NR 325 Week 3 Case Study

Student Name

Chamberlain University

NR-325 Adult Health II

Prof. Name

Date

NR 325 Adult Health II – Case Study #1

Patient Profile

P.J. is a 74-year-old woman with a significant and complicated medical history. She has been hospitalized multiple times in the past, most recently discharged one month ago following a 14-day admission for a gangrenous open cholecystectomy. During that hospitalization, the gangrene extended into the common bile duct, resulting in a postoperative bile leak. This complication was further influenced by her history of diabetes mellitus.

Currently, P.J. presents to the emergency department with a seven-day history of progressively worsening blurry vision in her left eye. She describes her vision as “fuzzy and distorted.” She reports feeling frustrated, noting that after surviving her gallbladder ordeal, she is now faced with new visual problems. P.J. has never been married but has strong social support through friends and caregivers.

She is taking the following prescribed medications:

Medication	Dosage & Route	Classification	Indication
Valsartan/Hydrochlorothiazide	160 mg/25 mg PO daily	ARB + thiazide diuretic	Hypertension
Amitriptyline	25 mg PO daily	Tricyclic antidepressant	Depression
Aspirin	81 mg PO daily	NSAID/antiplatelet	Cardiovascular prophylaxis
Alprazolam	0.25 mg PO q6h PRN	Benzodiazepine	Anxiety

Subjective Data

• Blurred and distorted vision in the left eye.
• Frustration regarding new vision problems following recent surgery.

Objective Data

• Vital signs: BP 119/79 mmHg (ARB effective), HR 82 bpm, Temp 97.7°F, RR 16 breaths/min.
• Alert and oriented to person, place, and time.
• Diminished breath sounds in bilateral lower posterior lung fields (likely postoperative atelectasis, with potential early pneumonia risk).
• Oxygen saturation: 96% on room air.

Discussion Question 1: Name six potential causes of P.J.’s blurry vision.

Possible causes of blurry vision in this patient include:

NR 325 Week 3 Case Study

Potential Cause	Mechanism/Notes
Age-related macular degeneration	Degeneration of central retina affecting sharp vision.
Hypertensive retinopathy	Chronic high BP causing retinal blood vessel damage.
Diabetic retinopathy	Microvascular retinal damage due to diabetes.
Amitriptyline use	Anticholinergic side effects causing blurred vision.
Alprazolam use	CNS depressant effects impacting visual processing.
Acute eye inflammation or infection	May cause swelling and blurred vision.
Open-angle glaucoma	Gradual loss of peripheral vision leading to blurry central vision.
Ocular tumor	Rare, but possible in elderly patients.
Retinal detachment	Sudden vision loss, medical emergency.

Discussion Question 2: What will you include in P.J.’s focused assessment?

A focused assessment should include:

1. Detailed family and past medical history (especially eye diseases, hypertension, diabetes).
2. Assessment of extraocular muscle strength (EOMs).
3. Visual acuity testing.
4. Inquiry about recent eye examinations and ophthalmologist visits.
5. Detailed hypertension history (diagnosis date, medication compliance).
6. Comprehensive ophthalmic examination (fundoscopy).
7. Smoking history (past or present).
8. Symptoms of ocular dryness or reduced tearing.

Case Study Progress

An ophthalmology consult was obtained. Examination revealed scarring in the central macula, suggesting age-related macular degeneration (AMD). The ophthalmologist recommended treatment aimed at slowing disease progression and preventing further vision loss. Photodynamic therapy was scheduled.

Discussion Question 3: What are the early signs of age-related macular degeneration (AMD)?

• Distortion of straight lines (metamorphopsia).
• Difficulty reading fine print.
• Need for brighter lighting.
• Reduced central vision clarity.
• Dark or blurry area in the center of vision.

Discussion Question 4: What tests can be done to determine if P.J. has AMD?

1. Ophthalmoscopy – to visualize drusen deposits or pigment changes in the retina.
2. Visual acuity tests – to assess clarity and sharpness of vision.
3. Amsler grid test – to detect central vision distortion.
4. Optical coherence tomography (OCT) – to image retinal layers.

Discussion Question 5: What risk factors are associated with macular degeneration?

• Smoking (primary modifiable risk factor).
• Hypertension.
• Female sex.
• Short body stature.
• Family history of AMD.
• Diet low in carotene and vitamin E.
• Prolonged unprotected sun exposure.

Discussion Question 6: What diet-related teaching will you provide P.J.?

• Wear sunglasses outdoors to reduce UV exposure.
• Increase consumption of antioxidant-rich foods such as spinach, kale, and berries.
• Include vitamin E sources (nuts, seeds, whole grains).
• Consume carotenoid-rich foods (eggs, carrots, leafy greens).
• Add vitamin C-rich fruits and vegetables.
• Ensure adequate vitamin B12 intake (shellfish, lean meats).
• Consider multivitamin supplementation if dietary intake is inadequate.

NR 325 Adult Health II – Case Study #2

Patient Profile

S.H. is a 25-year-old male presenting to the emergency department with a one-day history of severe vertigo and vomiting. He has experienced several episodes of vertigo with right-sided tinnitus over the past month. The symptoms are worsened by head movement, and he reports crawling out of bed to prevent falls. Nausea is present at rest and aggravated by positional changes.

Subjective Data

• Recurrent vertigo with tinnitus in the right ear.
• Severe nausea, worsened on sitting up.
• Fear of falling, resulting in crawling for mobility.

Objective Data

• Vital signs: BP 139/72 mmHg, HR 90 bpm, Temp 97.7°F, RR 22 breaths/min.
• Right-sided spontaneous nystagmus.
• Two episodes of vomiting in the last 30 minutes.
• Intermittent diaphoresis.

Diagnostic Studies

Test	Result
Audiogram	Severe sensorineural hearing loss (35 dB), predominantly low-frequency loss in right ear
Weber test (tuning fork)	Right sensorineural hearing loss

Discussion Question 1: What is vertigo? How is it different from dizziness?

• Vertigo is the sensation of movement—either the environment spinning around you or you spinning in space.
• Dizziness is a general feeling of imbalance or lightheadedness without the rotational sensation.

Discussion Question 2: Based on the assessment, what do you think S.H. has and why?

The presentation is consistent with Ménière’s disease, given the triad of vertigo, tinnitus, and hearing loss, with episodic worsening and audiogram-confirmed low-frequency hearing loss.

Discussion Question 3: What other diagnostic tests may be ordered for S.H.?

• Romberg test – to assess balance.
• MRI or CT scan – to rule out central causes such as tumors or strokes.
• Vestibular testing – to evaluate inner ear function.
• Electronystagmography (ENG) – to assess nystagmus patterns.

Discussion Question 4: The health care provider diagnoses S.H. with Ménière’s disease. What are the common causes of Ménière’s disease?

• Excess endolymph fluid in the inner ear (endolymphatic hydrops).
• Viral infections affecting the inner ear.
• Head or ear trauma.
• Autoimmune disorders.
• Genetic predisposition.

Discussion Question 5: What are the priority nursing diagnoses for S.H.?

• Risk for falls related to vertigo and impaired balance.
• Nausea related to vestibular dysfunction.
• Anxiety related to unpredictable symptom episodes.

Discussion Question 6: S.H. is being discharged with prescriptions for prochlorperazine and diazepam and recommendations to follow up with his primary care physician in 3–4 days. What should you teach him?

• Take prescribed medications as directed to reduce nausea and vertigo.
• Avoid sudden head movements and position changes.
• Use assistive devices or stable support when walking.
• Limit caffeine, alcohol, and sodium intake to help reduce inner ear fluid buildup.
• Rest in a quiet, dark room during acute attacks.
• Keep follow-up appointments for ongoing evaluation.

References

American Academy of Ophthalmology. (2023). Age-related macular degeneration. https://www.aao.org

American Academy of Otolaryngology–Head and Neck Surgery. (2023). Ménière’s disease. https://www.entnet.org

NR 325 Week 3 Case Study

National Eye Institute. (2022). Macular degeneration: Facts and prevention. https://www.nei.nih.gov

Mayo Clinic. (2024). Vertigo: Symptoms and causes. https://www.mayoclinic.org