Introduction
Assessing a patient’s health promotion is essential in the nursing process and involves collecting comprehensive data to identify potential health risks and develop appropriate interventions. This report focuses on Jessica, a 32-year-old math teacher, presenting to the ER with sudden visual impairment in her left eye. The report will apply evidence-based research and the nursing process to assess Jessica’s health promotion needs and disseminate findings to course colleagues.
Background
Jessica is experiencing a sudden decrease in vision in her left eye, which has progressively worsened over the past few hours. She denies any history of trauma or injury but recalls experiencing some blurring of vision a month ago, which improved in a cool, air-conditioned environment. She reports pain on eye movement and inability to determine colors, along with other symptoms such as tearing, redness, or exposure to chemicals. However, she denies any systemic symptoms such as 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.
Assessment Findings
Upon examination, Jessica’s vital signs are within normal limits, with a blood pressure of 135/85 mm Hg, a heart rate of 64 bpm and regular rhythm, respiratory rate of 16 per minute, and a temperature of 98.5°F. Her visual acuity is significantly impaired in the left eye (20/200) compared to the right eye (20/30). The sclera is white, and the conjunctivae are clear. While the visual fields cannot be assessed in the left eye, they appear intact in the right eye. Pupil response to light is diminished in the left eye and brisk in the right eye. Notably, the optic disc is swollen. The patient demonstrates full range of motion, and there are no signs of swelling or deformity. Jessica’s mental status is intact and she is oriented to time, place, and person. Cranial nerves I to XII are intact, although horizontal nystagmus is present. There are no abnormalities in muscle bulk and tone. Finger-to-nose coordination test is normal, and the patient displays a negative Romberg test. Jessica’s temperature, vibration, and two-point discrimination are intact in the upper and lower extremities. Reflexes in biceps, triceps, brachioradialis, patellar, and Achilles tendons are 2+ and symmetric, with no Babinski sign.
Discussion
Based on the assessment findings, several potential differential diagnoses can be considered. The sudden decrease in vision, along with pain on eye movement and inability to determine colors, raises concern for optic neuritis. Optic neuritis refers to the inflammation of the optic nerve, which can cause vision impairment, pain, and changes in color perception (Nakashima et al., 2015). The swollen optic disc and diminished pupil response further support this diagnosis. Other possible differential diagnoses may include retinal detachment or central retinal artery occlusion, although additional assessment and diagnostic tests are required for confirmation.
Conducting a thorough health promotion assessment is crucial in providing appropriate care to Jessica. The assessment should include a detailed medical history, including any past eye issues, such as previous episodes of vision impairment, eye trauma, or chronic conditions like diabetes or hypertension. A review of Jessica’s current medications is also essential to identify potential side effects or interactions that may contribute to her symptoms. Additionally, exploring her lifestyle factors, including exposure to environmental conditions or triggers, such as excessive heat, may provide further insights into her vision issues. Collecting data on her level of physical activity, diet, and stress levels can help identify any modifiable factors that may contribute to her health concern.
Applying the nursing process and evidence-based research, interventions aimed at promoting Jessica’s health can be developed. Education on proper eye care and the importance of regular eye exams should be provided to Jessica. This will empower her to take control of her eye health and seek appropriate medical attention promptly. Additionally, educating Jessica on potential triggers for her symptoms, such as excessive heat, can assist her in managing and preventing future episodes. Encouraging her to maintain a healthy lifestyle, including regular exercise and a balanced diet, may contribute positively to her overall eye health. Collaborating with an ophthalmologist or eye care specialist for further evaluation and treatment is crucial in addressing Jessica’s specific eye concerns.
Conclusion
Assessing Jessica’s health promotion needs requires a systematic and thorough approach. Based on the assessment findings, potential differential diagnoses of optic neuritis, retinal detachment, or central retinal artery occlusion can be considered. Applying the nursing process and evidence-based research, interventions to promote Jessica’s health can be developed, including patient education on eye care, identifying potential triggers, and collaboration with eye care specialists for further evaluation and treatment. Disseminating these findings to course colleagues enhances collective knowledge and ultimately improves patient care.
