Nursing Diagnosis: Poor Visual Acuity in an Eye

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Table of Contents

Background and Patient History
Physical Examination
Physical System Evaluation
Presumptive Nursing Diagnosis
Assessment and Analysis of Data
Identification and Selection of the Most Appropriate Nursing Diagnosis
Verification and Documentation of Nursing Diagnosis
Physical Findings
References

Background and Patient History

Chief Complaint

The patient reports a sudden decrease in vision in the left eye, which commenced in the morning upon waking up and worsened slowly over the past few hours.

History of Present Illness

The patient denies any trauma or injury; she experienced the blurring of her vision one month ago and thought it could be because of overheating, given that there was no problem when she got in a cool, air-conditioned environment. The patient experiences some pain upon trying to move her eye; no pain is felt while just resting; she cannot observe different colors, no tearing, redness, or prior exposure to any chemicals. The condition is not expected in any way to become better or worse.

Social History

She is a math teacher and was accompanied by a friend to the ER

Physical Examination

General

Jessica is alert and cooperative; she can comprehend information and respond to questions but shows some anxiety; key test results include BP 135/85 mm Hg, HR 64bpm and regular, RR 16 per minute, and T: 98.5F.

Mental state: The patient is alert, oriented x 3

Skin: No abnormalities; no change in color or pigmentation; no signs of rashes, flakiness, or lesions; skin not cold, unduly moist, or dry.

Head: No abnormalities; no headache.

Eyes: Pain when moving eye but none when at rest; cannot distinguish colors; the right eye is okay (visual acuity 20/30), but the left eye cannot assess visual fields (visual acuity 20/200); diminished left eye responds to light but the right vision is bright; sclera white; conjunctivae clear; swollen optic disc.

Hearing: No aberrations were observed; no change in functioning.

Nose: No deformities; no shortness of breath or cough; nasal or sinus congestion.

Throat and mouth: No alteration or pain in the mouth; no sore throat

Neck: No pain, abnormalities, discomfort, neck pain, or stiffness.

Breasts: Symmetric with no alterations, discharge, or lesions.

Chest and Lungs: No deformities; lungs clear on both sides; regular chest operation; normal breathing; standard respiration rate – 16 breaths per minute.

Heart: No pulse abnormalities were detected; it is operating normally at HR 64bpm and BP 135/85 mm Hg.

Stomach: No abnormalities; no diarrhea or constipation.

Abdomen: No abnormalities; no abdominal pain, palpation, tenderness, or mass.

Physical System Evaluation

Musculoskeletal System: No deformities or swellings; reports slight pain in hands and wrists; patient reports full range motion; no leg swelling.

Neurological Test: Intact cranial nerves I-XII; horizontal nystagmus observed; oriented x 3; negative Romberg reflex; horizontal nystagmus present; temperature and vibration within normal range; two-point discrimination in lower and upper extremities; normal and symmetric reflexes – 2+ (patellar, brachioradialis, triceps, biceps, and Achilles tendons; no Babinski – tested negative

Gastrointestinal and Endocrine Systems: No vomiting, abdominal pain, polydipsia, polyuria, and polyphagia.

Genitourinary System: No dysuria or vaginal discharge.

Nervous System: No weakness signs of weaknesses

Presumptive Nursing Diagnosis

A presumptive nursing diagnosis is a preliminary diagnosis made by a nurse about a patient’s health condition using the available information and assessment data. It can further be described as an informed guess about a patient’s health status based on observed symptoms, signs, and medical history. It is a functional inference that guides the nurse in formulating a care plan, collecting data, and making an elaborate nursing diagnosis and further planning and interventions. It can be improved as the nurse collects more information and is subject to change based on ongoing assessment. The classical framework for developing a presumptive nursing diagnosis comprises several stages.

Assessment and Analysis of Data

Assessment is the first and most critical stage of the presumptive nursing diagnosis. During the examination, the nurse must gather extensive information and data about the patient’s health status. The assessment covers historical, physical, psychological, social, and environmental aspects. The nurse can collect data from different sources, including patient interviews, observation, review of medical records, and laboratory tests. Once the data is collected, the nurse has to move to the second step of analyzing the information to identify trends, patterns, and relationships. The analysis phase helps the nurse to specify problems or issues that may affect the patient’s health and prioritize them.

Identification and Selection of the Most Appropriate Nursing Diagnosis

Once the first analysis of the patient data is completed, the next step involves identifying the probable nursing diagnoses applicable to the health status. It requires an extensive understanding of nursing diagnoses and the nursing process. Afterward, the nurse has to choose the most appropriate diagnosis based on the patient’s examination and the priority of the health problem. The diagnosis reveals that Jessica could most probably be suffering from optic neuritis.

Verification and Documentation of Nursing Diagnosis

The nurse must substantiate the designated nursing diagnosis by searching for supplementary information or reassessing the patient. This step helps the nurse affirm or refine the diagnosis and guarantee its accuracy. It is then documented in the patient’s medical record, and the data and justification are used to make the diagnosis. This records the continuity of care and provides a basis for future evaluations.

Physical Findings

There are several physical findings applicable to determine the presumptive nursing diagnosis. Jessica has poor visual acuity in the left eye, which has reduced pupil response to light. She experiences pain while moving the eye and cannot distinguish colors. Lastly, the examination revealed that Jessica had an optic disc swelling.

References

Cachon-Perez, J. M., Gonzalez-Villanueva, P., Rodriguez-Garcia, M., Oliva-Fernandez, O., Garcia-Garcia, E., & Fernandez-Gonzalo, J. C. (2021). Use and significance of nursing diagnosis in hospital emergencies: A phenomenological approach. International Journal of Environmental Research and Public Health, 18(18), 9786. Web.

Kishner, S. (2019). Pain assessment: Practice essentials, overview, technique. Medscape.com. Web.

Murthy, S., Das, S., Deshpande, P., Kaushik, S., Dave, T., Agashe, P., Goel, N., & Soni, A. (2020). Differential diagnosis of acute ocular pain: Teleophthalmology during COVID-19 pandemic – A perspective. Indian Journal of Ophthalmology, 68(7), 1371. Web.

Vera, M. (2022). Nursing diagnosis: The complete guide and list for 2019. Nurseslabs. Web.

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