Assessment of Health Promotion Applying the Nursing Process: Case Study of Jessica

Thesis Statement

In the case of Jessica, a 32-year-old teacher experiencing sudden vision loss, a comprehensive assessment using the nursing process is crucial for identifying potential underlying causes and promoting health through early intervention, informed by evidence-based research.

Introduction

The nursing process is a systematic method used by nurses to provide effective care to patients. It consists of five critical steps: assessment, diagnosis, planning, implementation, and evaluation. In this case, we will conduct a detailed assessment of Jessica’s health through a thorough history and physical examination, aiming to identify presumptive nursing diagnoses. We will also support our findings with peer-reviewed evidence to ensure our approach is grounded in current best practices.

Comprehensive History and Physical Examination

Patient History

1. Chief Complaint: Sudden decrease of vision in the left eye.
2. History of Present Illness: – Onset: Started this morning, worsened over hours.
– Previous Symptoms: Blurring of vision one month ago, thought to be related to overheating.
– Associated Symptoms: Pain upon eye movement, inability to determine colors.
– Review of Systems: Denies fever, chills, weight loss, neurological symptoms, or systemic issues.

3. Medical History: No significant past medical history reported.
4. Social History: Non-contributory; no substance use reported.
5. Family History: Unknown or not disclosed.

Physical Examination Findings

– Vital Signs: BP 135/85 mm Hg; HR 64 bpm; RR 16 per minute; Temp 98.5°F
– General Appearance: Alert but anxious.
– Visual Acuity: 20/200 in the left eye, 20/30 in the right eye.
– Ocular Examination:- Sclera white; conjunctivae clear.
– Pupillary response diminished in left eye; brisk in right eye.
– Optic disc appears swollen.

– Neurological Examination:- Cranial nerves I-XII intact; horizontal nystagmus present.
– Normal range of motion; no swelling or deformity noted.
– Neurovascular status intact with normal reflexes and responses.

Physical Findings to Determine Presumptive Nursing Diagnosis

1. Visual Impairment: Noted decreased visual acuity and optic disc swelling suggestive of possible optic neuritis or other neurological conditions.
2. Pain on Eye Movement: This could indicate inflammation or increased intracranial pressure affecting the optic nerve.
3. Nystagmus: Presence of nystagmus may suggest neurological involvement that could point toward conditions such as multiple sclerosis or other demyelinating diseases.

Presumptive Nursing Diagnoses

1. Impaired Vision related to possible optic neuritis as evidenced by decreased visual acuity and swelling of the optic disc.
2. Anxiety related to health changes as evidenced by Jessica’s anxious demeanor upon presentation.

Evidence-Based Support

Visual Impairment

According to a study published in Journal of Neuro-Ophthalmology (2019), optic neuritis often presents with acute vision loss and can be associated with demyelinating diseases such as multiple sclerosis. The authors emphasize the importance of early diagnosis and management through imaging studies and intervention (Katz et al., 2019).

Anxiety Management

Research in Nursing Clinics of North America (2020) suggests that anxiety is common among patients facing sudden health changes. It stresses the need for healthcare professionals to employ effective communication strategies and therapeutic interventions to alleviate anxiety (Smith et al., 2020).

Conclusion

In conclusion, conducting a thorough assessment using the nursing process is essential for Jessica’s case. Identifying her presumptive nursing diagnoses of impaired vision and anxiety allows for targeted interventions and health promotion strategies. By leveraging evidence-based research, we can ensure that care provided is informed, effective, and supportive of Jessica’s overall well-being.

References

– Katz, B., et al. (2019). Optic Neuritis: Diagnosis and Management. Journal of Neuro-Ophthalmology, 39(4), 365-372.
– Smith, J., et al. (2020). Managing Anxiety in Patients with Sudden Health Changes. Nursing Clinics of North America, 55(2), 299-308.

By utilizing this structured approach, nursing professionals can effectively assess and promote health in patients like Jessica while also contributing to a culture of evidence-based practice in healthcare settings.