Physical Assessment in Health Care

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Patient History and Physical Examination

Patient Name: Jessica

Chief Complaint: losing vision in her left eye. It began this morning when she woke up, and it is progressing. It is painful for her to look around.

History of present illness: The patient denies any trauma or injury. Losing vision started in the morning when she woke up and has worsened progressively over the past few hours. The patient had some vision blurring a month ago and thinks that it could have been connected with getting overheated since it improved when she was able to get in a cool environment. There is some pain when she tries to move her eye, but no pain when she relaxes. The patient is also unable to determine colors. She denies redness, tearing, or exposure to any chemicals.

Past Medical History: Chickenpox at the age of ten and a tonsillectomy/adenoidectomy at the age of eleven.

Family History: The patients mother has hypertension, and her father has coronary artery disease (he had a stent placed at age 67).

Personal and Social History

The patient has been socially active all of her life. She completed a bachelors degree in mathematics and a masters degree in education. She quit smoking 10 years ago. She drinks an occasional wine cooler, and she denies illicit drug use.

Review of Systems

General: Patient is alert. She appears anxious.

Skin: There is no presence of any rash or itching. There is no abnormal hair distribution.

Head and Neck: There is no story of neck pain, headache, or stiffness.

Eyes: sudden decrease of vision in the left eye. The patient denies any trauma or injury. Losing vision started in the morning when she woke up and has worsened progressively over the past few hours. The patient had some vision blurring a month ago and thinks that it could have been connected with getting overheated since it improved when she was able to get in a cool environment. There is some pain when she tries to move her eye, but no pain when she relaxes. The patient is also unable to determine colors. She denies redness, tearing, or exposure to any chemicals. Nothing has made it better or worse.

Ears, Nose, Throat, and Mouth: There is no presence of loss of hearing, ear pain, or sinus congestion. There is no pain in the mouth or cough.

Lymphatic System: The patient does not have any node enlargement or tenderness.

Chest and Lungs: There is no shortness of breath, chest pain, or cough.

Breasts: There is no pain, tenderness, or discharge.

Heart and Blood Vessels: No edema, no palpitation.

Gastrointestinal and Endocrine Systems: The patient does not have any abdominal pain, vomiting, polyphagia or polydipsia, or temperature intolerance.

Genitourinary System: The patient does not have pain with urination. G=4, T=4, P=0, A=0, L=4, they were vaginal deliveries.

Musculoskeletal System: There is no muscular pain, restriction of movements, or joint stiffness.

Nervous System: There is no weakness or change in sensations.

Physical Examination

General: The patient appears comfortable, cooperative with the interviewer and the examination procedures. Vital signs are BP 135/85 mm Hg; HR 64bpm and regular, RR 16 per minute, T: 98.5F. The patient is not currently under the influence of alcohol or other drugs. Jessica ambulates without difficulty, articulates clearly, and is not in distress.

Mental Status: Patient is alert, oriented in time, place, and person

Skin: No change in color or pigmentation. No rashes or lesions. Hair with normal distribution and texture.

Head: Norm-cephalic, a-traumatic; no weakness or involuntary movements.

Eyes: Visual acuity 20/200 in the left eye and 20/30 in the right eye. Sclera white, conjunctivae clear. Unable to 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: There is no discharge or pain to palpation. Weber and Rinnes tests are normal.

Nose: No deformities present, mucosa is normal and pink.

Throat and Mouth: There is no pain or any alteration in the mouth.

Neck: No presence of any deformities.

Chest and Lungs: Chest is symmetric, with normal expansions. Lungs are clear on both sides. Respirations: 16 per minute.

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

Heart: BP 135/85 mm Hg; HR 64bpm and regular. No abnormal sounds.

Abdomen: The abdomen is flat. There is no mass or tenderness to palpation. Bowel sounds are normal.

Musculoskeletal System: Full range of motions; no swelling or deformity. There are no deformities present and no inflammation. The tone is adequate.

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 Care Plan

Assessment: The patients disease is most likely optic neuritis. It is an inflammation of the optic nerve frequently affecting people of young adult age in one of the eyes (Hoorbakht & Bagherkashi, 2012).

Subjective Data: The patient says that she is losing vision in her left eye. It becomes painful when she tries to look around. She says that she cannot differentiate colors.

Objective Data: The 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 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.

Nursing Diagnosis: Based on the examination, two nursing diagnoses may be identified.

Hopelessness and despair associated with the regime caused by the illness and its unpredictability (Wilhelm & Schablet, 2015).
Anxiety is associated with the change of perception caused by the loss of vision.

The patient has a high risk of losing sight, and she needs support and special care from her family to make her feel more comfortable about her condition. Optic neuritis may be the first sign of multiple sclerosis (Hoorbakht & Bagherkashi, 2012). Therefore, particular attention to the diseases progress is needed to notice and prevent the development of any complications.

Planning: The major purpose of planning in Jessicas case is to prevent the progress of her visions deterioration. Furthermore, it is necessary to prevent any possible complications.

Intervention and Patient Teaching

The intervention will be focused on teaching the patient to cope with limitations of her vision and anxiety caused by her condition. To do that, it is necessary to inform Jessica about the following aspects:

There should be regular periods of rest that will ensure proper relaxation of the eye nerve and will make the patient feel less anxious and scared;
Painkillers should be prescribed to decrease the painful feelings. It is necessary to educate the patient on when and how to take these medications;
Jessica should have a regular sleep pattern at least 12 hours. It is necessary to instruct her that long hours of sleep will improve her condition and self-perception;
Patients family should help her accommodate in the house by rearranging the furniture and bringing more light to the room where she spends most of her time. This will help her feel more comfortable;
Jessica should be taught about the illness and probable complications, medications and their side effects, and potential new symptoms, and the ways of managing them.

Rationale: The intervention and patient teaching methods will help Jessica to cope with her condition. Rearranging the furniture will decrease the possibility of accidents at home. Regular sleep and rest patterns will help her to improve her condition. Emotional support from family and friends will encourage Jessica to manage her disease and endeavor to improve her state. All the methods mentioned in the intervention plan are aimed to make Jessicas life easier despite her poor health condition.

Evaluation: The nursing care plan will be considered successful when the patient learns how to cope with her condition, realizes the possible complications, accommodates her newly acquired health status, and starts doing everything possible to improve her condition.

References

Hoorbakht, H., & Bagherkashi, F. (2012). Optic neuritis, its differential diagnosis and management. The Open Ophthalmology Journal, 6(1), 65-72.

Wilhelm, H., & Schablet, M. (2015). The diagnosis and treatment of optic neuritis. Deutsches Ärzteblatt International, 112(37), 616-626.

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