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Presumptive nursing diagnosis
A presumptive nursing diagnosis is based on reasonable conclusions on nurses knowledge and prior experiences. It can be conducted at the initial stages of patient care or when diagnostic tests are unavailable. It is considered the opposite of a definitive diagnosis (Huber & Gillaspy, 2000).
To conduct a presumptive nursing diagnosis, the nurse needs to interview the patient for their sensory data, study their health history, and conduct a physical assessment, including inspection, palpation, percussion, and auscultation. Following this, the nurse can attempt to interpret the results of the assessment.
The patient is Jessica, a 32-year old female math teacher. She arrived at the ER with complaints about a sudden decrease in vision in the left eye. According to her, she had vision blurring for about a month. This morning, it became especially noticeable, with progressively declining eyesight over the next several hours until she arrived at the ER. The accompanying symptoms were a pain when trying to move the eye, swollen optical disc, and inability to distinguish colors. BP 135/85 mm Hg denotes pre-hypertension, HR 64bpm, and regular.
The presumptive nursing diagnosis, in this case, is disturbed visual sensory perception-related vision alteration, evidenced by an abrupt loss of vision.
The symptoms point to the possibility of optic neuritis. It occurs when the optic nerve, which carries visual information from the eye to the brain, becomes inflamed and causes swelling of the optical disc (Mayo Clinic Staff, 2014).
Its principal symptoms include vision loss in one eye, periocular pain, felt stronger during eye movement, and inability to see colors correctly. Other symptoms that reinforce the presumptive diagnosis are changes to the pupil reactions to bright light, and Uthoffs phenomenon, characterized by vision worsening with increases in body temperature, as reported by the patient.
Further tests should be performed by a physician to produce a definitive diagnosis and determine what may have caused it.
Nursing care plan
The first step in this situation is to conduct a full physical exam to confirm the disorders nature so that an appropriate nursing care plan can be developed. Due to optic neuritis often being caused or associated with the onset of multiple sclerosis, the physician may need to conduct an optical coherence tomography, to study the nerves at the back of the eye, a computed tomography, and a brain MRI, to produce a detailed image of the brain.
The next stage of care would be to inform Jessica about her diagnosis. Since she has not experienced prior symptoms like this, she would need to be provided with full and inclusive information about optic neuritis, what it is, and how it is caused.
Ideally, the information will be delivered in several sections, detailing the possible causes and effects of the disease and what developments she can expect next.
In most cases, this disorder resolves on its own. However, if it is caused by a different disease, like multiple sclerosis, it would necessitate addressing this disease in the teaching and care plans, and organize care to treat it. Once the disease is cured, the optic neuritis will cease as well.
Treatment for optic neuritis includes intravenous methylprednisolone and immunoglobulin, and interferon injections. With them, Jessica can expect complete vision recovery within 6 to 12 months. However, there is a possibility of a varying amount of damage to the optic nerve and resulting in a permanent decrease in eyesight. This is very probable because the recommended time to contact the doctor is within the first two weeks. Consequently, it may be important to include eye care and work with optician into the nursing care plan (Krause & Kim, 2015).
References
Huber, J. T., & Gillaspy, M. L. (2000). Encyclopedic dictionary of AIDS-related terminology. New York: Haworth Information Press.
Krause, L., & Kim, S. (2015). Optic Neuritis. Web.
Mayo Clinic Staff. (2014). Optic neuritis. Web.
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