Nursing Case Study History And Physical Examination - 1100 Words

Nursing Case Study: History And Physical Examination (Case Study Sample) Content: History and Physical ExaminationNameInstitutionHistory and Physical ExaminationChief Complaint: Jessica, a female-aged 32 years old, presents to the emergency room accompanied by her friend with the chief complaint being sudden decline of vision her left eye.Present Illness HistoryJessica claims that the decline of vision in the left eye began early in the morning after she got up. Since then, the problem has gradually deteriorated over the last few hours. The patient reports that she had not had any injury or trauma and chemical exposure. Additionally, she claimed that a month ago, she experienced some blurring of her vision though she thought that this might have resulted from being overheated given that it improved after going in a well air-conditioned surrounding. Currently, Jessica claims that she feels some pain when she attempts to move the affected eye, though the pain resolves when she rests. In addition, she is not also able to differentiate colors. Accordi ng to her, nothing has enhanced or made her condition.Medical HistoryJessica reports that she is usually healthy. At the age of 10, she reports that she suffered from chickenpox. She reports that she has never been hospitalized.Surgical HistoryAt the age of 11, she had an adenoidectomy/tonsillectomy. No history of caesarian section was reportedMedicationsCurrently, she reports that she has no medical problems and thus, she is not under any medications.AllergiesThe patient does not report any allergiesFamily HistoryShe reports that her father has a coronary artery disease.She also reports that her mother suffers from hypertensionReproductive HistoryThe patient has four children, all delivered through spontaneous vaginal deliveryDrug Abuse HistoryThe patient has a history of tobacco smoking though she quit 10 years ago. Before quitting, she reports that she used to take two cigarettes packs every day for a period of around five years. She also takes wine cooler seldom. Jessica denies any history of illicit drug usePsychosocial HistoryThe patient is a mathematics teacher. She reports that she finished her degree in mathematics as well as a masters degree in education.Review of systemsHEET: she denies headaches, alterations in hearing, sinus or nasal congestion, sore throat and stiffness or pain in the neck.General: she denies fever, night sweats, chills, and weight lossGenitourinary: she denies dysuria, hematuria, polyuria, and vaginal dischargeMusculoskeletal: All muscles have a normal bulk as well as toneCardiovascular: Denies chest pains, peripheral edema, shortness of breath, palpations, and coughGastrointestinal: No complaints of polydipsia and polyphagia. She denies adnominal pain, constipation, and diarrheaPhysical ExaminationVitals: Blood pressure 135/85 mm Hg; HR 64bpm; RR 16/min; T 98.5FGeneral: The patient seems alert. She appears to be anxiousEyes: The Visual of the left eye and right eye is 20/200 and 20/20 respectively; Sclera and conjunctive normal ; Unable to evaluate visual fields in the left eye; however, the visual field of the other eye is normal. The response of the pupil is reduced in the affected eye and brisk for the right eye. The left eyes optic disk seems distended.Musculoskeletal: All joints have full range motions in all joints; no deformity or swelling noted; all muscles have a normal bulk as well as tone.Neurological: Cranial nerves I-XII are intact, negative Romberg; motor along with sensory examination of the lower and upper extremities seems normal; intact to temperature and vibration; reflexes appear normal as well as symmetrical in all extremities ( reflexes 2+ as well as symmetric in triceps, biceps, patellar, brachioradialis as well as Achiles tendons; no Babinski noted.Mental status: The patient is fully oriented to person, time, and place (oriented x 3)Nursing DiagnosisProblem-Focused DiagnosisDisturbed visual perception alteration as evidenced by the sudden decrease in vision for the left eye (Brown, 2017). Loss of visual vision loss as evidenced by the visual acuity of 20/200 in the patients left eye and the inability to differentiate different colors. Optic disc edema as evidenced by the swollen optic disc in the left eye (Lorach et al., 2015). Anxiety as evidenced by the nervousness of the patient during anxiety. High blood pressure as evidenced by the patient's blood pressure of 135/85. Even though this level of blood pressure may be normal, there is a history of hypertension within the patients family and coronary artery disease, which is also associated with hypertension (Goel et al., 2015). Acute pain as evidenced by pain as the patient tries to move her left eye.Risk DiagnosisThe risk for injury as evidenced by the reduced vision in the patients left eye. When the vision of one eye is impaired, a person is usually a higher risk of misjudging activities and thus can cause unintentional harm to themselves (Lorach et al., 2015). The risk for blindness as evidenced by the r educed vision, pain, and inability to differentiate colors in the patient's left eye. The risk for hypertension as evidenced by a history the condition within the patient's family. The risk for physical immobility due to the reduced vision of the left eye (Lorach et al., 2015). The risk for atherosclerosis as evidenced by the family history of coronary heart disease (Goff et al., 2014). Another possible risk is that of acute confusion as shown by the patient's pain in the left eye and anxiety. The patient is also at the risk of papilledema as evidenced by the swelling of the optical nerve. Lastly, the patient is at the risk of chronic pain as evidenced by the acute pain in the left eye.Health PromotionThe patient shows readiness for enhanced vision as well as the desire for a better as shown by her cooperation with the inquiries of the nurse. Additionally, the patient demonstrates readiness for improved comfort as evidenced by her desire to seek clinical attention due to her condit ion.Nursing Care Plan and Teaching PlanThe most appropriate nursing care plan in the patients case should be aimed at preventing further visual deterioration, promoting adaptation to ch...