Question

A nurse at the local Senior Center made the following notation about a client: A 74-year-old female client wearing eyeglasses with bifocal lenses and hearing aid in her left ear. Walks with a shuffling gait, using a cane for support. Wearing house slippers and housedress. States, "My other doctor says I should have my eyes looked at by an expert. It's been a while, and my eyes seem to be acting up lately. I can't see so good anymore." The client states that she takes medication for "sugar" and her blood pressure and has worn glasses for years with the last prescription changed about 3 years ago. "I was a seamstress for many years and quit when I couldn't see to thread the needles anymore-just in time too. These new materials are too hard to work with!" Denies using any eye drops. Describes vision changes as difficulty seeing well at night, especially if trying to read. Uses a magnifying glass to help when reading. No eye pain or discharge, although eyes sometimes feel "dry and scratchy," with the left eye being worse than the right. Admits to rubbing eyes but without relief.

Develop a Plan of Care for this patient that includes:

2 Nursing Diagnosis

2 goals for each Nursing Diagnosis

Interventions with rationales

Answer 1

Nursing Care plan

1. Disturbed Sensory Perception Related to poor visual acuity and changes in the eyes due to ageing as evidenced by visual distortions, loss of vision, diminished visual acuity, low night vision and changes in usual response to stimuli

Expected Outcomes

·         Patient will be able to verbalize understanding of visual loss and diseases of eyes, deal with the potential for permanent visual loss, remain safe with no injury, use adaptive devices to compensate for visual loss and compliant with instructions given, and will be able to notify physician for emergency symptoms.

Nursing Interventions	Rationale
Assess the patient’s visual ability and perform activities.	The assessment provides baseline data for the determination of changes affecting the patient’s visual acuity.
Instruct and encourage a patient to visit an ophthalmologist at least yearly.	Regular checkups can monitor progressive visual loss or complications.
Arrange for sufficient lighting for a patient to carry out activities.	Elderly patients with visual disturbances need twice as much light as younger people.
Use lighting with less or no glare on surfaces of walls, reading materials, and so forth.	Elderly patient’s eyes are more sensitive to glare
Provide adequate night light for a patient’s room.	Provision of adequate lighting helps in accommodation and prevent injury.
Educate the patient on visual disturbance and its impact on life.	Provides knowledge, and improves compliance with a regimen.
Provide large print objects and visual aids for teaching.	Assists patient to see larger print and promotes a sense of independence.

2. A risk for Injury related to decreased vision, night blindness, increased the age

Expected Outcomes

·         Patient will remain free of injury and will be able to perform activities within parameters of sensory limitation.

·         The Patient and family will modify the environment to ensure patient safety and minimize injury.

Nursing Interventions	Rationale
Assess the extent and degree of visual impairment.	Baseline data allows the establishment of a plan of care based on reality.
Ensure a safe environment with adequate lighting and furniture moved away, toward the walls. Remove all potentially hazardous things like rugs and other objects.	A safe environment to reduce chances for injury.
Arrange patient’s glasses and call bell within easy reach.	Allows for assistance for the patient and for optimal visual acuity.
Educate the patient and/or family regarding a need to maintain the safe environment.	The awareness on the need for a safe environment aids in reducing the risk for injury.
Advice to wear sunglasses to reduce glare and use of contrasting bright colours in household furnishings.	Enhance visual discrimination and reduce the potential for injury.
Instruct patient to watch out for development of complications, such as sharp pain in the eye uncontrolled by analgesics, or clouding in the anterior chamber.	This may indicate infection and should be reported immediately.