Influence of Physical Findings in Nursing Diagnosis
With the nature of the complexity of illnesses currently, extensive research is essential to avoid misdiagnosis. Nursing diagnosis entails the nurses’ clinical judgment based on the patients’ reactions regarding their actual or potential health status, thus, using a selective intervention to achieve a precise outcome. According to the North American Nursing Diagnosis Association (NANDA), the diagnosis involves problem identification, etiology, and the classification of signs and symptoms (Doenges, 2016). This discourse seeks to elaborate on the influence of physical findings to determine an eye condition’s probable nursing diagnosis.
Physical findings classify patients to different admissions. This condition is based on the severity of the illness from the results of the environmental analysis. This is determined through observational assessments. In this process, the nurse examines a patient for any possible symptoms of a condition. Firstly, it is essential to understand the objective and subjective data about the patient. This is the first step in understanding the problem (Karaca, 2018). For instance, by obtaining data from the patients on the speed and time of onset of the problem, it facilitates broader knowledge understanding the beginning of the swollen eye.
Through physical findings, one can obtain information on any ocular associations to the conditions, for instance, the pain, the swelling, or even the blurry vision. Secondly, inquiring about the systemic associations (Pinto, 2017). Failure to investigate this can cause an overlook of essential information since most patients may fail to notify the nurses of such symptoms, as they may find them non-relatable to their condition, for instance, the eye’s swelling. Thirdly, it is imperative to obtain information from their past ocular history as part of the physical findings. To make an appropriate diagnosis. Also, the patient’s lineage eye history can be essential in ruling out the possibility of inherited conditions.
With a particular focus on the case study, understanding the cause of the eye inadequacy vision inadequacy is imperative. The nurse is required to assess the patient’s visual acuity. This can is conducted by using the universal standard hanging wall chart. Through this, the nurse can subjectively ascertain the acuity’s nature based on the patient’s ability to interpret the contents charts (Jeon, 2018). This physical procedure is essential to narrow down the diagnosis scope.
Additionally, another accepted terminology in the NANDA guidelines is through the pinhole testing to ascertain the refractive error of the swollen eye. This stage determines the correction method of the conditions; for instance, some cases might recommend glasses, lenses, or surgery. In the case of medicine, a more intrusive procedure will be performed to determine the nature of the operation required to correct the problem.
Also, understanding the patient’s vital signs, such as the heart rate, temperature, blood pressure, and breathing rate. It helps the nurse understand the patients’ health conditions; hence medical procedures are performed in line with their compatibility mode to reduce the chances of reactions and errors. This is also essential in the computation of dosing weights and other nutritional recommendations. Having obtained this information, the nurse can make a conclusive diagnosis concerning their classification terminology to determine the probable conditions before administering a medical prescription.
Physical findings have been adopted in the medical spectrum to facilitate diagnosis. It is an essential step used by nurses to assess the patient’s medical history and obtain crucial data. This data is then analyzed before the patient is subjected to more intrusive examination procedures. In less severe cases, physical findings can provide conclusive data and allow for an accurate diagnosis. For conditions with higher severity, physical findings help to narrow down the scope of diagnosis, hence, redirecting the examination to more specific procedures.
References
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2016). Nursing diagnosis manual: Planning, individualizing, and documenting client care. FA Davis
Karaca, T., & Aslan, S. (2018). Effect of ‘nursing terminologies and classifications’ course on nursing students’ perception of nursing diagnosis. Nurse education today, 67, 114-117.
Jeon, Sungwon. Has De-listing Routine Eye Examinations Increased the Use of Primary Care Providers for Ocular Diagnoses?. Diss. 2018.
Pinto, S., Caldeira, S., & Martins, J. C. (2017). A qualitative study about palliative care patients’ experiences of comfort: Implications for nursing diagnosis and interventions. Journal of Nursing Education and Practice, 7(8), 37-45