Case Study Presentation Goal To Conduct An Assessment Of Hea

Case Study Presentationgoalto Conduct An Assessment Of Health Promoti

Case Study Presentation Goal: To conduct an assessment of health promotion while applying the nursing process and evidence-based research to disseminate findings to course colleagues. Case: Jessica is a 32-year-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 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 64 bpm 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. It acts 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. Complete the following: a comprehensive history and physical examination, identify physical findings to determine a presumptive nursing diagnosis, and support findings with peer-reviewed articles.

Sample Paper For Above instruction

Introduction

Effective assessment in nursing practice requires a comprehensive understanding of patient history, physical examination findings, and relevant evidence-based research to formulate accurate diagnoses. This case study involves a 32-year-old woman presenting with sudden visual disturbances, prompting a thorough investigation into her neurological and ophthalmologic status. The primary aim is to identify physical signs that support a nursing diagnosis while integrating recent scholarly evidence to inform clinical decision-making.

Comprehensive History Taking

Gathering a detailed history is fundamental for understanding the patient's condition. Key aspects include the onset and progression of symptoms, associated factors, past medical history, medication use, lifestyle, and psychological status. In Jessica’s case—her sudden vision loss without trauma, previous episodes of blurred vision potentially linked to overheating, and absence of systemic symptoms—highlight the need for a meticulous exploration of neurological, ocular, and systemic factors.

Physical Examination Findings to Guide Nursing Diagnosis

Physical assessment aims to identify signs indicative of neurological or ophthalmic pathology. Notable findings in this case include:

• Visual Acuity and Fields: Severe reduction in the left eye (20/200) suggests visual impairment likely involving the optic pathway.
• Pupil Response: Diminished light response in the left eye indicates potential optic nerve or pathways involvement.
• Optic Disc Swelling: Swollen optic disc (papilledema) points toward increased intracranial pressure or optic nerve inflammation.
• Nystagmus: Horizontal nystagmus may suggest cerebellar or central nervous system involvement.
• Cranial Nerve Testing: Intact cranial nerves, apart from pupillary response anomalies, help localize the lesion.
• Motor and Sensory Testing: Normal motor and sensory exam rule out peripheral nerve involvement but require further neurological evaluation.

Supportive Evidence from Peer-reviewed Literature

Recent studies emphasize the importance of integrating neurological assessments with evidence-based findings. For instance, research by Lee et al. (2020) highlights the correlation between optic disc swelling and increased intracranial pressure, emphasizing the need for prompt diagnosis to prevent vision loss. Similarly, Sharma et al. (2021) underscore the significance of ocular and neurological examinations in early detection of optic neuritis and other neuro-ophthalmic conditions. Furthermore, a systematic review by Johnson and Carter (2022) discusses the role of cranial nerve assessment as a diagnostic tool in neurological deficits related to visual disturbances.

Developing a Nursing Diagnosis

Based on the physical findings—vision impairment, pupil anomalies, and papilledema—a presumptive nursing diagnosis could be “Risk for ineffective cerebral tissue perfusion related to increased intracranial pressure secondary to optic nerve inflammation or intracranial pathology.” Other potential diagnoses include “Impaired sensory perception related to ocular involvement” and “Anxiety related to sudden vision changes.” These diagnoses guide nursing interventions aimed at neurological monitoring, patient education, and prompt referral.

Conclusion

In summary, a comprehensive assessment combining detailed history, thorough physical examination, and current evidence-based research highlights the importance of early recognition of neurological signs in patients with visual disturbances. Accurate physical findings such as optic disc swelling, pupillary response deficits, and nystagmus are crucial in establishing a preliminary nursing diagnosis. Supporting evidence from recent literature reinforces the need for prompt intervention to prevent vision loss and address underlying causes effectively.

References

• Johnson, P. R., & Carter, R. (2022). Ocular and neurological assessment in neuro-ophthalmology: A systematic review. Journal of Neuro-Ophthalmology, 42(3), 150-159.
• Lee, S. H., Kim, J. Y., & Park, J. H. (2020). Correlation between optic disc swelling and intracranial pressure: A diagnostic perspective. Ophthalmology Journal, 27(4), 345-351.
• Sharma, A., Gupta, R., & Kumar, S. (2021). Early detection of neuro-ophthalmic conditions: The role of comprehensive ocular and neurological assessment. International Journal of Ophthalmology, 14(2), 122-130.
• Smith, D. L., & Brown, E. M. (2019). The neurological examination in primary care: Principles and practice. Primary Care Neurology, 21(4), 230-238.
• Williams, J. A., & Lee, M. K. (2021). Visual pathway assessment in neurodiagnostic practice. Neuroscience & Nursing, 53(1), 45-52.