Comprehensive History and Physical Examination
Name: Ms. Jessica Gonzalez
Chief Complaint: “My left eye hurts. When I woke up this morning, I noticed that my vision was poor because I could see almost nothing with my left eye, and it is getting worse now.”
History of Present Illness: The patient is a 32-year-old female who presented to the unit with decreased left eye vision. She did not have any cases of trauma, but she experienced the same deterioration in the eyesight a month ago. She started feeling better when being in a cool environment. She cannot determine colors, and the left eye hurts when the woman tries to move it. She has not been exposed to any chemical elements.
Past Medical History: Chickenpox – at 10. Tonsillectomy – at 11. Patient’s father – coronary artery disease (has a stent); mother – hypertension.
Personal and Social History: Has a bachelor’s and master’s degree. Quit smoking 10 years ago; claims no drug use; drinks wine occasionally.
Review of Systems
- General: Alerted; anxious.
- Skin: No complaints; no evident problems.
- Head and Neck: No complaints; no history of illnesses.
- Eyes: A sudden decrease in eyesight in the left eye (Gulanick & Myers, 2016). The condition is deteriorating. Pain in the left eye when moving it. Cannot determine colors.
- Ears, Nose, Throat, and Mouth: No complaints or problems observed.
- Lymphatic System: No problems; no tenderness.
- Chest and Lungs: No coughing or whizzing; no complaints.
- Brest: No masses; no complaints; no tenderness.
- Heart and Blood Vessels: No edema; no complaints.
- Gastrointestinal and Endocrine System: No complaints; no problems during observation.
- Genitourinary System: No pains; no complaints.
- Musculoskeletal System: No complaints; no pain. Full range of motion.
- Nervous System: Normal; visual perception complaints (Ferri, 2014).
- General: The patient is a white female. Answers questions appropriately. The woman is not in a state of intoxication.
- Mental Status: Alert and oriented; answers appropriately. Appears normal.
- Skin: No problems observed. Skin is normal with normal hair distribution (Ferri, 2014).
- Head: No problems observed.
- Eyes: Visual acuity. The right eye – 20/30. The left eye – 20/200. Cannot determine colors. Left eye pupil – poor reaction to light (swollen optic disc); right pupil – normal.
- Ears: No masses; no complaints.
- Nose: Mucosa – normal; no problems observed.
- Throat and Mouth: No lesions or problems observed; no complaints.
- Neck: No lesions or problems.
- Chest & Lungs: Normal respiration. Lungs are symmetric. No issues observed.
- Breast: No lesions or masses.
- Heart: BP – 135/85 mm Hg; HR – 64bpm and regular.
- Abdomen: No masses; no tenderness. Bowel sounds in all four parts.
- Musculoskeletal System: Full ROM (Ferri, 2014). No complaints.
- Neurologic System: Oriented x 3. Cranial nerves: I-XII intact; horizontal nystagmus is present. Muscles with normal bulk and tone; Normal finger to nose, negative Romberg. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achilles tendons; no Babinski.
Presumptive Nursing Diagnosis
To determine the presumptive nursing diagnosis, a specialist needs to specify the subjective and objective patient data. The subjective data includes the patient’s complaints about the loss of vision, pain in the left eye, and description of symptoms. The objective data implies visual acuity decrease (left eye – 20/200), and the fact that the patient cannot evaluate the color fields. In addition, pupils are not equally reactive to light, and the disc is bloated.
Other systems function normally. Based on the data, the patient presumably has Optic Neuritis and anxiety linked to her decreased health status (Gulanick & Myers, 2016). The optic nerve inflammation supposedly causes the described symptoms and the decrease in vision influences the patient’s psychological well-being.
Nursing Care Plan and Patient Teaching
Due to the disturbed visual sensory perception patient might experience other health-related problems such as increased anxiety, feeling of hopelessness, and other negative manifestations; therefore, it is necessary to determine the essential patient education in the plan of treatment. The nursing plan of care should concentrate on the prevention of further deterioration in a patient’s eyesight. Apart from that, it will ensure averting other health complications.
To meet these nursing care plan objectives, it is necessary to provide patient teaching. The main aim of this intervention is to educate the woman on how to manage the current limitation in visual perception. The patient should sleep and rest more. In addition, the woman should be prescribed medication to relieve pain. Importantly, it is crucial to instruct the individual to rearrange furniture and light in her dwelling to ensure a safer environment (Yanoff & Sassani, 2014). Moreover, the patient should be instructed to turn to the physician’s office as soon as possible if the symptoms become worse or new issues appear.
Ferri, F. F. (2014). Ferri’s clinical advisor 2015: 5 books in 1. New York, NY: Elsevier.
Gulanick, M., & Myers, J. L. (2016). Nursing care plans: Nursing diagnoses, interventions, and outcomes (9th ed.). New York, NY: Elsevier.
Yanoff, M., & Sassani, J. W. (2014). Ocular pathology (7th ed.). New York, NY: Elsevier.