https://tgldcdp.tg.org.au

• UpToDate: www.uptodate.com.au

Infective Conjunctivitis – Clinical Treatment Protocol

Overview:

Condition for Treatment : Infective conjunctivitis is the inflammation of the conjunctiva, secondary to an infective organism.

 Viral conjunctivitis: watery or mucoserous discharge. Mucoid discharge typically seen in lower tarsal conjunctiva

 Bacterial conjunctivitis: yellow, white, or green purulent discharge Inclusion criteria -

 Uncomplicated infective conjunctivitis.

Redirect:

 Moderate to severe eye pain or pronounced photophobia;

 Conjunctivitis that is resistant to treatment;

 Conjunctivitis associated with contact lens use;

 Profuse purulent discharge (suggestive of hyper-acute bacterial conjunctivitis);

 Papillae (cobblestone) found on upper eyelid eversion;

 Yellow-gray infiltrates across the limbus;

 Presence of ciliary injection;

 Reduced visual acuity;

 Known Keratoconus;

 Severe foreign body sensation that prevents the Client from keeping the eye open OR corneal opacity;

 Fixed pupil with severe headache and nausea,

 Peri-orbital swelling or erythema suggestive of cellulitis Redirect Client to GP/ED as clinically indicated.

Community Optometrist may be an option.

Differentials:

• Single red eye – beware acute glaucoma/keratitis/iritis

• Allergic conjunctivitis

• Giant papillary conjunctivitis

Management or Treatment:

Work-up

• Visual acuity should be assessed on all clients presenting with an eye complaint.

• If indicated by eye pain, or if history is suggestive of HSV infection, the cornea should be examined for abrasions/lesions using fluorescein.

• If history suggestive of a foreign body, evert the upper eyelid and examine for abnormalities.

Treatment

• Bacterial conjunctivitis is treated with chloramphenicol eye drops.

• Viral conjunctivitis can be treated using cold compresses.

Lubricant eye drops can be used for both types of infective conjunctivitis to help reduce discomfort.

Advice:

• The symptoms associated with conjunctivitis should resolve within 2-5 days; however symptoms may persist for as long as 2 weeks with viral conjunctivitis.

• It is important that discharge from the eyes is regularly washed away with warm water, using a new cotton wool ball or tissue to dry each eye.

• Conjunctivitis is infectious during the period that discharge is coming from the eyes.

Children should remain absent from school and childcare during this period.

• Washing hands regularly and not touching the infected eyes will help reduce the risk of infecting others.

• If applicable, client should not wear contact lenses until all symptoms and signs of infection have completely resolved and any treatment has been completed for 24 hours.

• Avoid sharing towels and pillow cases to prevent spreading of infection.

• Avoid contact sports and water-based sports until eye is no longer discharging.

• Client Information Sheet – Infective Conjunctivitis Medication Standing Order:

• Chloramphenicol 0.5%

References :

• Australian Medicines Handbook. Retrieved from: https://amhonline.amh.net.au/

• Jacobs, D.S. (2016). Conjunctivitis. In J. Trobe, H. Libman (Eds.) UpToDate. Retrieved

from:https://www.uptodate.com/contents/conjunctivitis?source=search_result&search=in

• National Health Service Institute for Innovation and Improvement: Clinical Knowledge Summaries 2015

• Therapeutic Guidelines. Retrieved from:

https://tgldcdp.tg.org.au/searchAction?appendedInputButtons=conjunctivitis

Dry Eye Syndrome – Clinical Treatment Protocol

Overview:

Condition for Treatment – Dry eye syndrome (also known as keratoconjunctivitis sicca) is the final common outcome of a number of different conditions which affect the tear film that normally keeps the eye moist and lubricated.

Inclusion criteria -

 Age ≥10 Redirect to GP/NP if:

 All Clients are to be referred to GP/NP once treatment has been initiated at the WiC.

Redirection:

 Moderate to severe eye pain or pronounced photophobia;

 Papillae (cobblestone) found on upper eyelid eversion;

 Presence of ciliary injection,

 Reduced visual acuity.

Redirect Client to GP/ED as clinically indicated.

Community Optometrist may be an option.

Differentials:

• Allergic/infective conjunctivitis

• Entropion

• Blepharitis

• Vernal or atopic keratoconjunctivitis

• Giant papillary conjunctivitis Management or Treatment:

Work-up

• Visual acuity should be assessed on all clients presenting with an eye complaint.

• If indicated by eye pain, the cornea should be examined for abrasions using fluorescein.

• If Client is a regular wearer of contact lenses, or if history suggestive of a foreign body, evert the upper eyelid and examine for abnormalities (e.g. papillae, foreign body).

• Assess for presence of risk factors, e.g. blepharitis, allergic conjunctivitis, rheumatoid

arthritis, Sjogren’s syndrome, SLE, dehydration, contact lens use, antihistamines, tricyclic

antidepressants, SSRIs.

Treatment

• Ocular lubricants should be used to manage the symptoms of dry eye.

Advice:

• Dry eye is a chronic condition that may be a symptom of an underlying, more complex condition.

• Avoid dry eye irritants such as dry windy conditions, air-conditioned environments, cigarette smoke, dust or chemical exposure.

• When outdoors the client should be encouraged to wear sunglasses to reduce the impact of wind and sun.

• Use a humidifier to moisten the air.

• Limiting the use of contact lenses if these cause irritation.

• Stopping non-essential medication that worsens the dry eye condition e.g. antihistamines.

• Cessation of smoking may help reduce dry eye symptoms.

• If using a computer for long periods, ensure that the monitor is at or below eye level. Take frequent breaks from the computer screen.

• Client Information Sheet – Dry Eye Syndrome Medication Standing Order:

• Carmellose 0.5% eye drops References :

• Australian Medicines Handbook https://amhonline.amh.net.au/

• National Health Service Institute for Innovation and Improvement: Clinical Knowledge Summaries 2012

• Therapeutic Guidelines https://tgldcdp.tg.org.au/etgAccess

Corneal Abrasion – Clinical Treatment Protocol

Overview:

Condition for treatment – Corneal abrasion refers to a defect in the epithelial surface of the cornea that is caused by mechanical trauma to the surface of the eye. Clients generally present with a history of trauma with tearing, sensitivity to light, and foreign body sensation. An abrasion may be found in the context of a penetrating injury, contusion, chemical burn, ‘Christmas eye’ or eyelid injury.

Inclusion criteria -

 Age ≥ 6,

 Superficial, uncomplicated corneal abrasion found on examination using fluorescein.

Redirection:

 Age < 6 with confirmed simple, uncomplicated abrasion;

 Large abrasion > 4mm;

 Significant eyelid swelling;

 Reduced visual acuity;

 Bilateral abrasions;

 Abrasion that has not healed after 3-4 days of treatment;

 Abrasion associated with contact lens use;

 Identified abrasion is dendritic;

 Presence of embedded foreign body;

 Protrusion of eyeball (proptosis);

 Double vision or impairment of eye movement;

 Pain not relieved by topical anaesthetic;

 Hyphaema;

 Corneal opacity;

 Pus in anterior chamber (Hypopyon);

 Purulent discharge accompanying corneal abrasion,

 Presence of facial/peri-orbital/orbital cellulitis.

Redirect Client to GP/ED as clinically indicated.

Community Optometrist may be an option.

Redirect to GP/NP if:

 Intolerance/allergy to chloramphenicol.

Redirect to ED if:

 Chemical/acid/alkali exposure (see relevant protocol);

 Penetrating injury/obvious open globe injury;

 Suspected embedded FB associated with high velocity injuries (e.g. grinding, lawn-mowing);

 Pupil irregular, dilated, or fixed;

 Client is systemically unwell,

 Central nervous system symptoms, e.g. drowsiness, vomiting, headache, seizure, or cranial nerve lesion.

Differentials:

• Herpes simplex/zoster (dendritic ulcer/s)

• Single red eye – beware acute glaucoma/keratitis/iritis

• Foreign body

• Infective conjunctivitis

• Subconjunctival haemorrhage Management or Treatment:

Work-up

• Take client thorough history – mechanism of injury, contact lens history, presence of systemic symptoms or facial/periorbital lesions.

• Visual acuity should be assessed on all clients presenting with an eye complaint.

• Instil tetracaine into affected eye as required.

• The cornea should be examined for abrasions using fluorescein.

• Evert the upper eyelid and examine for foreign body/lesion with magnification.

• Screen for associated injuries -

o Test the extra-ocular eye muscles by assessing eye movements in all directions.

o Assess eyelid position and function.

o Examine pupil size, shape, and reactivity to light.

• Upon completion of examination, if tetracaine has been used, patient to wear eye patch until anaesthesia has worn off.

Treatment

Advice:

• Most corneal abrasions will heal in 24-72 hours.

• See GP if condition not improving daily.

• Do not wear contact lenses until the corneal abrasion has completely healed and for 24 hours after finishing treatment with topical antibiotics.

• The eye will feel uncomfortable until the abrasion heals but should improve daily.

• Infection resulting from abrasion is rare.

• Recurrent abrasion may occur due to improper healing.

• Client Information Sheet – Corneal abrasion Medication Standing Order:

• Chloramphenicol

• Tetracaine (Amethocaine)

• Paracetamol

• Ibuprofen References :

• Jacobs, D. S. (2017). Corneal abrasions and corneal foreign bodies: Management. In J.

Trobe, R. G. Bachur, & J. F. Wiley (Eds.). UpToDate. Retrieved from:

http://www.uptodate.com/contents/corneal-abrasions-and-corneal-foreign-bodies- management

• National Institute for Health and Care Excellence: Clinical Knowledge Summary (accessed June 2015)

• Therapeutic Guidelines. Retrieved from: http://online.tg.org.au/ip/desktop/index.htm

• Wipperman, J. L., & Dorsch, J. N. (2013). Evaluation and management of corneal

abrasions. American family physician, 87(2).

Stye (Hordeola) – Clinical Treatment Protocol

Overview:

Condition for treatment – A Stye is an acute, localised abscess situated on the eyelid. An external Stye is situated on the eyelid margin and is caused by infection of an eyelash follicle. An internal Stye occurs on the conjunctival surface of the eyelid and represents an infection of a Meibomian gland.

Inclusion criteria -

 Uncomplicated Stye.

Redirection:

 Moderate to severely painful external Stye – for consideration of epilating the eyelash from the infected follicle or incising and draining;

 Stye is persistent and not responsive to conservative treatment;

 Stye has an atypical appearance or reoccurs in the same location;

 Protrusion of eyeball (proptosis);

 Double vision or impairment of eye movement;

 Reduced visual acuity;

 Reduced light reflexes;

 Presence of peri-orbital (preseptal)/orbital cellulitis,

 When a full eye examination is not possible.

Redirect Client to GP/ED as clinically indicated.

Community Optometrist may be an option.

Redirect to GP/NP for:

 Treatment of any underlying condition such as blepharitis or acne rosacea which may predispose individual to developing Stye’s.

Redirect to ED if:

 Client is systemically unwell,

 Central nervous system symptoms such as drowsiness, vomiting, headache, seizure, or cranial nerve lesion.

Differentials:

• Meibomian cyst

• Dacryocystitis

• Herpes zoster/simplex

• Orbital cellulitis

• Preseptal cellulitis

• BCC/SCC

• Rosacea

Management or Treatment:

Work-up

• Visual acuity should be assessed on all clients presenting with an eye complaint.

• If indicated by eye pain, the cornea should be examined for abrasions using fluorescein.

• Evert the upper eyelid if history suggests a foreign body or Stye appears to be internal.

Treatment

• Apply a warm compress to the affected eye for 5-10 minutes. Repeat 3-4 times daily until the Stye drains or resolves. Clean flannel rinsed in hot water can be used. Avoid excessively hot compresses which may cause scalding.

• Assuming the eye is normal and the abscess pointing, gentle expression with cotton buds may be attempted after instilling Tetracaine.

Advice:

• Reassure client that Stye’s are self-limiting and rarely cause serious complications. Drainage and resolution tends to occur within 5-7 days.

• Advise that attempts should not be made to puncture the Stye.

• Client to see GP about managing any blepharitis to reduce the risk of future episodes.

• Suggest paracetamol or ibuprofen to relieve pain if required.

• If symptoms become worse or does not resolve within the expected timeframe, client to see a GP.

• Occasionally an internal Stye can develop into a Meibomian cyst.

• Avoid using contact lenses and eye make-up until the Stye has healed.

• Topical antibiotics are not recommended.

• Client Information Sheet – Stye Medication Standing Order:

• Paracetamol

• Ibuprofen

References :

• National Institute for Health and Care Excellence: Clinical Knowledge Summary. (2010).

• Therapeutic Guidelines - http://online.tg.org.au/ip/desktop/index.htm

Non-Invasive Foreign Body (FB) of the Eye – Clinical Treatment Protocol

Overview:

Condition for Treatment: This protocol is for non-invasive foreign bodies of the eye.

Inclusion criteria :

 Uncomplicated non-invasive foreign body of the eye Redirect if:

 Presence of embedded foreign body in eye (consider optometrist as another option);

 Moderate to severe eye pain or pronounced photophobia;

 Irregular shaped pupil;

 Presence of ciliary injection;

 Reduced visual acuity,

 Hyphaema present.

Redirect Client to GP/ED as clinically indicated.

Community Optometrist may be an option.

Differentials:

• Corneal abrasion

• Embedded foreign body

• Dry eye syndrome

• Flash burns

Management or Treatment:

Work-up

• Visual acuity should be assessed on all clients presenting with an eye complaint.

• Instil Tetracaine into affected eye if necessary.

Upon completion of examination, if Tetracaine has been used, patient to wear eye patch until anaesthesia has worn off.

Treatment

For multiple particles (e.g. sand):

• First, attempt irrigation with saline or water.