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 y/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 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 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. Intact to temperature, vibration, and two-point discrimination in upper and lower extremities. Reflexes: 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achiles tendons; no Babinski.
Submission Instructions:
- 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)
Goal: To conduct an assessment of health promotion while applying the nursing process and evidence-based research to disseminate findings to course colleagues.
Introduction The nursing process is a systematic and organized approach used by nurses to provide care to patients. The nursing process is composed of five steps which include assessment, diagnosis, planning, implementation, and evaluation. Health promotion involves actions that aim at enhancing the well-being of individuals and preventing illness. This paper aims to conduct an assessment of health promotion while applying the nursing process and evidence-based research to disseminate findings to course colleagues.
Comprehensive History and Physical Examination Jessica, a 32-year-old math teacher, presents to the emergency room with a friend for evaluation of sudden decrease of vision in the left eye. In conducting a comprehensive history and physical examination, the nurse will take a detailed history of the patient, perform a physical examination, and order relevant investigations to identify the cause of the problem. The history will involve asking the patient about the symptoms, the duration, and any other relevant information. The physical examination will involve an eye exam, neurological exam, and general examination of the body. Investigations such as MRI, CT scan, and blood tests may be ordered to identify the cause of the problem.
Physical Findings to Determine Presumptive Nursing Diagnosis The physical findings will help to determine the presumptive nursing diagnosis. The presumptive nursing diagnosis includes impaired vision, acute pain, anxiety, and disturbed sensory perception. The impaired vision is evidenced by the decrease of vision in the left eye, inability to determine colors, and swollen optic disc. The acute pain is evidenced by pain when moving the eye. The anxiety is evidenced by the patient’s appearance, and the disturbed sensory perception is evidenced by the horizontal nystagmus present.
Supporting Evidence-Based Research Evidence-based research provides the basis for the nursing interventions aimed at promoting health. In this case, the nurse can use evidence-based research to promote eye health. According to the World Health Organization (WHO), the leading causes of visual impairment include uncorrected refractive errors, cataracts, glaucoma, age-related macular degeneration, and diabetic retinopathy (WHO, 2021). Nurses can provide education to patients on the importance of regular eye exams, wearing protective eyewear, and avoiding eye strain. Studies have also shown that nutritional supplements such as vitamins C and E, zinc, and omega-3 fatty acids can help to prevent age-related macular degeneration (AREDS Research Group, 2001). Nurses can also provide education on healthy nutrition to promote eye health.
Conclusion In conclusion, conducting a comprehensive history and physical examination is important in identifying the cause of a patient’s health problem. The nursing process provides a systematic approach that can be used to provide care to patients. Evidence-based research provides the basis for nursing interventions aimed at promoting health. Nurses can play a crucial role in promoting eye health by providing education to patients on the importance of regular eye exams, wearing protective eyewear, and avoiding eye strain. Nurses can also provide education on healthy nutrition to promote eye health. It is essential to continually disseminate research findings to course colleagues to promote evidence-based nursing practices.
References AREDS Research Group. (2001). A randomized, placebo-controlled, clinical trial of high-dose supplementation with vitamins C and E, beta-carotene, and zinc for age-related macular degeneration and vision loss: AREDS report no. 8. Archives of ophthalmology, 119(10), 1417-1436.
World Health Organization. (2021). Visual impairment and blindness. Retrieved from https://www.who.int/news-room/fact-sheets/detail/blindness-and-visual-impairment