Question

A nurse at the local Senior Center made the following notation about a client: A 74-year-old female client wearing eyeglasses with bifocal lenses and hearing aid in her left ear. Walks with a shuffling gait, using a cane for support. Wearing house slippers and housedress. States, "My other doctor says I should have my eyes looked at by an expert. It's been a while, and my eyes seem to be acting up lately. I can't see so good anymore." The client states that she takes medication for "sugar" and her blood pressure and has worn glasses for years with the last prescription changed about 3 years ago. "I was a seamstress for many years and quit when I couldn't see to thread the needles anymore-just in time too. These new materials are too hard to work with!" Denies using any eye drops. Describes vision changes as difficulty seeing well at night, especially if trying to read. Uses a magnifying glass to help when reading. No eye pain or discharge, although eyes sometimes feel "dry and scratchy," with the left eye being worse than the right. Admits to rubbing eyes but without relief.

Develop a Plan of Care for this patient that includes:

2 Nursing Diagnosis

2 goals for each Nursing Diagnosis

Interventions with rationales

Answer 1

1. Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to impaired sensory reception or limited status of the sensory organs as evidenced by reduced visual acuity, visual disturbance, change in normal response to stimuli.

Goals:

a. Maintain the usual level of mentation.

b. improved visual acuity within the limits of individual situations.

Interventions and Rationale

• Assess visual acuity

Rationale: Assessment helps in determining individual needs and choice of interventions

• Orient the patient to the environment

Rationale: Improved comfort and familiarity reduces the chance of disorientation

• Arrange all articles needed within limits

Rationale: It helps the patient to reach objects more easily

• Remove environmental hazards like loose rugs, fix rails for steps

Rationale: Helps to reduce the chance of falls

• Keep routine as consistent as possible and encourage participation in activities of daily living (ADLs)

Rationale : Maintains orientation to the environment.

• Monitor laboratory values like blood glucose

Rationale: Imbalance in these values can lead to impaired mentation

• Evaluate for retinal damage

Rationale: retinal damage occurs as a long-term complication of DM

Observe and investigate for hyperesthesia, pain, or sensory loss in the feet or legs.

Rationale: Peripheral neuropathies can lead to other

• Advice the family members to assist the patient with ambulation or position changes.       

Rationale: It promotes patient safety and sense of well being.

2. The risk for Injury related to impaired sensory function secondary to diabetes mellitus as evidenced by patient’s used of assistive devices.

Goals

a. The individual remains free of injury

b. A patient will explain methods to prevent injury

Interventions with rationale

• Assess the fine motor and gross motor coordination

Rationale: Assessment provides baseline data for further planning

• Arrange all articles within reach

Rationale: This will improve participation in daily activities without fear of injury

• Assess the patient’s mood coping abilities, personality style that may result in carelessness.

Rationale: this will aid to determine the patient’s level of cooperation.

• Evaluate the patient’s perceptions of risk for injury in relation to the cultural beliefs, norms, and values on them.          

Rationale: The patient’s consideration of risky behaviour may be based on cultural perceptions.

• Evaluate home environment for threats to safety like clutter, improper storage of chemicals, slippery floors, scatter rugs, unstable stairs and stairwells, blocked entries, dim lighting, extension cords across pathways, hazardous electrical or gas connections, unsafe heating devices, inappropriate oxygen placement, high beds without rails, extremely hot water, pets, and pet excrement.       

Rationale: By assessing the common possible hazards, patients risk can be minimized.

• Teach proper use of aids like a walker

Rationale: Effective use of comfort aids will maintain mobility and minimize injury.