Assessment
To get better involved in the issue, defining characteristics, namely subjective and objective data should be examined. Subjective data – The client claimed that she experienced a sudden decrease in vision in her left eye.
Objective data – blood pressure: 135/85 mm Hg; heart rate: 64bpm and regular; respiratory rate: 16 per minute, Temperature: 98.5F. Visual acuity (left eye): 20/200 Visual acuity (right eye): 20/30
Diagnosis
The diagnosis is Optic Neuritis. Optic Neuritis is an inflammatory process that results in a decline of vision. In the vast majority of cases suffers only one eye. The optic disk can be swollen. Optic Neuritis is accompanied by the formation of certain autoimmune diseases (Weiner & Stankiewicz, 2012).
Depending on the level of damage to the nerve fibers, the degree of inflammation, and its location, the patient will experience the symptoms better or worse.
The onset of this eye disease can be provoked by multiple sclerosis (Rae-Grant, Fox, & Bethoux, 2013). There is the loss of the myelin covering the nerve cells not only in the brain but also in the spinal cord. The disease affects the immune system as well. People, who suffer from optic neuritis, are in the risk zone as they consequently may have multiple sclerosis.
The fact that the patient feels worse in the hot environment, however, in the room with the air-conditioning she feels better proves that she has optic neuritis. As the vast majority of clients have the same symptom (Filippi & Simon, 2014).
In addition, the patient is not able to determine colors. People with optic neuritis claim that the colors fade to become brighter, sometimes they are unable to distinguish colors. The fact that the patient has pain while moving an eye is also the symptom of the stated disease.
Planning
There are short term and long-term goals that should be taken into consideration. Short term goal – the patient will not experience pain while moving her eye. The blurring will be reduced to the minimum. Long-term goals – the patient will be able to determine colors, the vision of the left eye will be improved, the pupil will respond to light.
Intervention
Diagnostic
The diagnosis of optic neuritis includes a detailed survey on concomitant diseases and conditions that could lead to an inflammatory process in the optic nerve. Visual acuity tests and visual field tests are essential to be taken into consideration.
Treatment
- Provide the patient with appropriate care.
- Educate the client regarding the peculiarities of disease and possible treatment.
- It is beneficial for the treatment process to establish the cause of neuritis and nerve inflammation. Unfortunately, in the vast majority of cases, it is almost impossible to establish the cause.
- Provide the client with assistance.
Evaluation and Teaching Plan
Short term goal
As a matter of fact, the short term goal was achieved as the patient noticed that she does not experience pain while mowing her eye. After a week of treatment, the client stated that the vision of the left eye was improved, and blurring was reduced to the minimum. However, she stated that when she drinks hot coffee or feels too hot in the room, she still has trouble with vision. The prescribed treatment improves the health status of the patient.
Long-term goal
As a result of the treatment process and assistance, the client shows better results in visual tests. The long-term goal was met. The patient recovers faster than was expected previously. Moreover, the client noted that she had no pain in the eye, and the vision of the left eye improved significantly. After the same tests that were performed earlier, the conclusion can be drawn that the treatment worked and improved the vision. Nevertheless, further monitoring is needed to eliminate the chances of multiple sclerosis.
The patient should get appropriate support and be provided with the essential knowledge needed to eliminate the risk of relapse.
References
Filippi, M., & Simon, J. (2014). Imaging acute neurologic disease: A symptom-based approach. Cambridge, UK: Cambridge University Press.
Rae-Grant, A., Fox, R., & Bethoux, F. (2013). Multiple sclerosis and related disorders: Clinical guide to diagnosis, medical management, and rehabilitation. New York, NY: Demos Medical.
Weiner, H., & Stankiewicz, J. (2012). Multiple sclerosis: Diagnosis and therapy. Chichester, UK: Wiley-Blackwell.