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Nursing Diagnosis Cataract

Nursing Diagnosis Cataract

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Published by shamar
Nursing Diagnosis for a patient with cataract
Nursing Diagnosis for a patient with cataract

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Categories:Types, School Work
Published by: shamar on Jun 20, 2012
Copyright:Attribution Non-commercial

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12/04/2012

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NursingDiagnosisExpectedOutcomeNursing Intervention Evaluation Discharge Instruction
Alteredsensoryperception(visual) relatedto alteredsensoryreception dueto cataractAfter 16hours ofnursingintervention,the patientwill be able torecognizeandcompensatefor sensoryimpairments.
1.
To assess causative/contributing factorsand degree of impairment:
Identify client with condition that can affectsensing, interpreting, and communicating stimuli(e.g., cataract).
Review results of laboratory tests (e.g., serumelectrolytes, chemical profile, ABGs, serum druglevels).
Assist with/review diagnostic studies andsensory /motor neurological testing.
Monitor drug regimen
to identify medicationswith effects or drug interactions that maycause /exacerbate sensory/ perceptualproblems.
Assess ability to speak, hear, interpret andrespond to simple commands
to obtain an
overview of client’s mental/cognitive
 
statusand ability to interpret stimuli
.
Evaluate sensory awareness:eapeciallystimulus 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 andtake these into consideration in planning care.Goal met.The patientwas able toidentify waytocompensatewith visualimpairments.
MedicationsEnvironmental ModificationsTeachingsHome InstructionsOutpatient Follow upDrug InteractionsSocial Support
 
2.
To promote normalization of responseto stimuli:
Provide means of communication, as indicated.
Encourage use of listening devices (e.g., hearingaid, audiovisual amplifier, closed-caption TV,signing interpreter)
to
 
assist in managingauditory impairment.
Avoid isolation of client, physically oremotionally,
to prevent sensory deprivation/limit confusion.
 
Promote a stable environment with continuity ofcare by same personnel as much as possible.
Interpret stimuli/offer feedback
to assist clientto separate reality from fantasy/alteredperception.
Reorient to person, place, time, and events, asnecessary. Explain procedures/activities,expected sensations, and outcomes.
Limit/carefully monitor use of sedation,especially in older population.
Minimize discussion of negatives (e.g., client andpersonnel
problems) within client’s hearing.
Clientmay misinterpret
 
and believe references are tohimself or herself.
Eliminate extraneous noise/stimuli, includingnonessential equipment, alarms/audible monitorsignals when possible.
Provide undisturbed rest/sleep periods.
 
Speak to visually impaired or unresponsive clientduring care
to provide auditory stimulation andprevent startle reflex.
Provide tactile stimulation as care is given.
Touching is an important part of caring and adeep psychological need communicatingpresence/connection with another humanbeing.
Encourage SO(s) to bring in familiar objects, talkto, and touch the client frequently.
Provide sensory stimulation, including familiarsmells/ sounds, tactile stimulation with a variety ofobjects, changing of light intensity and other cues(e.g., clocks, calendars).
Provide diversional activities, as able (e.g.,TV/radio, conversation, large-print or talkingbooks).
Promote meaningful socialization. (Refer to NDSocial Isolation.)
Collaborate with/involve other health-teammembers in providing rehabilitative therapies andstimulating modalities (e.g., music therapy,sensory training, remotivation therapy)
to achieve maximal gains in function andpsychosocial well-being.
Identify and encourage use of resources /prosthetic devices (e.g., hearing aids,computerized visual aid/glasses with a levelplumbline for balance).
Useful for augmentingsenses.3.
To prevent injury/complications:

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