Disturbed Sensory Perception Nanda Definition : Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
Cataracts in its early development can cause blurred vision, nearsightedness or color blindness. A significant cataract formation blocks and distorts light passing through the lens, causing visual symptoms and complaints. If it goes without treatment and the cataract advances to covering up the lens of the eye, the person can go blind and cannot recover his or her vision unless subjected to cataract surgery.
Causes of cataract include eye surgery, eye inflammation, congenital cataract, exposure to excessive ultraviolet light, diabetes, smoking, and the use of certain medications like steroids, statins and phenothiazines. Blurred vision, difficulty with glare, increased near-sightedness, and occasionally double vision are some of the symptoms of cataract.
There are things that must be done in order for the operated eye to heal faster and heal successfully. Medicated eye drops, taking antibiotics and regular check-up with the doctor would be necessary. Generally, the eye needs to be covered with sterile gauze after the surgery to prevent contamination and during this time no eye makeup should be used around the eye. After a day or two, the gauze can be removed but for a week the eye cover should be worn at night for assured protection.
Nursing Care Plan for Cataract
Nursing Diagnosis : Disturbed Sensory Perception (Visual) related to impaired sensory reception / status of the sensory organs are limited.
Characterized by reduced acuity, visual disturbance, change in response to stimuli normally.
Goal: no visual changes
Expected outcomes: improved visual acuity within the limits of individual situations.
Interventions and Rational
1. Determine visual acuity, note whether one or both eyes are involved.
Rational: individual needs and choice of interventions varied because loss occurs slowly and progressively.
2. Orient the patient to the environment, the staff, everyone else in the area.
Rationale: Provides improved comfort and familiarity, decrease postoperative anxiety and disorientation.
3. Observation of the signs and symptoms of disorientation; maintain fences bed until completely from anesthesia.
Rational: woke up in an unknown environment and have limited vision can lead to confusion in the elderly.
4. Approach from the side that is not in operation. Talk and touched often; push the people closest to the patient's stay.
Rational: providing appropriate sensory stimuli to the insulation and reduce confusion.
5. Notice of blurred vision and eye irritation, which can occur when using the eye drops.
Rational: vision problems / irritation can end up 1-2 hours after the eye drops but gradually decreases with usage.
6. Remind the patient to use with the goal of cataract glasses magnify approximately 25%, peripheral vision and blind spot may exist.
Rational: changes in acuity and depth perception can lead to confused vision / boost the risk of injury to the patient learns to compensate.
7. Put the items needed / call bell position, on the side that is not in operation.
Rationale: allows the patient to see objects more easily and facilitate the call for help when needed.