Optic Neuritis Case Study Example

Jessica is a 32 year old female who is employed as a math teacher who entered the ER with a friend for an evaluation of sudden decrease in vision in her left eye. Jessica denies any trauma, injury, tearing, redness, or exposure to chemicals. She states she noticed the decrease in vision this morning when she woke up and since then it has progressively worsened. She states she has had some blurring of her vision that started about a month ago. Jessica attributes the blurring to becoming overheated, as it resolves when she enters a cool, air-conditioned environment. She also states she has some pain in her eye when she tries to move it, but on resting. Additionally, Jessica states she is unable to determine any colors. Jessica denies any known factors that make it any better or worse.
Jessica has a positive medical history of chickenpox at age 10 and a tonsillectomy/adenoidectomy at age 11. Since then, Jessica has been a healthy female with no medical problems or hospitalizations. She has four children, all delivered via spontaneous vaginal births. Jessica received a bachelor’s degree in mathematics and a master’s degree in education. She previously smoked two packs of cigarettes a day for five years but quit the habit 10 years ago. She drinks an occasional wine cooler and denies illicit drug use.
Jessica has a positive family history of coronary artery disease and hypertension. Her father received a stent at the age of 67 to correct his coronary artery disease while her mother is positive for hypertension.
Upon examination, Jessica’s other body symptoms remain asymptomatic and negative for any recent changes. She denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia. Jessica is alert and oriented while appearing anxious. Jessica has BP of 135/85 mmHg, HR of 64 bpm and regular, RR of 16 breaths per minute, and a temperature of 98.5 degrees Fahrenheit. Her visual acuity measures 20/200 in her left eye and 20/30 in her right eye. Her sclera are white and the conjunctivae is clear. I was unable to assess her visual fields on her left side and those are her right are intact. Pupillary response to light is diminished in the left eye and brisk in the right eye. Her left optic disc is swollen. Jessica’s cranial nerves I through XII are intact. Horizontal nystagmus is present; her muscles have normal bulk and tone; she can touch her finger to her nose; she is negative for the Romberg test; her sensation to temperature, vibration, and two-point discrimination in her upper and lower extremities is intact; her reflexes measure 2+ and symmetric in biceps, triceps, brachioradialis, patellar, and Achilles tendons; and she is negative for a Babinski reflex.
I suspect Jessica is suffering from optic neuritis in her left eye. Optic neuritis is sudden inflammation of the optic nerve, causing reduced vision in the affected eye (Lusby). The exact cause is unknown, but has been linked to certain autoimmune diseases (Lupus, Sarcoidosis), cryptococcosis (a fungal infection), certain bacterial infections (TB, syphilis, Lyme disease, meningitis), certain viral infections (viral encephalitis, measles, rubella, chickenpox, herpes zoster), respiratory infections (mycoplasma pneumonia), and multiple sclerosis (Lusby). The patient should also be questioned if he or she has used the drug ethambutol, a medication used to treat tuberculosis, as it can also cause optic neuritis (Optic neuritis). The symptoms of the condition include loss of vision in one eye that comes on suddenly without a few hours, changes in the way the pupil reacts to light, loss of color vision, and pain on movement of the eye (Lusby). According to another source, patients may also experience flashing lights in their visual field (Optic neuritis). A complete medical examination and visual testing can be done to rule out other possible diagnoses (Lusby). Visual testing to confirm a diagnosis includes color vision testing, MRI of the brain to visualize the optic nerve, visual acuity testing, visual field testing, and examination of the optic disc via indirect ophthalmoscopy. Vision is likely to return within two to three weeks with no treatment. If the patient or health care provider would like to expedite the healing process, corticosteroids can be administered via IV or by mouth (Lusby). However, corticosteroid use should be cautioned as it can cause widespread side effects and increase the risk of having a future episode (Optic neuritis). The cause of the condition should be explored if linked to one of the previous stated illnesses so as to treat the illness and prevent further reoccurrences (Lusby). If the optic neuritis is of idiopathic etiology, the prognosis is good, whereas if the cause is an autoimmune disease, the prognosis can be poor. Furthermore, patients with optic neuritis are more likely to develop an autoimmune disease (Lusby).
During Jessica’s acute episode of visual loss, she is experiencing disturbed sensory perception and anxiety and is at risk for injury and falls. Nursing interventions for the diagnosis for disturbed sensory perception include decreasing visual stimuli so as not to exacerbate the visual disturbance, encourage and provide adequate rest, and orient patient to surroundings (Ackley). These would be completed within an inpatient setting, if Jessica were to be admitted into a hospital. However, all of these can be altered to happen in the home. For at home management, the nurse would educate Jessica on how to avoid stimuli, how to promote rest, and how to orient herself to her home, which should already be very familiar to her. If there is anyone else living with Jessica, such as her children and/or a significant other, she can also educate them on how to help her achieve these goals. Jessica should also look into having someone watch her children if they need supervision so that she can rest more easily. To reduce Jessica’s anxiety related to her vision loss, nursing interventions include creating a calm environment, listening to Jessica’s concerns, reassuring Jessica that she has a good chance of a good prognosis, increasing Jessica’s knowledge about optic neuritis, and giving Jessica the option of starting corticosteroid therapy. Most of these will be completed within her visit to the ER. However, the nurse can also give her ideas on how to create a calming environment at home to calm her as she recovers from the illness. Furthermore, Jessica is at risk for injuries and falls due to her decreased visual field, specifically on her left side. Interventions to decrease her risk for injury include clearing the area of hazards, orienting her to her surroundings, keeping commonly used items within reach, and limiting her activities. These goals can be achieved in both the inpatient and home setting. If Jessica were admitted to a hospital, the nurse will make sure the area is cleared of hazards, tell her where she might find anything she needs, and keep everything within reach. At home, as previously stated, she should be well acclimated to her surroundings, but she should also make sure there are no hazards in her walkway and that her most used items are close within reach to prevent further complications. I imagine the doctor would ask Jessica not to drive or operate machinery and limit her activities to simple tasks. The nurse would go over these instructions and ask her if she has resources to help her with the more complex tasks and driving her to places while her left field of vision is absent (Ackley). Finally, the nurse should reiterate if any of her symptoms should change or worsen, she should seek medical attention immediately.

References

Ackley, B. (2010). Nursing diagnosis handbook: An evidence-based guide to planning care
(10th ed.). Maryland Heights, Missouri: Mosby.
Lusby, F. (Updated 2013, August 23). Optic neuritis. Retrieved April 8, 2015, from
http://www.nlm.nih.gov/medlineplus/ency/article/000741.htm
Optic neuritis. (2014, February 18). Retrieved April 8, 2015, from
http://www.mayoclinic.org/diseases-conditions/optic-neuritis/basics/definition/con-20029723