Bowles Case Study

Case 7.5 ■ Visual Alterations
Mâ•›rs. Margaret Cooper is a 70-year-old African American female, who has come
to Eastridge Family Health Center (EFHC) for an annual physical examination.
Mrs. Cooper is a widow who lives alone in a small second-floor apartment and is a
retail sales clerk. EFHC admission nurse John Barton conducts a health interview with
Mrs. Cooper and notes that Mrs. Cooper is alert and oriented, dressed appropriately
for the weather, and answers questions readily and completely.
Mrs. Cooper states that she is allergic to dust mites and mold, and takes Claritin-D
(10 mg loratadine/240 mg pseudoephedrine sulfate) every day. She reports that she
has osteoarthritis in both hips and knees and takes 650 mg of Tylenol (acetaminophen)
every 6 hours. She also takes Restoril (temazepam) 15 mg at bedtime for sleep.
During the interview, Mrs. Cooper complains of being “unable to see cars coming
up alongside when driving,” but denies any eye pain. Mrs. Cooper reveals that she is
experiencing “blind spots,” which are darkening and increasing in size and number,
and that she is losing visual acuity and is beginning to see “halos” around lights. Mrs.
Cooper’s daughter has accompanied her to the clinic visit and notes that Mrs. Cooper
has had several small fender bender car accidents in the past year.
John performs standard admissions assessments on Mrs. Cooper and notes that
she has an absence of the red reflex in the right eye and that her Snellen chart reading
is 20/40 (left), 20/50 (right), and 20/50 (both eyes). He observes that she has difficulty
rising from a chair, has trouble finding her way from the intake area to the exam room,
and collides with the door frame.

1. What history or physical examination findings should be the
   greatest concern to the admissions nurse?
   John continues to talk with Mrs. Cooper and discovers that she has fallen four times
   on the steps leading to her apartment and has been tripped by rugs and furniture in
   her home in the past 3 months. She states, “I have more trouble seeing the keys on the
   cash register, and I am afraid I might get fired.”
   Mrs. Cooper says, “I hope that some stronger reading glasses might help; I don’t
   think Medicare covers eye care. I don’t have the money for a prescription drug plan
   through Medicare.”
   After the clinic visit, Mrs. Cooper has been given a referral for a complete eye exam,
   including tonometry (a test of intraocular pressure). John arranges an appointment
   with a local ophthalmologist, who participates in a no-cost vision screening program
   for low-income patients. Mrs. Cooper calls after the appointment and reports that the
   tonometry tests revealed that she has open-angle glaucoma.
2. Why was Mrs. Cooper at high risk for glaucoma?
   The ophthalmologist writes prescriptions for the treatment of Mrs. Cooper’s glaucoma.
   Mrs. Cooper brings them to EFHC and asks John to give her more information about
   the medications.

Suggested Resources
Alcon Cares, Inc.–U.S. Patient Assistance. (2014). U.S. patient, clinic & institutional Â�assistance.
Retrieved from http://www.alcon.com/en/corporate-responsibility/patient-clinic-instassistance.
asp
Glaucoma Research Foundation. (n.d.). Are you at risk for glaucoma? Retrieved from http://
www.glaucoma.org/learn/are_you_at_risk.php
Hendrich, A. (2013). Fall risk assessment for older adults: The Hendrich II Fall Risk ModelTM.
The Hartford Institute for Geriatric Nursing. Retrieved from http://consultgerirn.org/
uploads/File/trythis/try_this_8.pdf
Medicare Interactive. (n.d.) When does Medicare cover eye care? Retrieved from http://www
.medicareinteractive.org/page2.php?topic=counselor&page=script&script_id=1593
National Eye Institute. (2014). Facts about glaucoma.

Case 19.2 ■ Side Effects of Opioids
Hâ•›elen Neuschwander, age 77, is in an inpatient hospice facility with the diagnosis
of end-stage lung disease. Her husband of 56 years is with her on a daily basis,
and her children are also able to visit almost daily. She is awake and alert, able to eat
small amounts, but is beginning to withdraw from her family. She is talking less and
sleeping for short periods of time throughout the day. Morphine (1 mg every 4 hours)
around the clock is being used to decrease the sensation of shortness of breath and
manage pain she is experiencing. When the first two doses of morphine are given,
Helen complains of nausea that subsides after she eats several crackers.

1. As a nurse, what would you teach Helen about the side effect of
   nausea, which may occur when an opioid narcotic is given?
2. What is the most common side effect of opioid analgesics? What
   nursing interventions can act to prevent this unwanted side
   effect?
   Mrs. Neuschwander’s family is concerned that the morphine being used to treat her
   shortness of breath and pain is causing her to sleep more. As the nurse caring for
   Helen, you have seen a decline in her overall condition and a decreased level of pain;
   in addition, she is breathing comfortably with a rate of 16 breaths per minute.
   For more than 4 weeks, the family notices that when Helen’s pain increases, the
   �dosages of morphine are also increasing. They are fearful of the higher doses and
   that Helen may suffer an “overdose.” You have assessed Helen and find that her blood
   �pressure is 110/70, heart rate 86, and respirations are 16 (regular and nonlabored).
3. Describe the term “tolerance” that is found with narcotic
   medications and how you would discuss this term with Helen’s
   concerned family.
   Mrs. Neuschwander begins to have a decreased urine output despite no change in oral
   intake. You assess her abdomen and find that her bladder is distended and firm. She
   states that she “feels like I have to go” but cannot urinate.
4. What side effect of the opioid, morphine, may be occurring?
   Why is this occurring; and what nursing interventions will you
   implement?
   One month later, it is apparent that her overall physical condition is declining and
   that she is “actively dying,” which means that death is going to occur. The family has
   been provided support and teaching about Helen’s decline in function and impending
   death. Two months after beginning morphine for pain and shortness of breath,
   Mrs. Neuschwander becomes somnolent and begins to have jerking motions in her
   upper and lower extremities.

Sample Solution