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John Jerome is a 45-year-old male who made an appointment for an annual employment physical

assessment. Mr. Jerome completed a written questionnaire in preparation for his meeting with a

healthcare professional. He checked “none” for all categories of family history of disease except

diabetes. He indicated that he knew of no changes in his health since his last assessment.

The focused history reveals the following: A male wearing eyeglasses entered the room. He

turned his head to the left and right and looked about the room before sitting across from the

examiner. The patient had some redness in the sclera of both eyes. During the interview, the

patient reveals that his last eye examination occurred 6 months ago, and he received a

prescription for new glasses. He states that he is still having a problem with the new glasses and

needs to have them checked. When asked to describe the problem, Mr. Jerome replies, “I just

don’t feel right with these glasses, and these are the second pair in a little over a year.” He further

states, “I just think I am overworking my eyes lately. I need to rest them more than ever, and I

have had some headaches. I thought the glasses would help, but it hasn’t gotten better.” The

patient denies any other problems. In response to inquiries about family history, he reports that

his mother had diabetes but had no problems with her eyes. He doesn’t know of any other eye

problems in his family, except his mother had told him that an aunt of hers had been blind for

some time. He reiterates that his only problem of late has been “this thing with my glasses,

otherwise I feel fine.”

The physical assessment reveals the following:

• Vital signs: BP 128/84—P 88—RR 22

• Height 6 3 , weight 188 lb

• Eyeballs firm to palpation

• Moderately dilated pupils

SAMPLE DOCUMENTATION The following information is summarized from the case study.

SUBJECTIVE DATA:

Visit for annual employment physical assessment. Negative family

history except diabetes. No changes in health since last assessment. Last eye assessment 6

months ago—result prescription for new glasses. Stated he was having a problem with the new

glasses. “I don’t feel right with them.” Stated, “I think I’m overworking my eyes lately. I thought

the new glasses would help, but it hasn’t gotten better.” History of aunt with blindness.

OBJECTIVE DATA:

Turns head to left and right and looked around room before sitting across

from examiner. Scleral redness bilaterally. Eyeballs firm to palpation. Pupils moderate dilation.

Cupping of optic discs. Height 6 3 , weight 188 lb. VS: BP 128/84—P 88—RR 22.

 

1. What conclusions would the nurse reach based on this data? How was this conclusion formulated?

2. What information is missing?

3. What is the priority of this patient, and what options would apply?

4.As Mr. Jones ages, for what age-related vision changes will he be at risk?

SCIENCE
HEALTH SCIENCE
NURSING
NURS 321L

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