Comprehensive History
The patient is a 32-year-old teacher of mathematics. She complains of a sudden decrease of vision in the left eye.
Review of Systems
- General: Anxious and alert.
- Skin: Clean
- Head and Neck: No complaints of headaches or neck pain or stiffness.
- Eyes: sudden reduction of vision in the left eye which appeared this morning after awakening and got worse within a couple of hours. Denies any trauma or injury. The patient had some blurring of her vision one month ago. She connects this case with overheating. The eye hurts when she tries to move it. Also, a patient cannot determine colors. The patient does not experience tearing, redness, or exposure to any chemicals.
- Ears, Nose, Throat, and Mouth: No evidence of ear pain, hearing loss, or sinus congestion. No mouse soreness or coughing.
- Lymphatic System: No node enlargement or tenderness detected.
- Chest and Lungs: No chest pain, shortness of breath, or cough.
- Breast: No pain or tenderness.
- Heart and Blood vessels: No complaints.
- Gastrointestinal and Endocrine System: The patient does complain of abdominal pain, vomit, polydipsia, or polyphagia.
- Musculoskeletal System: No complaints of muscular pain, joint stiffness, or restriction of movements.
- Nervous System: No complaints.
Physical Examination
- General: The patient is alert and anxious. The measurements reveal BP 135/85 mm Hg; HR 64bpm and regular, RR 16 per minute, T: 98.5F.
- Mental Status: Patient is alert, oriented in time, place, and person
- Skin: Clean, no change in color or rash.
- Eyes: Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Cannot assess visual fields on the left side; visual fields on the right eye are intact. Pupil response to light is diminished in the left eye and brisk in the right eye. The optic disc is swollen.
- Ears: No lesions or pain.
- Nose: No deformities.
- Throat and Mouth: No pain or lesion.
- Chest & Lungs: Lungs are clear. Respirations rate – 16 per minute.
- Breast: Symmetric, no lesion.
- Heart: BP 135/85 mm Hg; HR 64bpm and regular.
- Abdomen: Flat, no pain.
- Musculoskeletal System: Muscles with normal bulk and tone. No deformity.
- 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.
Nursing Diagnosis
One of the nursing diagnoses for Jessica is anxiety (“NANDA International,” 2015). It is connected with coping responses and could be provoked by the sudden vision loss.
Another nursing diagnosis is connected to self-concept. It is hopelessness (“NANDA International,” 2015). This condition developed due to the unexpected start of the disease and unknown outcomes.
Nursing Care Plan
Nursing care plans for patients with partial vision impairment should include actions that will help the patient orient in surroundings (Krisna, 2013). Attention should also be concentrated on a patient’s emotional condition. The patient with a sudden loss of vision can feel anxious and depressed. Thus, a nurse should provide the necessary assistance and support.
Teaching Plan
The educational component of nursing intervention includes teaching the patient to manage visual impairment. A nurse should explain the patient’s peculiarities of behavior during the process of treatment which includes enough sleep to provide rest to the eyes. A nurse can help to organize the patient’s room to avoid trauma. Finally, it is necessary to inform a patient of the diagnosis, medications to take, and possible side-effects. If the patient can be treated at home, a nurse should inform her of the necessary measures which should be taken to prevent home accidents due to partial vision impairment.
References
Krisna, M. (2013). Disturbed sensory perception. Web.
NANDA International. (2015). NANDA nursing diagnosis list 2015-2017. Web.