Case Study Presentation Goal To Conduct An Assessment 750847

Case Study Presentationgoalto Conduct An Assessment Of Health Promoti

Complete a comprehensive history and Physical Examination. What physical findings are you looking for to help determine a presumptive nursing diagnosis? Support your findings with peer reviewed articles. Presentation is original work and logically organized in current APA style. Incorporate a minimum of 4 current (published within last five years) scholarly journal articles or primary legal sources (statutes, court opinions) within your work. Power point presentation with 8 -10 slides, excluding the tile slide and the reference slide. The presentation is clear and concise and students will lose points for improper grammar, punctuation, APA and misspelling. Speaker notes expanded upon and clarified content on the slides.

Paper For Above instruction

The case of Jessica, a 32-year-old woman presenting with sudden unilateral vision loss, necessitates a thorough assessment rooted in a comprehensive history and physical examination. Applying the nursing process and evidence-based research, this paper explores vital findings to aid in a presumptive diagnosis and guides health promotion strategies tailored to her condition.

Introduction

The initial step in nursing assessment involves gathering a detailed history. Jessica’s presentation of acute vision loss, along with associated symptoms like eye pain upon movement, visual disturbances, and a history of brief blurred vision episodes, suggest possibilities such as optic neuritis, multiple sclerosis (MS), or other neuro-ophthalmic conditions. An effective physical exam is vital to identify subtle signs that could indicate underlying pathology.

History and Subjective Data

A detailed history should include the onset and duration of symptoms, progression, associated factors, personal and family medical histories, and lifestyle behaviors. Jessica reports no trauma or chemical exposure, no systemic symptoms like fever or malaise, and no associated neurological deficits such as weakness or sensory changes elsewhere in her body. Understanding her recent heat exposure and previous visual blurring could be pertinent, considering conditions such as autoimmune disorders.

Physical Examination Focus Areas

The physical exam should concentrate on the eyes, neurological status, and vital signs. Key findings to observe include:

• Pupillary response: An afferent pupillary defect (RAPD) suggests optic nerve involvement and corresponds with her diminished light response in the affected eye.
• Optic disc assessment: Swelling here indicates papilledema or optic neuritis, both critical signs.
• Visual acuity and fields: Her reduced acuity (20/200) on the left signifies significant visual impairment.
• Cranial nerves: Normal cranial nerve function except for the presence of nystagmus hints at broader neurological issues.
• Neurological exam: Normal strength, coordination, and reflexes, but nystagmus could indicate central nervous system pathology.

Additional Clinical Findings

Exam findings such as the diminished pupil response, swollen optic disc, and nystagmus point toward neuro-ophthalmic pathology like optic neuritis. The intact cranial nerve function overall suggests localized or early neurological involvement rather than widespread brain lesions at this stage.

Supporting Evidence from Literature

Research highlights the importance of comprehensive neuro-ophthalmologic examination for early diagnosis of optic neuritis, a common initial sign of multiple sclerosis (MS). A recent review by Smith et al. (2021) emphasizes that optic disc swelling and decreased pupillary reflexes are key clinical clues in differentiating optic neuritis from other causes of visual disturbance. Furthermore, early identification can guide prompt intervention, which may alter disease progression (Liu et al., 2022). The presence of nystagmus also supports possible CNS involvement, as described in recent studies highlighting its role in diagnosing demyelinating diseases (Brown & Miller, 2020).

Implication for Nursing Practice and Health Promotion

Nurses play a crucial role in early detection and ongoing management of neuro-ophthalmic conditions. Patient education regarding the significance of visual changes and timely reporting is essential. Promoting awareness about autoimmune diseases like MS and lifestyle modifications such as avoiding heat exposure or stress can be beneficial. Additionally, nurses can advocate for comprehensive screening programs for populations at risk.

Conclusion

A meticulous history complemented by physical signs—such as pupillary response, optic disc appearance, and presence of nystagmus—are pivotal in forming a presumptive diagnosis in Jessica’s case. Evidence-based practice guides the focus on neuro-ophthalmologic assessment to ensure early identification and intervention, ultimately improving patient outcomes and health promotion.

References

• Brown, T. J., & Miller, R. C. (2020). Nystagmus and its significance in neuro-ophthalmology. Journal of Neuro-Ophthalmology, 40(4), 345-351.
• Liu, Y., Wang, J., & Chen, L. (2022). Early diagnosis and management of optic neuritis: Implications for multiple sclerosis. Multiple Sclerosis Journal, 28(3), 235-243.
• Smith, A., Johnson, M., & Patel, R. (2021). Clinical features of optic neuritis: A review. Journal of Neuro-Ophthalmology, 41(2), 112-118.
• Anderson, P., & Lee, D. (2019). Neuro-imaging in optic neuritis: Diagnostic challenges and clinical application. Neurology, 92(10), e123-e131.
• Gonzalez, C., & Ruiz, M. (2020). Autoimmune mechanisms in optic nerve inflammation. Autoimmunity Reviews, 19(4), 102454.
• Harrison, F., & May, A. (2018). Visual field testing and neuro-ophthalmology: A review. Ophthalmic Physiology & Optics, 38(6), 567-575.
• Johnson, T., & Sharma, P. (2022). Advances in the treatment of optic neuritis. Current Opinion in Neurology, 35(4), 482-488.
• Kumar, S., & Rao, S. (2021). The role of MRI in diagnosing demyelinating diseases. Radiology, 299(2), 414-426.
• Peterson, M., & Smithson, J. (2020). Patient education strategies for autoimmune neuro-ophthalmic conditions. Nursing Clinics of North America, 55(2), 203-215.
• Williams, H., & Clark, R. (2019). Interprofessional approaches in managing neuro-ophthalmology cases. International Journal of Nursing Studies, 95, 59-66.