CASE STUDY Summary of Health History Name: A.

C Address: Kingston 3 Gender: Male Marital Status: Single Brief History: Age: 14 years old Occupation: Student Date of Admission: February 7, 2012 Religion: Christianity

The patient lives with his mother and father in a two (2) bedroom concrete house. His mother indicated a family history of blindness by grandmother and also hypertension by an aunt and grandfather. He is currently in fourth form at a High School and his academic performances are up to standards. Past Medical History: Is a known Sickle Cell patient from birth at University Hospital of the West Indies. Past Surgical History: The patient has never had a surgical intervention done until on February 9, 2012 where he had a Vitrectomy done. Drug History: Patient was not taking any form of medication. Allergy: There are no known allergic reactions to any foods or substances. Chief Complaint: Pain in both eyes, right eye greater than left. The patient was well until 3 days ago, where he had a sudden onset of pain to the right eye. Then, this morning noticed that the left eye was extremely red and slight pain. There was a slight accumulation of pus-like secretion noted in the anterior chamber of the left eye (hypopyon). He was then taken to Kingston Public Hospital for treatment where a diagnosis of Bilateral Anterior Uveitis, possibly Ponuveitis was given and was sent for admission on the ophthalmic ward for further management.

CASE STUDY Related Physical Assessment Received patient lying in supine position, in no cardiopulmonary distress. Client made

compliant of pain to both eyes rating it at 6/10 on the pain rating scale and he also voiced concerns about the outcome of the procedure done asking if he could become blind. On assessment, head is normo-cephalic with no deformities noted. An eye patch and dressing is seen to A.C.s left eye same is clean and intact. Eyebrows have even hair distribution, even alignment, equal movement as facial expression changes, eyelashes present and evenly distributed along the eyelid margin. Conjunctiva of the right eye was moderately injected (reddened) with mild discharge noted to same. He was breathing spontaneously on room air with no nasal flaring or use of accessory muscles noted. No adventitious breath sounds heard on auscultation of lung field with a respiratory rate of 18 breaths per minute, regular and effortless. Heart sounds S1 and S2 auscultated and the radial pulse was assessed at a rate of 68 beats per minute full and bounding and a blood pressure of 110/74 millimetres per mercury. His appetite was fair as he didnt want to eat the hospital food because he doesnt like it. Abdomen is soft, flat and non tender to touch. Bowel sounds heard in all four abdominal quadrants. Bladder function and bowel action are normal. Movement and sensation was present in all extremities. Skin is adequately hydrated and with good skin turgor. Skin was warm to touch at a temperature reading of 36.10C.

Diagnostic/Laboratory Evaluation

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Visual acuity tests, such as the use of the Snellen chart is a part of routine eye examination to determine the smallest letters a person can read on a standardized chart or card held 14 to 20 feet away. When there are abnormal results it indicates an eye condition requiring further evaluation of vision impairments. A.C. had a 20/70 visual acuity for the right eye and a 20/30 visual acuity for the left eye. A tonometry should have been done but no evidence was seen in A.C.s docket. A tonometry measures the intraocular pressure (IOP) by recording the resistance of the cornea to pressure (indentation) (normal range: 10 to 21 mm Hg) (Doenges, Moorhouse & Murr, 2010). He also did Blood Studies where abnormal findings were recorded for the white blood cells (WBC) - 11.4 x 109/L (Reference range: 4.5-11x 109/L), and neutrophils- 7.63 x 109/L (Reference range: 2.0-7.5 x 109/L). Abnormalities in blood studies are as followed respectively, there is an increase in WBC which indicates that there is an infection. With the increased neutrophil this is indicative of bacteria; overall, indicative of a bacterial infection (Myers, 2010).

Medication History Cyclopentolate Hydrochloride is an ophthalmic anti-cholinergic drug that prevents the muscle of the ciliary body and the sphincter muscle of the iris from responding to cholinergic stimulation, causing mydriasis and cycloplegia which is required in specific diagnostic procedures. Nursing responsibilities when administering this drug are that finger pressure should be applied to lacrimal sac for 1-2 minutes after instillation to decrease risk of absorption and systemic reactions and avoid bright light (photophobia due to cycloplegic action) (Wilson, Shannon & Shields, 2011). Predforte (Prednisolone Acetate) is an ophthalmic corticosteroid drug that decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability; suppresses the immune system by reducing activity and volume

CASE STUDY of the lymphatic system. Its use is to treat inflammation of the anterior segment of globe, cornea, and palpebral and bulbar conjunctiva. Nursing considerations when administering this drug are to not administer acetate or tebutate salt intravenously and because prednisolone can produce many adverse reactions, assess patient regularly for evidence of such reactions, including heart failure and hypertension (Wilson, Shannon & Shields, 2011).

Needs Approach Based on the subjective and objective data collected above the following needs were identified: i). Rest, Comfort and Activity were disturbed as he complained of pain to both eyes, ii) Safety and Security because he had recently did an eye surgery and has a break in the tissue and is at risk for infection and also falls due to visual limitations, iii) Nutrition need is affected as A.C. is not eating properly as he should and iv)Psychosocial need is also affected because he expressed concerns about not be able to see every again.

Comprehensive Nursing Care Plan A nursing care plan was formulated for Mr. A.C. after his surgical intervention. Priority nursing diagnosis is Acute Pain related to surgical incision as evidence by patient verbalizing pain rated at six (6) on the pain rating scale. Patients objective: At the end of thirty (30) minutes, client will have a reduction in the level of pain following nursing and collaborative as evidenced by a

CASE STUDY decreased figure on the pain rating scale. Interventions: 1) Assess and document intensity, character, duration, aggravating and relieving factors of the pain. Rationale: Initial assessment

provides direction for the pain treatment plan. Adjustments are based on clients response (Ackley & Ladwig, 2008). 2) Provide optimal pain relief with prescribed analgesic and monitor for adverse effects. Rationale: Pain management should be aggressive and individualized to eliminate any unnecessary pain (Carpenito-Moyet, 2010). 3) Practice relaxation techniques such as deep breathing exercises. Rationale: Studies have shown that the human brain secretes endorphins, which have opiate-like properties that relieve pain (Carpenito-Moyet, 2010). 4) Explain and commence implementation of non-invasive pain relief methods to client and his mother such as massages, positioning and distraction such as music. Rationale: These can enhance the therapeutic effects of pain relief medications (Ackley & Ladwig, 2008). Evaluation: Goal met, at the end of thirty (30) minutes following nursing and collaborative management patient is now verbalizing a reduction in the level of pain which is now at two (2). Risk for Injury (Falls) related to visual limitations is A.C.s potential nursing diagnosis. Patients objective: At the end of the eight (8) hour shift, client will report no falls following nursing and collaborative interventions. Interventions: 1) Orient the patient in the room. Rationale: Improving safety and mobility in the environment (Doenges, Moorhouse & Murr, 2010). 2) Help the patient set the environment. Rationale: Providing facilities of independence and lower the risk of injury (Carpenito-Moyet, 2010). 3) Give the patient the position head high, or tilted to the side that is not ill, according to patient preference. Rationale: this will lower the risk of fall accidents (Doenges, Moorhouse & Murr, 2010). 4) Help the patient when able to do until postoperative ambulation and achieve stable vision and adequate coping skills, using techniques of vision guidance. Rationale: Reduce the risk of falling or injury when the step stagger or have no coping

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skills for vision impairment (Carpenito-Moyet, 2010). Evaluation: Goal met, at the end of the eight (8) hour shift client reported no falls. Anxiety related to change in health status as evidenced by verbalization of uncertainty regarding changes in eyes, which is an actual diagnosis pertaining to the psychosocial need. Patients objective: At the end of the eight (8) hour shift, client will express no anxiety following nursing interventions as evidenced by reporting anxiety is reduced to a manageable level. Interventions: 1) Assess anxiety level, degree of pain experienced, suddenness of onset of symptoms, and current knowledge of condition. Rationale: These factors affect clients perception of threat to self, potentiate the cycle of anxiety, and may interfere with medical attempts to control IOP (Doenges, Moorhouse & Murr, 2010). 2) Provide accurate, honest information. Discuss probability that careful monitoring and treatment can prevent additional loss of vision. Rationale: Reduces anxiety related to unknown or future expectations and provides factual basis for making informed choices about treatment (Doenges, Moorhouse & Murr, 2010). 3) Encourage client to acknowledge concerns and express feelings. Rationale: Provides opportunity for client to deal with reality of situation, clarify misconceptions, and problem-solve concerns (Doenges, Moorhouse & Murr, 2010). 4) Identify helpful resources. Rationale: Provides reassurance that client is not alone in dealing with problems (Doenges, Moorhouse & Murr, 2010). Evaluation: Goal partially met, at the end of the eight (8) hour shift client reported that he is understands the risks associated and expresses less anxiety.

Application of Ethical and Legal Issues Ethical/legal principles in nursing play a significant role in total patient care. Nursing care is guided by the institutions policy, the nurses ethical conduct, moral principles and her personal

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value system. Every patient has the right to make their own decision as informed consent is needed in their care (Burkhardt & Nathaniel, 2007). Throughout A.C.s nursing care the nurses ensured that beneficence and privacy and confidentiality are upheld. According to Parker (2007), the principle beneficence is about doing more that just not harming another person. This principle suggests that ethical behaviour must "do good". In fact this principle in its true meaning suggests an obligation to benefit others. Also, privacy belongs to each person and, as such, it cannot be taken away from that person unless he/she wishes to share it. According to the ICN Code of Ethics (2006), nurses have four fundamental responsibilities. They are to promote health, to prevent illness, to restore health and to alleviate suffering. In providing care, the nurse promotes an environment in which the human right, values, customs and spiritual beliefs of the individual, family and community are respected. When caring for A.C, the nurses incorporated his mother in teachings associated with his care as she visited on a regular basis. Overall, A.C.s care was done within all the stipulated guidelines for nursing care.

References Ackley, B J., & Ladwig, G.B. (2008). Nursing diagnosis handbook (8th ed.). Missouri: Mosby, Elsevier. Burkhardt, M., & Nathaniel, A. (2007). Ethics and issues in contemporary nursing (3rd ed.). Denmark, DE: Cengage Learning.

CASE STUDY Carpenito-Moyet, L.J. (2010). Handbook of nursing diagnosis (13th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing care plans: Guidelines for individualizing client care across the life span (8th ed.). Philadelphia, PA: F. A. Davis Company. International Council of Nurses Code of Ethics for Nurses (2006). Retrieved February 28, 2011, from http://www.icn.ch/icncode.pdf. Myers, E. (2010). RNotes: Nurses clinical pocket guide (3rd ed.). Philadelphia, PA: F.A. Davis Company. Parker, F. M. (2007). Ethics: The Power of One. The Online Journal of Issues in Nursing, 13(1). doi:10.3912/OJIN.Vol13No01EthCol01 Wilson, B. A., Shannon, M.T., & Shields, K.M. (2011). Pearson nurses drug guide 2011. Upper Saddle River, NJ: Pearson Education.