History and Physical Examination
Jessica has come to the emergency room with a complaint about the decrease of vision in the left eye. She qualifies the decrease as sudden; it started in the morning of the day of her visit, and the vision continued to decrease for several hours; Jessica denies any traumas or injuries that could cause vision problems. Approximately one month before her visit, the patient experienced blurred vision, which she links to being overheated due to sunlight exposure; her vision was back to normal once she reached an air-conditioned setting. Jessica claims it painful to try to move her left eye, but there is no constant pain when the eye is at rest. Also, the patient cannot determine colors.
The patient is 32 years old and has no history of chronic disease or hospitalization. Her state can be assessed as healthy. The history of the disease includes chickenpox when she was ten; the surgical history includes tonsillectomy/adenoidectomy when she was 11. Apart from the decreased vision in the left eye, Jessica presents no other complaints and does not report any medical problems. The patient is a mother of four; all the deliveries were vaginal.
Jessica used to be a smoker and consumed two packs every day for five years, but she quit ten years ago. She drinks wine occasionally and denies the use of any illegal drugs. Her family history includes her father’s coronary artery disease (and his surgery for placing a stent when he was 67) and her mother’s hypertension. Jessica is a math teacher; she holds a bachelor’s degree in mathematics and a master’s degree in education. Her lifestyle does not suggest exposures that could cause the decrease of her vision; she denies recent contacts with chemicals; she was also unable to determine factors that have improved or deteriorated her current condition.
During her examination, Jessica appeared anxious. Her blood pressure is 135/88 mm Hg; heart rate is 64 bpm, regular; the respiratory rate is 16 bpm; temperature is 98.5 F. Visual acuity is 20/200 in the left eye and 20/30 in the right eye; her sclera is white, and her conjunctivae are clear. Visual fields in the left eye could not be assessed; pupil response in it is diminished; the optic disk is swollen; the full range of motions is observed; no deformity was detected. Muscles’ bulk and tone are normal; the finger-to-nose test results are normal; Romberg’s test results are negative. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achilles tendons; negative Babinski sign.
Nursing Diagnosis
Physical findings that will help determine nursing diagnoses are those related to the patient’s psychological state and her planned interaction with the environment in which treatment will be provided. In the presented case, a major piece of findings is the disturbing visual perception due to a sudden decrease of vision in one of the eyes (Pitts & Mitchell, 2013). Another important result of the examination is that the patient is anxious due to the alteration of sensory perception (Gordon, 2014).
Nursing Care Plan and Teaching Plan
One of the main goals of nursing care provided to Jessica is preventing complications that may arise from the decrease of her vision and ensuring that her state is not worsened. Another goal is to deal with her anxiety. A major component of achieving both goals is a teaching plan that could effectively help the patient cope with the limitations of her vision and the anxiety associated with them (Gordon, 2014). The nursing care plan and the teaching plan should be based on practical advice concerning managing various environments without complications from the decrease of vision and on emotional support from nursing care providers that are needed to prevent depression or other possible negative effects of altered sensory perception.
References
Gordon, M. (2014). Manual of nursing diagnosis (13th ed.). Burlington, MA: Jones & Bartlett Learning.
Pitts, J., & Mitchell, S. J. (2013). Vision and eye disorders. In K. T. Palmer, I. Brown, & J. Hobson (Eds.), Fitness for Work: The Medical Aspects (pp. 174-195). Oxford, UK: Oxford University Press.