After gathering the necessary information about the health condition and the patient’s problems, a nurse can define the presumptive nursing diagnosis, which provides details of the specific symptoms of the disease and determines the patient’s problems. The presumptive nursing diagnosis is required to provide detailed information on the patient’s difficulties, both existing and potential ones. The nursing diagnosis should state the obvious patient difficulties that represent the body’s response to external factors, including the development of the disease.
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It should be noted that several physical findings should be obtained to determine the most precise diagnosis. For instance, the patient’s comprehensive medical history, including the CC, HPI, ROS, FH, SH, PMH, and medications, needs to be investigated (Doenges & Moorhouse, 2012).
As per the description, Jessica has the chief complaint. The patient claimed to have a sudden worsening of vision in the left eye with no prior injuries. She had an obvious worsening in the vision for several hours and had pain when moving her left eye. Additionally, the patient claimed to be incapable of determining colors. As per an examination, the patient was anxious; the visual acuity in the left eye was 20/200. The woman could not assess the visual fields on the left side; the pupil’s responsivity to light examination was reduced in the left eye. The optic disc was bloated, and the horizontal nystagmus was present. It can be diagnosed that the patient has Disturbed Visual Sensory Perception (Swearingen, 2015). The patient has left eye organ alterations and altered sensory reception, as evidenced by the nursing check. The patient had altered sensory acuity. Also, Jessica can be diagnosed with Anxiety. This diagnosis is defined by psychological factors. The patient experiences stress related to the change in health condition, pain, and the fear of losing vision.
The nursing care plan for the patient includes nursing interventions, expected outcomes, and evaluations. Firstly, cognitive stimulation and environmental management are crucial interventions. The nurse should help the patient-oriented to time and space. The nurse should ensure the patient’s access to relevant means and devices (Gulanick & Myers, 2013). It is crucial to refer the woman to the ophthalmologist and continuously check all the patient’s health status and emotional needs. The nurse shall evaluate how well the patient can meet the expected outcomes and provide support throughout treatment.
Regarding the teaching plan, the nurse should teach the patient how to use the devices to resolve vision problems. Further, the woman should be taught how to use the appropriate lighting and methods to enhance the reading skills and so on (Gulanick & Myers, 2013). Also, Jessica should be informed about the low-vision clinics and other healthcare institutions aimed at providing help in the cases similar to hers.
The presumptive nursing diagnosis cannot and should not be considered final, and it should be adjusted during the disease and treatment. Special attention should be paid to the moods of the patient who may be experiencing the disease’s influence. Thus, the nurse must consider if the patient is in an altered mental state or has some deviation from the behavioral norm. When deciding upon the presumptive diagnosis, it is important to consider the changes in a patient’s body reaction and to provide such nursing interventions in the plan of care, which implies the actual professional competence of nurses.