Objective and Subjective Data
In order to determine a presumptive nursing diagnosis, it is necessary to collect and document all subjective and objective data that can be obtained from a patient. Accurate physical assessment, medical history, laboratory data, and verbal reports from either the patient or their friend are the primary sources of such data (Herdman & Kamitsuru, 2014). In order to make a correct judgment about the patient’s clinical status and create a presumptive nursing diagnosis, it is necessary to carefully consider both subjective and objective data available at the moment.
Therefore, the following objective data will be taken into consideration during the process of diagnosing Jessica: the patient contracted “chickenpox at age 10 and a tonsillectomy/adenoidectomy at age 11″, the patient’s father suffers from coronary artery disease, the patient’s mother has hypertension, BP 135/85 mm Hg, HR 64bpm and regular, RR 16 per minute, T: 98.5F, Visual acuity 20/200 in the left eye and 20/30 in the right eye, the patient’s sclera is white, conjunctivae clear, the patients is alert and appears to be anxious, the patient is unable to assess visual fields in the left side, “pupil response to light is diminished in the left eye and brisk in the right eye, the optic disc is swollen, full range of motions, mental status: oriented x 3, cranial nerves: I-XII intact, horizontal nystagmus is present” (Case Study, n.d.). The following objective data will be considered in order to determine a presumptive nursing diagnosis: monocular vision loss, the patient denies any traumatic head injury, the symptoms worsened time, the patient experienced a blurring of visual field a month ago, inability to differentiate colors, self-reported smoking cessation, the patient denies substance abuse (Case Study, n.d.).
Nursing Care Plan
Diagnosis
Disturbed Sensory Perception: Visual
Definition
Change in the number of incoming stimuli accompanied by diminished visual acuity as a result of a lessened response to such stimuli (Ralph & Taylor, 2011).
Assessment
- History of coronary artery disease and hypertension in the family;
- Visual status including extraocular movement, inspection, and palpation of lid and eyeball, visual acuity, and confrontational visual field test (Ralph & Taylor, 2011);
- Age;
- Medication;
- Ocular history;
- Behavioral assessment (Ralph & Taylor, 2011).
Defining Characteristics
- Reported change in visual acuity;
- The measured change in visual acuity;
- Decrease in peripheral vision;
- The diminished response of the left pupil to light;
- The optic disc in the left eye is swollen;
- Associated ocular complaints (Ralph & Taylor, 2011).
Expected Outcomes
- The patient will be able to “discuss the impact of vision loss on lifestyle” (Ralph & Taylor, 2011, p. 294);
- The patient will either regain visual functioning or be able to accept vision loss (Ralph & Taylor, 2011);
Interventions and Teaching Plan
- Provide the patient with an avenue for expressing her feelings about blurred vision;
- Provide the patient with a clear explanation of all assessment procedures and treatments while minimizing the use of medical terms in order to avoid information overload (Ralph & Taylor, 2011);
- Encourage the patient to consider alternative ways of coping with partial vision loss;
- Provide the patient with information on the following ways of coping with partial vision loss: eyeglasses, contact lenses, artificial eye, or other adaptive devices (Ralph & Taylor, 2011).
Evaluations for Expected Outcomes
- The patient is able to discuss various aspects of vision loss on her life;
- The patient regains the normal functioning of the left eye or starts to accept the results of vision loss (Ralph & Taylor, 2011).
References
Case Study. (n.d.).
Herdman, T., & Kamitsuru, S. (2014). NANDA International: nursing diagnoses. New York, NY: John Wiley & Sons Inc.
Ralph, S., & Taylor, C. (2011). Sparks & Taylor’s nursing diagnosis reference manual (1st ed.). Philadelphia, PA: Lippincott Williams & Wilkins.