Nursing Diagnosis Cataract

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Nursing Diagnosis for a patient with cataract

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Nursing Diagnosis Altered sensory perception (visual) related to altered sensory reception due to cataract

Expected Outcome After 16 hours of nursing intervention, the patient will be able to recognize and compensate for sensory impairments.

Nursing Intervention 1. To assess causative/contributing factors and degree of impairment: • Identify client with condition that can affect sensing, interpreting, and communicating stimuli (e.g., cataract). • Review results of laboratory tests (e.g., serum electrolytes, chemical profile, ABGs, serum drug levels). • Assist with/review diagnostic studies and sensory /motor neurological testing. • Monitor drug regimen to identify medications with effects or drug interactions that may cause /exacerbate sensory/ perceptual problems. • Assess ability to speak, hear, interpret and respond to simple commands to obtain an overview of client’s mental/cognitive status and ability to interpret stimuli. • Evaluate sensory awareness:eapecially stimulus of visual acuity and hearing; gait/mobility • Observe for behavioral responses (e.g., illusions/hallucinations, delusions, withdrawal, hostility, crying, inappropriate affect, confusion /disorientation). • Ascertain client’s/SO’s perception of problem /changes in activities of daily living. Listen to and respect client’s expressions of deprivation and take these into consideration in planning care.

Evaluation Goal met. The patient was able to identify way to compensate with visual impairments.

Discharge Instruction Medications

Environmental Modifications

Teachings

Home Instructions

Outpatient Follow up

Drug Interactions

Social Support

2. To promote normalization of response to stimuli: • Provide means of communication, as indicated. • Encourage use of listening devices (e.g., hearing aid, audiovisual amplifier, closed-caption TV, signing interpreter) to assist in managing auditory impairment. • Avoid isolation of client, physically or emotionally, to prevent sensory deprivation /limit confusion. • Promote a stable environment with continuity of care by same personnel as much as possible. • Interpret stimuli/offer feedback to assist client to separate reality from fantasy/altered perception. • Reorient to person, place, time, and events, as necessary. Explain procedures/activities, expected sensations, and outcomes. • Limit/carefully monitor use of sedation, especially in older population. • Minimize discussion of negatives (e.g., client and personnel problems) within client’s hearing. Client may misinterpret and believe references are to himself or herself. • Eliminate extraneous noise/stimuli, including nonessential equipment, alarms/audible monitor signals when possible. • Provide undisturbed rest/sleep periods.

• Speak to visually impaired or unresponsive client during care to provide auditory stimulation and prevent startle reflex. • Provide tactile stimulation as care is given. Touching is an important part of caring and a deep psychological need communicating presence/connection with another human being. • Encourage SO(s) to bring in familiar objects, talk to, and touch the client frequently. • Provide sensory stimulation, including familiar smells/ sounds, tactile stimulation with a variety of objects, changing of light intensity and other cues (e.g., clocks, calendars). • Provide diversional activities, as able (e.g., TV/radio, conversation, large-print or talking books). • Promote meaningful socialization. (Refer to ND Social Isolation.) • Collaborate with/involve other health-team members in providing rehabilitative therapies and stimulating modalities (e.g., music therapy, sensory training, remotivation therapy) to achieve maximal gains in function and psychosocial well-being. • Identify and encourage use of resources /prosthetic devices (e.g., hearing aids, computerized visual aid/glasses with a level plumbline for balance). Useful for augmenting senses. 3. To prevent injury/complications:

• Record perceptual deficit on chart so that caregivers are aware. • Place call bell/other communication device within reach and be sure client knows where it is/how to use it. • Provide safety measures, as needed (e.g., side rails, bed in low position, adequate lighting; assistance with walking; use of vision/hearing devices). • Review basic and specific safety information (e.g., “I am on your right side”; “This water is hot”; “Swallow now”; “Stand up”; “You cannot drive”). • Position doors and furniture so they are out of travel path for client with impaired vision, or strategically place items/grab bars to aid in maintaining balance. Ambulate with assistance/devices to enhance balance. • Describe where affected areas of body are when moving client. • Monitor use of heating pads/ice packs; use thermometer to measure temperature of bath water to protect from thermal injury. • Refer to NDs risk for Injury; risk for Trauma; risk for Falls. 4. To promote wellness • Assist client/SO(s) to learn effective ways of coping with and managing sensory disturbances, anticipating safety needs according to client’s sensory deficits and developmental level.

• Identify alternative ways of dealing with perceptual deficits (e.g., vision and hearing aids; augmentative communication devices; computer technologies; specific deficit-compensation techniques). • Provide explanations of and plan care with client, involving SO(s) as much as possible. Enhances commitment to and continuation of plan, optimizing outcomes. • Review home safety measures pertinent to deficits. Discuss drug regimen, noting possible toxic side effects of both prescription and OTC drugs. Prompt recognition of side effects allows for timely intervention/change in drug regimen. • Demonstrate use/care of sensory prosthetic devices (e.g., assistive vision or listening devices, etc.). • Identify resources/community programs for acquiring and maintaining assistive devices. • Discuss with client/SO ways to prevent/limit exposure to conditions affecting sensory functions (e.g., how exposure to loud noise and toxic side effects of some drugs can impair hearing; early childhood screening for speech and language disorders; vaccines to prevent measles, mumps, meningitis[once known to be major causes of hearing loss]). • Refer to appropriate helping resources, such as Society for the Blind, Self-Help for the Hard of Hearing (SHHH), or local support groups, screening programs, etc.

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