Cataract - Risk for Injury and Acute Pain

Cataract - Risk for Injury and Acute Pain

Nursing Diagnosis for Cataract : Risk for injury related to an increase in intraocular pressure (IOP), hemorrhage, vitreous loss.

Expected outcomes:

• Clients can mention the factors that lead to injury.
• Clients do not do activities that increase the risk of injury.

Intervention:

1. Talk about pain, activity limitation and bandaging the eyes.
R /: Improving cooperation and the necessary restrictions.

2. Put the client on a low bed and recommended to restrict the movement of abrupt or sudden and excessive head move.
R /: Absolute rest was given only a few minutes to one or two hours post-surgery, or one night if there are complications.

3. Assist patients in activity during the resting phase.
R /: Prevent or reduce the risk of injury complications.

4. Teach client to avoid any action that could cause injury.
R /: Measures to increase IOP and cause structural damage to eye post-surgery:

• Straining (Valsalva maneuver)
• Moving the head suddenly
• Bending too long
• cough

5. Observe the condition of the eye: injury protruding, bulging anterior chamber, sudden pain every 6 hours or as needed at the beginning of the operation.
R /: Various conditions such as cuts stand, booth protruding eyes, sudden pain, hyperemia may indicate postoperative eye injury. If sight seeing floating objects (floaters) or dark spots may be attributed retinal detachments.

Nursing Diagnosis for Cataract : Acute Pain related to postoperative wound.

Goal: decrease pain, loss and control.

Expected outcomes:

• Clients demonstrated pain reduction techniques.
• Clients reported pain decreased or disappeared.

Intervention:

1. Assess the degree of pain every day.
R /: Normally pain occurs in less than five days after surgery and gradually disappear. Pain may increase due to increased IOP 2-3 days post-surgery. Pain suddenly showed massive increase in IOP.

2. Instruct to report the development of pain every day, or as soon as an increase in sudden pain.
R /: Improve collaboration; provide security to increase psychological support.

3. Encourage clients to not do any sudden movements that can provoke pain.
R /: Some of the activities the client can increase the pain as sudden movement, bent, rubbed his eyes, coughing, straining.

4. Teach distraction and relaxation techniques.
R /: Reduce stress, reduce pain.

5. Perform collaborative action for topical or systemic analgesic administration.
R /: Reduce pain by increasing pain threshold.

Disturbed Sensory Perception (Visual) - NCP Cataract

Disturbed Sensory Perception (Visual) - NCP Cataract

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.