Objectives
Develop a plan of care for the eyes and ears
Demonstrate documentation of the eyes and ears assessment findings
Explain how to conduct a physical assessment of the eyes and ears
Assignment Overview
In this writing assignment, you will review a case scenario and submit an assignment providing information on how you would conduct a focused physical assessment of the client based on the presenting complaints. You will document your findings from the focused history and physical assessment data elicited and develop a nursing plan of care for this client.
Step 1
Review the case scenario.
Mrs. Young presents to the pediatric clinic with her son Marcus, who is a six-year-old African American male child. Marcus was sent home from school because the school nurse noticed he had discharge around his eye. You perform the following assessment:
Onset: Mrs. Young tells you Marcus woke up that morning with some discharge around his right eye. She thought perhaps he had gotten something in his eye during the night. When you ask Marcus when his eye started itching, he tells you when he woke up this morning his eye was all “gunky” and itchy, and his mom cleaned it up before he went to school. When asked how his eye feels, Marcus tells you his eye has been “itchy all day” and he has been rubbing it “all day.”
Location: When asked which eye itches Marcus points to his right eye. When asked if his other eye itches, Marcus shakes his head “no.”
Characteristics: When asked to describe the discharge, Mrs. Young tells you it was dry and crusty in the morning, and his right eye was stuck shut. She said his eye also looked red, which is why she thought he had gotten something in it that night.
Aggravating factors: When asked what makes his eye feel worse, Marcus tells you it itches all the time.
Alleviating factors: When asked what makes his eye feel better, Marcus tells you it felt better right after his mom washed his eye, but by the time he got to school it was itchy again.
Other background Information: Mrs. Angie Young is a married 30-year-old African American female who has a seven-year-old daughter at home in addition to Marcus and is currently pregnant with her third child. She is a stay-at-home mother but is very involved in school activities with her children.
You also perform a physical assessment, with the findings below:
Head: Normocephalic, atraumatic, without tenderness, visible or palpable masses, depressions, or scarring. Hair is of normal texture and evenly distributed.
Ear: The pinna, tragus, and ear canal are non-tender and without swelling. The ear canal is clear without discharge. The tympanic membrane is pearly gray in appearance with light reflex in appropriate location. Hearing is intact with acuity of whispered voice.
Eye: Right eye is red with some discharge. Left eye is clear with no discharge. (This is only a partial write up for eye-you must do the rest.)
Diagnosis and treatment: Marcus Young is diagnosed with bacterial conjunctivitis (pink eye) and started on antibiotic eye drops: Ciloxan ophthalmic ointment to his right eye three times a day for two days, then twice a day for five days.
Step2
Write a 3-page (750 word) paper using APA 7.0 format style and address the information below.
You are precepting a student nurse today who is taking her assessment class. She is learning about focused history and assessment skills. In your paper, discuss the following items:
Write a detailed explanation describing what you would say to the student, explaining the assessment techniques utilized and the findings. Discuss the eye assessments that should be performed and any additional assessments you would perform. What are other factors related to the probable diagnosis you would be concerned about with this client?
Explain how you would document your findings in the medical record.
Develop your plan of care. Identify two NANDA nursing diagnoses and two nursing interventions for each diagnosis. The interventions must be evidence based. Cite the references used in your plan in APA 7.0 format.
Identify the client education necessary for Marcus, given his background and presenting illness. Describe your teaching strategy and how you will evaluate the effectiveness of the educational intervention.
Be sure to cite all the sources you used in the completion of this assignment and include a reference list.