Disturbed Sensory Perception (visual) related to Glaucoma

Nursing Care Plan for Glaucoma

Glaucoma is a group of eye disorders characterized by increased intraocular pressure. (Barbara C. Long, 2000: 262)

Glaucoma is an eye condition that is usually caused by an abnormal increase in intraocular pressure (up to more than 20 mmHg). (Elizabeth J.Corwin, 2009: 382)


Classification

Glaucoma is divided into; primary glaucoma, secondary, and congenital.

1. Primary Glaucoma

In primary glaucoma has no known cause, obtained form:

• Closed angle glaucoma, acute congestive glaucoma.
• Open angle glaucoma, chronic simple glaucoma.

2. Secondary Glaucoma

Secondary glaucoma occurs as a result of other diseases in the eye, caused by:
a. Lens aberration.

• Luxation.
• Swelling (intumescent).
• Phacolytic.

b. abnormalities of the uvea

• Uveitis.
• Tumors.

c. Trauma

• Bleeding in the anterior chamber. (Hyphema).
• Perforation of the cornea and iris prolapse, which caused leucoma adherent.

d. Surgery

• Anterior chamber are not quickly formed after cataract surgery.

e. Other causes of secondary glaucoma

• Rubeosis iridis (due to central retinal vein thrombosis).
• Excessive use of topical corticosteroids.

3. Congenital glaucoma

• Primary congenital glaucoma or infantile glaucoma. (Buftalmos, hidroftalmos).
• Glaucoma concerned with other congenital abnormalities.

4. Absolute Glaucoma

• Final state of a glaucoma, ie with total blindness and eye pain.

(Sidarta Ilyas, 2002: 240-241)


Clinical Manifestations

1. Pain in the eye and surrounding areas (orbital, head, teeth, ears).
2. View of foggy, Seeing rainbows around lights.
3. Nausea, vomiting, sweating.
4. Red eye, conjunctival hyperemia, and ciliary.
5. Decreased visual acuity.
6. Corneal edema.
7. Shallow anterior chamber (may not be found in open-angle glaucoma).
8. Pupil wide oval, no reflex to light.
9. IOP increases.

(Anas Tamsuri, 2010: 74-75)


Nursing Diagnosis : Disturbed Sensory Perception (visual) related to decrease in visual acuity and clarity of vision.

Subjective:

• Stated vision blurred, indistinct, decreased vision area.

Objective:

• Decreased visual field examination.
• Decreased ability to identify the environment (objects, people, places)

Goal:
The client reported a greater ability to process visual stimuli and communicate the visual changes.

Expected outcomes:

• The client identifies the factors that affect visual function.
• The client identifies and shows patterns of alternatives to improve the visual stimuli reception.

Interventions :

1.Assess the client's visual acuity.
2. Approach the clients of the healthy side.
3. Identification of alternatives to optimize the stimulus source.
4. Adjust the environment to optimize vision:

• Orient the client to the ward.
• Place the tool that is often used near a client or on the sides of the eyes healthier.
• Provide sufficient lighting.
• Put in place a fixed tool.
• Avoid glare.

5. Encourage the use of alternative acceptable environmental stimuli: auditory, tactile.


Rationale :

1. Identify the client visual capabilities.
2. Provide sensory stimulation, reducing the sense of isolation / alienation.
3. Giving sight accuracy and maintenance.
4. Improving the ability of sensory perception.
5. Improving the ability of response to environmental stimuli.

Nursing Diagnosis Intervention Read more »

Disturbed Sensory Perception: Hallucinations related to Social Withdrawal

Nursing Care Plan for Hallucinations

Nursing Diagnosis : Disturbed Sensory Perception: Hallucinations related to Social Withdrawal

Goal : The client is able to control the hallucinations .

Outcomes :

• Patients can and want to shake hands .
• Patients want to mention names , would call out the name of the nurse and want to sit together .
• Patients can mention the cause of the client withdrew .
• Patients want to connect with other people .
• After a home visit to a client in touch with family gradually

Intervention :

1. Construct a trusting relationship .
2. Make a contract with the client .
3. Perform introductions .
4. A name calling .
5. Invite a conversation with a patient friendly .
6. Assess the client's knowledge about the behavior of withdrawn and the signs
7. and give the client a chance to express feelings cause the patient does not want to hang out / withdrawal.
8. Explain to the client about withdrawn behavior , and signs that may be the cause .
9. Give praise to the client's ability to express feelings .
10. Discuss about the advantages of touch .
11. Slowly and with the patient in the room activity through defined stages .
12. Give credit for the success that has been achieved .
13. Instruct the patient to independently evaluate the benefits of touch .
14. Discuss daily schedule to do the patient to fill his time .
15. Motivation patient in following activity room .
16. Give credit for participation in the activity room .
17. Perform kungjungan home , building a trusting relationship with the family .
18. Discuss with your family withdrawn behavior , and the causes of a family facing car .
19. Encourage family members to communicate .
20. Instruct patient's family members routinely visit patients at least once a week .

Nursing Diagnosis Intervention Read more »