A nurse should determine the presumptive nursing diagnosis that furnishes details of the concrete symptoms of the illness and defines the patient’s problems. It is defined after collecting the essential information about the health condition and the personal data of the patient. The suppositional nursing diagnosis is required to give detailed information on the health status of the individual and specify the current and potential difficulties of the patient. It should define the obvious physical and psychological indicators that represent the body’s response to external triggers as well as reflect on the course of the disease development.
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It is essential to examine and analyze the physical findings to define the presumptive nursing diagnosis. Such aspects of the comprehensive medical history as FH, SH, PMH, CC, HPI, ROS, medications and other should be investigated to obtain an overview of the patient’s medical history and background (Ackley & Ladwig, 2014). Regarding the current patient, the woman is 32-years-old, she is normally healthy, has four children, leads a normal lifestyle (no drug or substance abuse), and she denies to have any of the diseases listed in the medical checklist.
However, as per the information and data presented to the ER, Jessica has the chief complaint. The patient affirms to have a sudden worsening of vision in the left eye, though she has not been injured in any way. The woman claims to have pain when moving her left eye and she has had an obvious worsening in vision during several hours. According to the description, the patient is incapable of defining colors. During the course of the examination, Jessica seems to be anxious. As per the eye check, the visual acuity in the left eye is 20/200 compared to 20/30 in the right eye. The patient cannot assess the visual fields in the left side; additionally, the pupil responsivity to light examination is reduced in the left eye. The optic disc is bloated, the I-XII intact but the horizontal nystagmus is present. The patient is diagnosed of the Disturbed Sensory Perception (visual) due to left eye organ alterations as well as altered sensory reception as evidenced from the nursing check (Gordon, 2010). Further, the woman has altered sensory acuity. In addition, Jessica is diagnosed with Anxiety evidenced by the psychological reaction to health factors. The patient experiences stress related to the diminishing health status, pain in the eye, and the fear of losing eyesight.
The plan of care provision for this patient will include several nursing interventions and evaluations. In terms of cognitive stimulation, the patient should be oriented to time and space; whereas regarding the environmental management, she should be provided with the access to the supportive means and devices (Hickey & Brosnan, 2012). Jessica should be referred to the ophthalmologist, and the nurse has to check continuously all the changes in the patient’s health status and emotional wellbeing.
In terms of the teaching plan, most importantly, Jessica should be informed about the low-vision clinics and healthcare institutions aimed at providing help in the cases similar to hers. Further, she will be instructed in using the appropriate lightning and methods to boost the reading skills (Hickey & Brosnan, 2012). The patient will be taught to use the means and devices that will help to resolve her vision problems.
The purpose of the presumptive nursing diagnosis is to identify the health problems that the patient experiences. The nurse should gather the information about the patient’s health status and personality, as well as his or her comprehensive medical history. The nursing assessment of the patient’s condition is a continuous, systematic process that requires the observational and communication skills; nevertheless, it cannot substitute the doctors’ assessment but serves as a platform for it. The presumptive nursing diagnosis should be adjusted during the course of the disease and treatment and should consider the moods of the patient who may be experiencing the influence of the disease. The nurses should reflect such nursing interventions in the plan of care, which imply their actual professional.
Ackley, B., & Ladwig, G. (2014). Nursing diagnosis handbook. New York, NY: Elsevier.
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Gordon, M. (2010). Manual of nursing diagnosis. Burlington, MA: Jones & Bartlett Learning.
Hickey, J., & Brosnan, C. (2012). Evaluation of health care quality in advanced practice nursing. New York, NY: Springer.