Nursing Diagnosis and Interventions for Glaucoma
1. Acute Pain related to an increase in IOP
Goal: Pain is reduced and the client is on the comfort level.
Expected outcomes:
- The Client do not complain of pain.
- Normal intraocular pressure / down.
- Calm facial expression.
- Assess the type, intensity and location of pain. Use pain scale to determine the level of analgesic doses.
- Keep the rest in bed in a quiet room and dark with the head elevated 30 ° or in a comfortable position.
- Rest of clients in the room that does not dazzle with the head rather an extension or a comfortable position for the client.
- Encourage relaxation techniques.
- Avoid nausea, vomiting, give anti-emetic if necessary.
- Collaboration with physicians in providing analgesic.
2. Disturbed Sensory Perception (visual) related to damage to the nerve fibers due to increased IOP.
Goal: Decrease of visual field can be reduced.
Expected outcomes:
- The client can use the drug correctly.
- Cooperative in every action.
- Realized loss of eyesight permanently.
- Vision did not decline further.
Interventions:
- Assess and record the visual acuity.
- Assess functional description of what can be seen / not.
- Environment with the ability to adjust the vision.
- Orient on the environment: Put the tools that are often used in client outreach vision, Provide adequate lighting, Put the tools in place which remains, Provide reading materials with great writing, avoid glare.
- Use the clock sound.
- Assess the amount and type of stimuli that can be accepted by the client.
- Advise on alternative forms of stimulation such as radio, TV.
3. Risk for injury related to a decrease in the visual field.
Goal: The client was not injured.
Expected outcomes:
- The client can explain how to prevent injury.
- The is able to demonstrate on alertness anxiety.
- The officer asked for help when the ends meet.
- Orient the client to the environment when it arrives.
- Explain the origin of a decrease in peripheral vision and do like bumping into objects.
- Suggest to turn his head to look into each side.
- Arrange the room in order to walk around freely.
- Make modifications to the environment to move all the dangers: Get rid of the obstacles on a walk. Get rid of the foot rolls. Get rid of items that may injure the client. Help clients and families to evaluate the home environment against the dangers that may occur.
4. Risk for infection related to the surgical wound.
Goal: infection can be prevented / controlled.
Expected outcomes:
- Free from signs and symptoms of infection.
- Wash hands before and after nursing actions.
- Improve sufficient nutrients (nutritious and contain vitamin A).
- Monitor signs and symptoms of systemic and local infections.
- Monitor susceptibility to infection.
- Inspection condition of the wound / surgical incision.
- Instrusikan clients to drink antibiotics as recommended.
- Teach clients and families about the signs and symptoms of infection, and how to avoid infection.
5. Disturbed body image related to the lesions on the skin which affects its appearance.
Goal: The client can accept the situation.
Expected outcomes:
- Discuss strategies to cope with changes in body image.
- Assess the patient's knowledge of the existence of a potential disability associated with surgery or skin changes.
- Monitor the patient's ability to see the changes against him.
- Encourage the patient to discuss feelings about the changes in the appearance of the surgery.
- Give support group for people nearby.
6. Anxiety related to loss of vision, lack of knowledge.
Goal: Anxiety is reduced.
Expected outcomes:
- Reduced feeling nervous.
- Reveals an understanding of the plan of action.
- Relaxed body position.
- Carefully deliver permanent loss of vision.
- Give the client the opportunity to express about the condition.
- Maintain a relaxed condition.
- Explain the purpose of each action.
- Prepare bell on the bed and instructed the client to indicate when asking for help.
- Maintain effective pain control.
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