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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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Anxiety related to Premenopausal Syndrome

 

Premenopause is the name given to the time before the cessation of menstruation with decreased estrogen levels, luteal insufficiency, increased gonadotropins and autonomic symptoms (Purwatyastuti, 2007). The term premenopause is still common in the ears, but every woman will definitely experience it. Before reaching menopause, a woman will experience several physical changes and hormonal symptoms, including irregular menstruation.

Premenopause is the period in which the body begins to transition to menopause. This period can last from two to eight years, plus one year at the end of the period leading to menopause. This symptom is natural, because it is a sign and process of stopping the reproductive period.

In this period, generally the level of production of the hormones estrogen and progesterone fluctuates, rises and falls irregularly. Menstrual cycles can suddenly lengthen or shorten. Usually, this premenopause period occurs in their 40s, but many also experience these changes when they are still in their mid-30s.

In relation to the age factor, the capacity for reproduction that takes place during menstruation or the first menstruation still continues regularly. With the cessation of this function will also end the function of service, devotion, and the preservation of the human species. Because with the end of menstruation, the process of ovulation or fertilization of the egg also stops because of it. Then all the glandular apparatus experience obstacles and reduce their activity. In addition, the genital organs also undergo an atrophic process, which is to become shriveled and function backwards. Finally, all parts of the body gradually show signs of aging. This phase in women is called menopause (Kartini Kartono, 2007).

Some women who experience premenopause think this condition is part of their life cycle, but many women complain that with the arrival of premenopause they will become anxious because premenopausal syndrome is often associated with anxiety in dealing with a situation that was previously unworried. This condition is because women who face premenopause generally do not get the correct information or knowledge so that what they imagine is the negative effects that will be experienced after entering the premenopause and menopause periods.

Premenopausal syndrome is experienced by many women almost all over the world.

To find out the symptoms of premenopausal syndrome and get rid of anxiety and worries when entering the premenopausal period is to recognize the signs of premenopausal syndrome as early as possible. Living a healthy life by consuming healthy food, drinks, regular exercise and adequate rest, is the capital for a pleasant menopause period, besides that, it is necessary to have a Pap smear, colposcopy, breast self-examination, mammography, colon cancer examination, laboratory tests, osteoporosis tests. (Proverawati, 2010)

Based on Larasati's research (2012), in some cases women who experience menopause begin to withdraw from social interactions because they feel they have no value and feel useless. Such as limiting social interaction with friends and family. They prefer to be alone away from the crowd. Women who experience menopause will need family and closest friends as support so they are not inferior in adapting to their environment. In addition, there is motivation from him to live his life with enthusiasm (good quality of life), to become a good quality of life that needs to be done, namely maintaining health by eating vegetables, consuming vitamins and exercising, regulating sleep patterns of at least 8 hours per day, reducing heavy work and do light things, and reduce emotions so as not to get angry easily. While Notoatmodjo (2007) knowledge that a person has influences his behavior, the better a person's knowledge, the better his behavior will be and knowledge itself is influenced by the level of education, sources of information and experience.

Disturbed Sleep Pattern - Insomnia related to Fear and Anxiety

 Source : https://nandacareplan.blogspot.com/2021/08/anxiety-related-to-premenopausal.html

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Nursing Diagnosis for Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a long-term autoimmune disorder that primarily affects joints. It typically results in warm, swollen, and painful joints. Pain and stiffness often worsen following rest. Most commonly, the wrist and hands are involved, with the same joints typically involved on both sides of the body. The disease may also affect other parts of the body, including skin, eyes, lungs, heart, nerves and blood. This may result in a low red blood cell count, inflammation around the lungs, and inflammation around the heart. Fever and low energy may also be present. Often, symptoms come on gradually over weeks to months. 

While the cause of rheumatoid arthritis is not clear, it is believed to involve a combination of genetic and environmental factors. The underlying mechanism involves the body's immune system attacking the joints. This results in inflammation and thickening of the joint capsule. It also affects the underlying bone and cartilage. The diagnosis is made mostly on the basis of a person's signs and symptoms. X-rays and laboratory testing may support a diagnosis or exclude other diseases with similar symptoms. Other diseases that may present similarly include systemic lupus erythematosus, psoriatic arthritis, and fibromyalgia among others. 

Nursing Diagnosis for Rheumatoid Arthritis


Nursing Diagnosis for Rheumatoid Arthritis


1. Pain (acute / chronic)

related to:

tissue distended by the accumulation of fluid / inflammation,

joint destruction.


2. Impaired physical mobility

related to:

skeletal deformity,

pain,

decreased muscle strength.


3. Disturbed Body Image

related to:

changes in the ability to carry out common tasks,

increased use of energy,

imbalance mobility.


4. Self-care deficit

related to:

musculoskeletal damage,

decreased strength and endurance,

pain when moving,

depression.


5. Knowledge Deficit: about the disease, prognosis, and treatment needs

related to:

lack of exposure / recall,

misinterpretation of information.


Source :


 

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Nursing Diagnosis for Cataract

A cataract is a clouding or opacification of the normally clear lens of the eye or its capsule (surrounding transparent membrane) that obscures the passage of light through the lens to the retina of the eye. This blinding disease can affect infants, adults, and older people, but it predominates the latter group. It can be bilateral and vary in severity. The disease process progresses gradually without affecting daily activities early on, but with time, especially after the fourth or fifth decade, the cataract will eventually mature, making the lens completely opaque to light interfering with routine activities. Cataracts are a significant cause of blindness worldwide. Treatment options include correction with refractive glasses only at earlier stages, and if cataract mature enough to interfere with routine activities, surgery may be advised, which is very fruitful.

Cataracts are a common part of the eye’s aging process. Eventually, they can cause:

  • Vision that’s cloudy, blurry, foggy or filmy.
  • Sensitivity to bright sunlight, lamps or headlights.
  • Glare (seeing a halo around lights), especially when you drive at night with oncoming headlights.
  • Prescription changes in glasses, including sudden nearsightedness.
  • Double vision.
  • Need for brighter light to read.
  • Difficulty seeing at night (poor night vision).
  • Changes in the way you see color.


Nursing Diagnosis for Pre and Post Cataract Surgery :


Pre Cataract Surgery :

1. Impaired sensory perception (vision): related to changes in sensory reception.

2. Anxiety related to lack of information about operating procedure.


Post Cataract Surgery :

1. Acute pain related to postoperative wounds.

2. Risk for infection related to increased susceptibility secondary, due to surgical interruption of the ocular surface.

 

Source : https://creativenurse.blogspot.com/2021/08/nursing-diagnosis-for-cataract.html

 

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5 Nursing Diagnosis for Pancreatitis

Pancreatitis is an inflammation of the pancreas gland, the occurrence of a sudden, there is light, there is also to lead to fatal consequences. Even the deaths occurred mostly in just over two weeks since the first symptoms of pancreatitis or the pain symptoms first appear.

Symptoms of pancreatitis is divided into two types, acute pancreatitis and chronic pancreatitis. The difference, acute pancreatitis damage to the pancreas by certain enzymes sudden and thorough, while chronic pancreatitis occur destructively, pancreatitis mild type that does not heal, ongoing and increasingly severe and repetitive.

The cause of pancreatitis is due to the blockage so that the enzymes produced by the pancreas will still accumulate in the pancreas and pancreatic cells digest themselves from there emerged inflammation. Besides inflammation of the pancreas can also be caused by excessive alcohol consumption, taking certain medications, high triglycerides, high levels of calcium in the blood, inveksi virus, pancreas damage due to trauma or surgery, a lack of blood flow to the pancreas, pancreatic cancer or the use of estrogen in ladies high triglyceride levels.

Symptoms of Pancreatitis :
  • Pain in the pit of the stomach that breaks down to the back.
  • While eating, pain in the gut will be even worse.
  • Ongoing pain felt and the longer the severity increases.
  • Pain will continue to be felt for days.
  • The pain will get worse if the patient coughs.
  • Nausea and vomiting.
  • Increased body temperature.
  • Yellow skin.
  • Heartbeat becomes rapid.
  • Patients appears uneasy.
  • Swelling in the upper abdomen.
  • Acute inflammation of the pancreas that has been accompanied by severe symptoms of dehydration and low blood pressure.
  • Chronic pancreatitis symptoms are accompanied by diarrhea, oily dirt and also weight loss.

5 Nursing Diagnosis for Pancreatitis
  1. Ineffective breathing pattern.
  2. Impaired tissue perfusion.
  3. Fluid volume deficit.
  4. Acute pain.
  5. Hyperthermia.


Source :

https://nandacareplan.blogspot.com/2021/06/4-nursing-diagnosis-for-pancreatitis.html
http://www.nurseskomar.com/2015/11/nursing-diagnosis-for-acute-and-chronic.html

 

 

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5 Nursing Diagnosis for Anaphylactic Shock

 Anaphylactic Shock

Definition

Anaphylactic is a collection of symptoms that result from an acute reaction to a foreign substance to a person who previously had the sensitization (immediate / hypersensitivity reactions indirect immunity).

Etiology

  • Because drugs indirect histamine reaction that usually follows the injection of the drug weight, serum, the x-ray contrast media.
  • Certain foods, insect bites.
  • The reaction can sometimes idiopathic / immunologic abnormalities manifestations.
Symptoms
  • Cardiovascular: tachycardia, hypotension, shock, arrhythmia, palpitations.
  • Respiratory tract: rhinitis, sneezing, itching of the nose, bronchospasm, hoarseness, shortness, apnea.
  • Gastrointestinal: nausea, vomiting, abdominal pain.
  • Skin: pruritus, urticaria, angioedema, skin pale and cold.



Nursing Diagnosis for Anaphylactic Shock

1. Impaired gas exchange related to ventilation perfusion imbalance.
characterized by: shortness of breath, tachycardia, flushing, hypotension, shock, and bronchospasm.

2. Altered tissue perfusion related to decreased blood flow secondary to vascular disorders due to anaphylactic reactions.
characterized by: palpitations, skin pale, cold acral, hypotension, angioedema, arrhythmias, ECG features horizontal and inverted T waves.

3. Ineffective breathing pattern related to the swelling of the nasal mucosa wall
characterized by: shortness of breath, breath with the lips, there rhinitis.

4. Acute pain related to gastric irritation
characterized by: abdominal pain, looked grimacing while holding stomach.

5. Impaired skin integrity related to changes in circulation
characterized by: swelling and itching of the skin and the nose, there are hives, urticaria, and runny nose. 

 Source : https://purba-java-indo.blogspot.com/2014/11/5-nursing-diagnosis-for-anaphylactic.html

 

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9 Nursing Diagnosis for Encephalitis

Encephalitis is an acute inflammation of the brain. Usually the cause is a viral infection, but bacteria can also cause it. It can be mild or severe. Most cases are mild. Examples of viral infections that can cause encephalitis include herpes simplex virus (the virus that causes cold sores and genital herpes), varicella zoster virus (the chickenpox virus), mumps virus, measles virus and flu viruses. In the UK, the most common virus to cause encephalitis is herpes simplex virus.





Most cases of encephalitis are caused by the virus directly infecting the brain. However, sometimes encephalitis can develop if your immune system tries to fight off a virus and, at the same time, attacks the nerves in your brain in error. This is known as post-infectious or autoimmune encephalitis. Rarely, this type of encephalitis can develop after an immunisation.


Adult patients with encephalitis present with acute onset of fever, headache, confusion, and sometimes seizures. Younger children or infants may present irritability, poor appetite and fever. Neurological examinations usually reveal a drowsy or confused patient. Stiff neck, due to the irritation of the meninges covering the brain, indicates that the patient has either meningitis or meningoencephalitis.

Vaccination is available against tick-borne and Japanese encephalitis and should be considered for at-risk individuals.

Post-infectious encephalomyelitis complicating small pox vaccination is totally avoidable now as small pox is now eradicated. Contraindication to Pertussis immunisation should be observed in patients with encephalitis. An immunodeficient patient who has had contact with chicken pox virus should be given prophylaxis with hyperimmune zoster immunoglobulin.


9 Nursing Diagnosis for Encephalitis
  1. Hyperthermia
  2. Acute Pain
  3. Impaired physical mobility
  4. Impaired gas exchange
  5. Disturbed thought processes
  6. Risk for impaired skin integrity
  7. Risk for deficient fluid volume
  8. Imbalanced nutrition: Less than body requirements
  9. Anxiety

Source : https://purba-java-indo.blogspot.com/2014/12/9-nursing-diagnosis-for-encephalitis.html

 

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