Case:

Ny I 20 years of coming to the hospital RSU M.Djamil Padang with impaired vision.
Patients report decreased visual acuity, glare, look at the colors of the rainbow around
lights, severe headache around the eyes, pain scale 7, the pain sometimes make patients
feel nauseous. The results of the examination IOP = 24 mmHg. Visus examination results
VOD 6/30 6/12 VOS. Patients say the move is difficult because of the view that glare,
hard to read. Mengatakn patient's family, patients often fall when walking alone at home.
Nursing Process:
1. Assessment
The patient's name
: Ny I
Age
: 20 years old
Mother's name
: Rosa
Subjective data
:
a) The patients said reduced visual acuity, glare, look at the colors of the
rainbow around lights, severe headache around the eyes
b) The patients says frequent nausea
c) The patient complains of difficult move because of the glare, difficulty
reading
d) Families of patients said patients often fall when walking alone at home
Data Objective
:
a) pain scale 7
b) The results of visual acuity examination VOD VOS 6/30 6/12.
2. Diagnosis
a. Imbalance nutrition
Definition : wavelike sensation in the back of the throat, epigastric, or
abdomen that is subjective and unpleasant that may cause the urge or
desire to vomit
Limitations Characteristics:
Aversion to food
vomiting sensation
Increased salivation
Increased swallow
reported nausea
Sour taste in the mouth
FACTORS RELATED
Biophysical
Biochemical disorders (eg., Uremia, diabetic ketoacidosis)
esophageal disease
gastric distention
stomach irritation
Increased intracranial pressure
Intra-abdominal tumors

Labyrinthitis
Stretching the liver capsule
The tumor is localized (ie., An acoustic neuroma, a primary or
secondary brain tumors, metastatic bone at the base of the skull)
Meniere's disease
meningitis
travel sickness
painful
pancreatic diseases
gestation
Stretching capsule spleen

Toxins (ie., A peptide produced tumor, abnormal metabolites

from cancer)
b. Risk of Falling
Note: the risk that increases tranquility to fall which may cause physical
damage.
Limitations Characteristics :
Risk Factors:
adult:
Age 65 years old OR MORE
Fall Chronology
Living alone
Lower extremity Protesis
Use tools (for example: a walker, cane)
Wearing a wheelchair
Children:
Age 2 Years OR MORE young
BED is located near Window
Lack of car restraints
Lack of banisters
Lack of Parental Supervision
Less carefully at the window
Boys Age Less Than One Year
Children are NOT supervised place altitude (eg: Beds, Tables)
Theory
Reduce Status soul
Environment
messy Environment
The room is dim
Lack of antislip material in the bathroom
The absence of antislip material in the bathroom
Limiting
Woven carpets Rugs
The unusual room
Weather conditions (for example: The floor was wet, ice)

Medications
alcohol drinkers
Angiotensin - modifiers of enzyme inhibitors
antianxiety agent
anti-hypertensive agents
diuretics
Hypnotic
The drug addict
sedative Drugs
CYCLE anti depression
Physiological
Acute Disease
Anemia
Rheumatoid
Strength extremities decreased
Diarrhea
Difficulty hearingBalance Disorders
Impaired Physical Mobility
Incontinence
Neoplasms
Ortostaik hypotension
Changes in blood sugar levels after pradial
propioseptive deficit
Sleep Disorders

Analysis Of Nursing
N
DATA
NURSING
ETIOLOGY
O
PROBLEMS
1.
DS:
Patients
said
reduced
visual
acuity, glare see
rainbow colors on
light bulbs
Patients say severe
pain around the
eyes
Patients
said
frequent vomiting
Families
of
patients
said
patients often slip
when
walking
alone at home
Patients
saydifficultmovebe

NURSING
DIAGNOSES
Nausea

cause of difficult to
see because of
glare and hard to
read
DO:

2.

Scale pain 7
The results of
visual
acuity
examination VOD
6/30 and 6/12 VOS

DS:

DO:

Patients
said
reduced
visual
acuity, glare see
rainbow colors on
light bulbs
Patientssay severe
pain around the
eyes
Patients
said
frequent vomiting
Families
of
patients
said
patients often slip
when
walking
alone at home
Patients
say
difficult
move
because of difficult
to see because of
glare and hard to
read

Scale pain 7
The results of
visual
acuity
examination VOD
6/30 and 6/12 VOS

The risk of
falling due
to
the
visually
impaired
andhard to
see
objects
thatexistarou
nd
the
patient.

The process of The risk of falling

reduction in brain
response
due
toimpaired eyesight

NOC Liked to NANDA

NANDA
1. nausea

2. risk of
falling

NOC
OUTCOMES
Appetite; the desire to eat
Nausea will be reduced as
when
ill
or
are
evidenced by appetite, level
undergoing pengubatan
of
comfort,
hydration,
The level of comfort; the
control of nausea, vomiting,
degree
of
positive
nausea
and
vomiting:
perception of the physical
interference effects, severity
and
psychological
of nausea and vomiting,
comfort
adequate nutrition status
hydration; adequacy of
Shows the interference effect
adequate fluid in the
of nausea and vomiting that
intracellular
and
can be received, as
extracellular
evidenced by the indicator as
compartments of the body
follows:
Control
of
nausea,
1. very heavy
2. Weight
vomiting;
individual
3. Moderate
actions to control nausea
4. Light
and vomiting
5. not experience
Nausea and vomiting:
interference effects; the
severity
of
the
interference effects were
observed or reported due
to nausea, feel like
vomiting, and vomiting
on daily functioning
The severity of nausea
and vomiting; the severity
of nausea, vomiting and
vomiting curiosity
Nutritional status: food
and fluid intake; the
amount of food and fluids
into the body within 24
hours
Balance; the ability to
The risk of falls will be
maintain equilibrium
reduced or limited, as
Coordinated movements;
evidenced
by,
balance,
the ability of muscles to
coordinated
movement,

work
together
as
volunteers to perform the
movements that aim
Fall prevention behaviors;
individual actions or
caregiver to minimize the
risk factor that could
trigger a fall in the
environment
of
the
individual
Genesis falls; the number
of events falling in the
last few days
Knowledge:
fall
prevention;
level
of
understanding regarding
the
prevention
of
tumbling

Outcomes To Measure
Resolution Of Diagnosis

appetite

Preventive fall, Genesis

falls,
fall
prevention
knowledge.
Shows the incidence of falls,
as evidenced by the
following indicators:
1. >10
2. 7-9
3. 4-6
4. 1-3
5. There is no

Additional Outcomes To Outcomes Associated With

Measure
Defining Related
Factors
Or
Characteristic
Intermediate Outcomes

client
satisfaction:

Anxiety level

symptom control

electrolyte and acid

base balance

comfort status:
physycal

fear level

discomfort level

fluid balance

maternal status:
antepartum

gastrointestinal
function

medication
response

hydration

infection severity

nutritional
status: food and
fluid intake

kidney function

liver function

pain level

suffering severity

symptom control

symptom severity

nausea and
vomiting control

nausea and
vomiting:
disruptive effect
nausea and
vomiting
severity

1. RISK OF FALLING

sensory function:
taste and smell
swallowing
status