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Case Study: Nursing History and Physical Examination

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Case Study Nursing History and Physical Examination
25.12.2018
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Introduction

Whenever a patient goes to the hospital or healthcare facility, the first thing that happens is the taking of patient history. The medical officer, clinical officer or nurse receives the patient. This is followed by physical examination, prescription of drugs and any other form of treatment. In the case of a very serious situation, the patient is admitted. Otherwise, the patient is treated and discharged. In this particular incident, the patient arrived at the Emergency Room (ER) with vision problems and as a nurse, I attended to her.

Patient’s History

I sought to know the patient’s gender, age and occupation first. Since the patient complained about a sudden decrease in vision, I asked her whether she had an injury or trauma of any kind. The patient denied any trauma or injury. This was very important, as the physical injury is a probable cause of eye problems. On realization that physical injury was not the cause of the decreased vision, I checked for a pathological condition.

The patient had to answer a question when a particular problem started. I asked when the vision on the eye started to decrease. The condition that ensued was of importance too. This helped reveal how long the problem took to develop. The duration of a disease is important in knowing the extent of its spread and potential damage.

There was a need to know whether such a condition was a recurrence or if that was the first time. This bit of information is useful in understanding the extent of the spread of disease in the body. I also sought the patient’s medical history. This was to determine whether a previous medical condition was the cause of the current problem. The patient’s academic records revealed whether her left eye’s condition impacted negatively on her studies.

I questioned the patient about her parents’ medical records. This was in search of an outstanding medical condition that might be genetically linked to the patient’s current condition. In addition, I asked the patient about other physical discomforts that might relate to eye problems. These conditions included malaise, vaginal discharge, headache, and weight loss. The patient denied any case of physical discomforts.

Physical Examination

Clinical officers do the examination systematically. The parts of the body are examined one after the other. In this particular situation, the patient went to the hospital because of vision problems and, therefore, I had to perform a physical examination of the eye to determine the cause of visual loss. I examined other parts of the body as well. The factors tested from the other body parts included heart rate, blood pressure, body temperature, mental status, and even anxiety. Other conditions involving the nerves also featured, such as a test for Babinski’s sign and Romberg. The report on the patient’s history was of much importance on the kind of physical examination performed and even the treatment and prescription required.

During the patient’s vision evaluation, I asked her to sit in a manner that allowed her to view and read conveniently. The hospital personnel placed an adjustable bed table in front of the examination chair to facilitate her convenience.

Eye Examination

I then proceeded to examine the patient’s eyes from a variety of angles. The methods used were to help in the diagnosis of any kind of clinical issue that affected the patient. Some of the issues examined included macular function, near point vision, and retinal appearance. Other aspects included the status of blood vessels in the retina, visual acuity and scope of vision.

Macular examination

I asked simple questions like counting of fingers. The patient was given time to check and count my fingers. I altered the number of fingers and checked to see whether the patient gave the correct answer.

Fundoscopy

With the help of an ophthalmoscope or a fundoscopy, I examined the patient’s retina. This examination took place in a dark room to help eliminate the interference of external light during the examination of the retina. This was to check for any bulge. A bulge would indicate intracranial pressure and, hence, treatment of intracranial issues to solve the vision problems. I identified the swollen optic disc.

The instrument helped check whether the fluid components of the eye were clear or not. The fluids examined included vitreous and aqueous senses of humor. Presence of any obstacle may interfere with the transmission of light and, hence, interfere with vision.

Examination of Blood Vessels

I checked the blood vessels to the increase in size. During the examination, I recorded the sclera as white and the conjunctivae clear.

Near Point Vision

To check for the near-vision I used a visible letter written on a piece of paper and a 30 cm-ruler. The ruler was placed just below the eyes and the writing put on it from a visible position. I then moved the paper slowly towards the patient’s eye and asked her to indicate the point at which she could no longer see the writing on the paper clearly. This distance is the near point.

Color Blindness

I used Ishihara charts to check for color blindness. This is a chart with various letters written using a combination of different colors. Some of the colors include blue, green and red. The patient read some of the colored numbers wrongly, hence, exhibiting color blindness.

Visual Acuity

I checked the patient for long or short-sightedness. Visual acuity gives the estimate of the amount of magnification needed to do standard chores. I placed a Snellen’s chart six meters away from the patient in a well-lit room. I proceeded to ask the patient to identify the letters or numbers starting from the largest to the smallest. I stopped at the point when the patient read out a wrong answer. The patient performed this procedure for each eye one at a time blocking the untested eye. In this particular case, the patient had a visual acuity of 20/200 for the left eye and 20/30 for the right eye. This spelled a case of shortsightedness on the left eye and almost normal acuity for the right (Regan, 440).

Scope of Vision

The testing for visual field involved checking for vision in the temporal and nasal fields. This involves the perimetry test, whereby the patient placed the chin on the chin rest and attempted to view the light from various angles. The patient was unable to assess visual fields in the left eye while the visual fields on the right eye were intact.

Response to light

I alternatingly exposed the patient’s eyes to a shining light to test for the response to light.

Other Conditions

Pupil response to light: when I exposed the patient’s eyes to bright and focused light, the left eye showed diminished response while the right eye showed brisk response.

I checked the patient’s pulse for the pulse rate. She counted the number of pulses in a minute and indicated this as the heart rate. This nurse recorded the heart rate at 64bpm and regular. This is below the heart rate of physiological man, hence, below the normal value.

I also examined the lower and upper extremities and identified intact nervous response to temperature, vibration, and proprioception (CELESIA, 637). The reflexes were intact. On scratching the solar part of the patient’s foot, I found negative Babinski’s sign.

Physical Conditions

Some of the physical conditions that a nurse looks for include: bulging of the retina, large blood vessels, swollen optic disc, and pupil size, the color of the sclera, body temperature and blood pressure.

Nursing Diagnosis

The patient had a short-sighted left eye (Cox and Newfield, 130)

Diminished pupil response to light in the left eye (Marcus Gunn pupil) may indicate optic nerve lesion, a severe disease of the retina or afferent pupillary defect.

Swollen optic nerve (papilledema) indicates orbital pathology such as glioma of the cranial nerve number two. It might also indicate respiratory system failure or even Guillain Barre Syndrome.

Horizontal nystagmus indicates damage to one or more vestibular system component.

Intact cranial nerves and the spinal cord indicated no nervous malignancy.

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