Risk for Injury - Nursing Diagnosis and Interventions for Glaucoma

Nursing Diagnosis and Interventions for Glaucoma

Risk for Injury

Glaucoma is a group of eye diseases which result in damage to the optic nerve (or retina) and cause vision loss. The most common type is open-angle (wide angle, chronic simple) glaucoma, in which the drainage angle for fluid within the eye remains open, with less common types including closed-angle (narrow angle, acute congestive) glaucoma and normal-tension glaucoma. Open-angle glaucoma develops slowly over time and there is no pain. Peripheral vision may begin to decrease, followed by central vision, resulting in blindness if not treated. Closed-angle glaucoma can present gradually or suddenly. The sudden presentation may involve severe eye pain, blurred vision, mid-dilated pupil, redness of the eye, and nausea. Vision loss from glaucoma, once it has occurred, is permanent. Eyes affected by glaucoma are referred to as being glaucomatous.

Nursing Diagnosis :

Risk for Injury related to decreased visual field

Risk Factors:

External

• Physical (example: design of community structures and codes, buildings and or equipment; mode of transport or mode of movement; people or service providers)
• Biological (pattern: level of immunization in the community, microorganisms)
• Chemicals (drugs: pharmaceutical agents, alsohol, caffeine, nicotine, preservatives, cosmetics; nutrients: vitamins, types of food; toxins; pollutants)

Internal

• Psychologic (affective orientation)
• Malnutrition
• Abnormal blood form, pattern: leukocytosis/leukopenia
• Changes in clotting factors
• Thrombocytopenia
• Sickle cell
• thalassemia,
• decrease in Hb,
• Immune doesn't work.
• Biochemistry, regulatory functions (e.g. sensory dysfunction)
• Dough dysfunction
• Effector dysfunction
• Tissue hypoxia
• Age development (physiological, psychosocial)
• Physical (example: skin damage/not intact, related to mobility)

Nursing Interventions :

Goals / Outcome Criteria: 

NOC :

Risk Control

Immune status
Safety Behavior
After nursing actions for…. The client does not experience injury with the following criteria:

• Client free from injury
• Clients can explain ways/methods to prevent injury/injury
• The client can explain risk factors from the environment / personal behavior
• Able to modify lifestyle to prevent injury
• Using existing health accommodation
• Able to recognize changes in health status

NICs :

Environment Management

• Provide a conducive environment for the patient
• Identify the patient's safety needs, according to the patient's physical condition and cognitive function and the patient's previous medical history
• Avoiding hazardous environments (e.g. moving furniture)
• Installing the bed side rail
• Provide a comfortable and clean bed
• Place the light switch in a place that is easily accessible to the patient.
• Restrict visitors
• Provide sufficient explanation
• Encourage the family to accompany the patient.
• Control the environment from noise
• Move items that can be dangerous
• Provide clarification to the patient and family or visitors of any changes in health status and causes of illness.

Tag : Glaucoma, NANDA Nursing Diagnosis, Risk for Injury