evaluation of sudden decrease of vision in the left eye
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Instructions:
Make a whole history and physical examination in a comprehensive manner with all its elements included: CC, HPI, PMH, FH, SH, MEDICATIONS, ALLERGIES, ROS PER APPARATUS OR SYSTEMNS, HEAD TO TOE PHYSIACL EXAMINATION PER SYSTEMS ( write your presentation in H&P format no paragraph format).
Based on this information, what is your presumptive nursing diagnosis? All nursing diagnosis that apply to the case (Minimum 3) written in NANDA format related to … and evidence by…., NO MEDICAL DIAGNOSIS.
Teaching plan and nursing care plan per each nursing diagnosis on this case.
Requirements.
1- All written assignment and documentations must be in APA 6th edition format.
2- Double spaces, minimum 4 pages long , minimum 3 up to date bibliography. (UP to date means last 3 years.), Note: you can use your test book as bibliography too, bibliography have to be written in APA format.
Case Study II
Jessica is a 32 y/old math teacher who presents to the ER with a friend for evaluation of sudden decrease of vision in the left eye. She denies any trauma or injury. It started this morning when she woke up and has progressively worsened over the past few hours. She had some blurring of her vision 1 month ago and thinks that may have been related to getting overheated, since it improved when she was able to get in a cool, air-conditioned environment. She has some pain if she tries to move her eye, but none when she just rests. She is also unable to determine colors. She denies tearing or redness or exposure to any chemicals. Nothing has made it better or worse.
She is normally healthy. She had chickenpox at age 10 and a tonsillectomy/adenoidectomy at age 11. She has no medical problems. She has never been hospitalized. She has four children, all spontaneous vaginal deliveries. She completed a bachelor’s degree in mathematics and a master’s degree in education. She quit smoking 10 years ago (two packs daily for 5 years); she drinks an occasional wine cooler, and she denies illicit drug use. Her father has a coronary artery disease (he had a stent placed at age 67) and a mother with hypertension.
She denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia.
Patient is alert; she appears anxious. 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. Sclera white, conjunctivae clear. Unable to assess visual fields in 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. Full range of motions; no swelling or deformity. Mental status: 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 Achiles tendons; no Babinski.
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Running Head: DISCUSSION WEEK 14
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Running Head: DISCUSSION WEEK 14
Discussion Week 14
Physical Assessment in Healthcare
Daylamis Gonzalez
Florida National University
Name: Jessica Date 11/28/2017
DOB: 11/11/1985 Tine 11:47 AM
Age 32 Sexo Female
Address 1245 west 47 st Hialeah Florida 33012 Ethics Hispanic
Nationality Cuban Occupation Math teacher
Allergies NDKA
Marital status
What is your highest education? Bachelor’s degree in mathematics and a master’s degree in education
Medications that you are now taking No
PAST MEDICAL HISTORY
Paralysis No
Smoking Quit smoking 10 years ago (two packs daily for 5 years)
Alcohol Occasional wine cooler
Previous Surgery Tonsillectomy/adenoidectomy at age 11
Chronic Health Condition No
Children 4
C-section No Vaginal Delivers 4 Abortions No
Epilepsy No Stroke No Chickenpox Yes Rubella No
Asthma No Lupus No Cancer No Diabetes No Cardiac Disease No
Kidney Disease No Hemophilia No Hypertension No GI Disease No
Herpes No HIV No Syphilis No Hepatitis No
If any of the answers is yes, explain: chickenpox at age 10
FAMILY HISTORY
Mother Hypertension
Father Coronary artery disease (he had a stent placed at age 67)
EXTENDED FAMILY PSYCHIATRIC PROBLEMS PAST & PRESENT:
Maternal relatives N/A
Paternal relatives N/A
Assessment
BP 135/85 mm/Hg HR 64 BPM Temp 98.5°F Resp 16 breath for min Pain 0
Nursing Note
Patient come to Emergency department with a friend for evaluation of sudden decrease of vision in the left eye. She denies any trauma or injury. It started this morning when she woke up and has progressively worsened over the past few hours. She had some blurring of her vision 1 month ago and thinks that may have been related to getting overheated, since it improved when she was able to get in a cool, air-conditioned environment. She has some pain if she tries to move her eye, but none when she just rests. She is also unable to determine colors. She denies tearing or redness or exposure to any chemicals. Nothing has made it better or worse.
Upon assessment, Patient AAOx3, hemodynamic stable. Patient able to answer all question. Afebrile. Resp. even and unlabored. No respiratory distress noted. Patient denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia. Bowel sound present in 4 quadrants. Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Unable to assess visual fields in 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. Full range of motions; no swelling or deformity. 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 Achiles tendons; no Babinski.
NURSING DIAGNOSIS
Risk for injuries due to impaired vision
Risk factor: falls
Desired outcome: Maintain safety without falls
Nursing Intervention: Environmental management
Teaching:
· Instruct patient to avoid rug
· Use appropriate lighting
· Orient patient to unfamiliar environment
Fear and Anxiety relate to visual impairment
Risk factor: lost vision
Desired outcome: Patient verbalizes feeling.
Nursing Intervention: Assess the patient’s fear related to feel depended.
Allow patients to verbalize feelings regarding recurrent visual problem,
Teaching:
· Teach patient how to manage anxiety, fear and stress
· Instruct patient to follow MD instruction as order
Pain
Risk Factor: Uncontrolled Pain
Desired outcome: Maintain pain controlled
Nursing Intervention: Assess patient pain level and take medication around the clock.
Bibliography Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s Guide to Physical Examination (8th ed.). St. Louis, MO: Elsevier/Mosby.
Nanda Nursing Diagnosis For Vision Impairment
http://allnurses.com/general-nursing-student/looking-for-nursing-185929.html
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