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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.

Source : https://nandacareplan.blogspot.com/2021/08/risk-for-injury-nursing-diagnosis-and.html

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