Comprehensive History and Physical Examination
Name: Jessica
Age: 32
Complaint: The patient’s vision has been dropping significantly in her left eye, with significant pain accompanying the problem.
History of the illness: The patient claims that she has been experiencing a drop in her left eye vision since morning. Jessica has also been feeling pain around the eye. No physical trauma has occurred to the eye. However, Jessica experienced blurred vision a month ago due to the prolonged exposure to excessive heat. However, since the problem vanished after the patient changed the environment to a cooler one, no medical assistance was sought.
History: the patient had chickenpox at the age of ten. She was also administered tonsillectomy at eleven. Jessica has been socially active and academically successful. The patient has no bad habits.
Physical Findings for a Presumptive Nursing Diagnosis
All systems of the patient’s body (skin, lymphatic system, ears, nose, and throat, etc.) have shown to have no deviation from the norm. A significant drop in the left eye, however, was noticed and confirmed. The patient’s current emotional state can be defined as alert and anxious, The vital signs of the patient are within the acceptable range (BP 135/85 mm/Hg; HR 64 bpm and regular, RR 16 per minute, T: 98.5 F). The examination of the eyes shows that the visual acuity has dropped greatly in the left eye (20/200), whereas the right eye showed regular results (20/30). The patient’s sclera is white, and the conjunctivae are clear. The response to light is regular in the right eye yet reduced in the left one. The visual fields on the left side are inaccessible.
The information retrieved in the course of the ophthalmological examination will be used as the foundation for a preemptive diagnosis. Particularly, the drop in the patient’s visual clarity, the responsiveness of the left-side visual fields, and the drop in the response to the light in the left eye will be used as the basis for the preemptive diagnosis.
Nursing Care Plan and Teaching Plan
Diagnosis
Based on the information retrieved in the course of the examination, the patient has developed optic neuritis (ON). The disease is defined as the inflammation of the optic nerve and, therefore, affects the process of transmitting the visual information to the patient’s brain, hence the blurred vision. It should be borne in mind that, when unattended, ON may lead to the development of multiple sclerosis, as well as indicate the development of immune disease in the patient. Therefore, well-thought-out nursing and patient teaching plans are required. Furthermore, the patient is suffering from anxiety that needs to be addressed accordingly (Perez-Cambrodia, Cubillana, Merino-Suarez, Pinero-Llorens, & Laria-Ochaita, 2014).
Intervention
The exposure to light should be restricted for the patient. Furthermore, steroid therapy should be viewed as the means of recovering Jessica’s vision. Pain medication will also be administered. To address the current anxiety issues, one should consider the intervention based on Cognitive Behavior Therapy (particularly, Acceptance and Commitment Therapy) (Hayes & Strosahl, 2013). As a result, Jessica will be able to develop a coping strategy that will help her deal with the temporary vision loss and acquire the knowledge and skills necessary for developing patient independence. As a result, the patient will gain confidence and develop a positive approach toward the treatment process.
Assessment
The patient’s progress will be assessed based on the improvements in her ability to see, as well as the skill of adopting the necessary coping strategies to manage stressful situations.
References
Hayes, S. C., & Strosahl, K. D. (2013). A practical guide to acceptance and commitment therapy. New York, NY: Springer Science & Business Media.
Perez-Cambrodia, R. J., Cubillana, A. G. H., Merino-Suarez, M. L., Pinero-Llorens, D. P., & Laria-Ochaita, C. L. (2014). Optic neuritis in pediatric population: A review in current tendencies of diagnosis and management. Journal of Optometry, 7(3), 125-130. Web.