Discussion Week 14 Physical Assessment In Healthcare Daylami

Discussion Week 14 Physical Assessment in Healthcare Daylamis Gonzalez Florida National University

The assignment is to analyze and discuss a comprehensive patient case study focusing on physical assessment in healthcare. The case involves a 32-year-old female patient presenting to the emergency department with sudden vision loss in her left eye. The discussion requires examining her medical history, current clinical findings, assessment results, and nursing diagnoses. It also requires proposing appropriate nursing interventions, patient education strategies, and understanding relevant pathophysiological considerations. The evaluation should incorporate evidence-based practices and appropriate scholarly references to support clinical reasoning and care planning.

Paper For Above instruction

In contemporary healthcare, thorough patient assessment is crucial for accurate diagnosis, effective intervention, and positive health outcomes. This case of a 32-year-old woman presenting with acute visual impairment provides an opportunity to explore comprehensive physical assessment skills, critical thinking, and evidence-based nursing practices. Understanding the multifaceted nature of her presenting complaints, medical history, and clinical findings guides the development of appropriate nursing diagnoses and tailored interventions.

The patient's presenting symptom, sudden decrease in vision in her left eye, is alarming and warrants prompt and detailed assessment to determine underlying causes such as neurological, ocular, or systemic etiologies. Her history of prior episodes related to overheating, unchanged since last examination, and her inability to discern colors are significant clinical clues. These symptoms suggest possible optic nerve pathology, such as optic neuritis or ischemic optic neuropathy, especially given her age and health background. Her visual acuity measurements (20/200 in the left eye and 20/30 in the right eye) further confirm significant impairment. The ocular examination findings—including diminished pupil response to light and swollen optic disc—support the diagnosis of optic disc swelling and potential nerve involvement.

During assessment, vital signs provided pertinent information: blood pressure of 135/85 mm Hg and heart rate of 64 bpm indicate stable hemodynamics, yet her blood pressure warrants monitoring due to her family history of hypertension. The absence of systemic signs such as fever, chills, or neurological deficits points towards a localized ocular pathology, but differential diagnoses such as multiple sclerosis, stroke, or ischemic events must be considered. The intact cranial nerves XII and normal motor and sensory findings suggest no widespread neurological impairment, but the presence of horizontal nystagmus indicates cerebellar or vestibular involvement which requires further investigation.

Assessment of the patient's lifestyle and medical history reveals risk factors that influence her care. She is a former smoker with a significant cardiovascular history—her father had coronary artery disease, and her mother experienced hypertension. These cardiometabolic risk factors are linked to ocular vascular conditions. Her history of chickenpox (varicella) could have some relevance to her immune status. Importantly, her mental status is alert and oriented, and she exhibits no signs of distress, facilitating a cooperative assessment process.

In light of this presentation, the primary nursing diagnoses include "Risk for injury related to impaired vision" and "Fear and anxiety related to vision loss." The former emphasizes environmental safety to prevent falls or injury, which is vital given her visual deficits. Immediate interventions include environmental modifications: securing loose rugs, providing sufficient lighting, and orienting her within the healthcare setting. Patient education on safety precautions and environmental awareness are critical to prevent falls, which are common and severe risks in patients with visual impairments.

Addressing her emotional response, such as fear and anxiety, involves assessing her psychological state, providing reassurance, and teaching anxiety management techniques. Allowing her to express her feelings and fears helps ensure comprehensive psychosocial support, essential in multimedia health care settings. Information on her condition, potential diagnoses, and treatment options should be communicated clearly to her, reducing uncertainty and fostering cooperation with ongoing management.

The evaluation of pain, although not currently a concern, is an essential component of ongoing assessment. She reports no pain at present, but monitoring for discomfort related to ocular or neurological issues remains critical. Interventions include regular pain assessments and administering analgesics as prescribed to maintain comfort, especially if her condition evolves.

Additional considerations include examining her neurological signs. The presence of nystagmus and decreased pupillary light reflex suggests involvement of the optic nerve or brain pathways. The intact superficial reflexes and sensory testing indicate no widespread neurological deficits. However, further diagnostic evaluations, such as neuroimaging (MRI or CT scan), are necessary to identify the precise etiology of her visual loss and plan definitive treatment.

Evidence-based nursing practices advocate for a holistic approach combining physiological assessment with patient education, emotional support, and safety measures. Literature supports prompt and comprehensive assessment in cases of sudden vision loss (Ball et al., 2015). Early recognition and intervention can preserve vision and prevent complications.

In conclusion, managing this patient requires a multidimensional approach considering her physical findings, medical history, psychosocial factors, and risk management. Effective communication, environmental safety, patient-centered education, and prompt referrals for specialized care are key strategies. Continuous monitoring and reassessment will inform clinical decisions and optimize patient outcomes in this acute setting.

References

• Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel's Guide to Physical Examination (8th ed.). Elsevier/Mosby.
• Bickley, L. S. (2017). Bates' Guide to Physical Examination and History Taking (12th ed.). Wolters Kluwer.
• Jarvis, C. (2016). Physical Examination and Health Assessment (2nd ed.). Saunders.
• Lewis, S. L., et al. (2019). Medical-Surgical Nursing: Assessment and Management of Clinical Problems. Elsevier.
• Ferrell, B., Coyle, N., & Paice, J. (2019). Oxford Textbook of Palliative Nursing. Oxford University Press.
• Gronseth, G. S., et al. (2014). Practice parameter: Vision preservation in nonarteritic anterior ischemic optic neuropathy: Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 83(1), 50-55.
• Hood, D. C., & Halpern, M. (2018). Ocular emergencies and their management. Ophthalmology Clinics, 31(1), 53-67.
• Lee, A. P., et al. (2017). Neurological assessment in emergency medicine. Emergency Medicine Clinics of North America, 35(2), 343-359.
• Schmidt, R. A., & Brown, J. M. (2019). Evidence-Based Practice for Nurses: Appraisal and Application of Research. Jones & Bartlett Learning.
• Seidel, H. M., et al. (2015). Seidel's Guide to Physical Examination (8th ed.). Elsevier.