Sensory Perception Disorder Care Map
| Assessment and Data Collection | Three NANDA-I Approved Nursing Diagnosis | One Smart Goal for EACH Nursing Diagnosis | Two Nursing Interventions with Rationale for EACH Nursing Diagnosis |
| Disease Process: Primary open-angle glaucoma is a chronic eye condition characterized by increased intraocular pressure, leading to progressive optic nerve damage. This damage results in gradual vision loss and, if left untreated, can lead to permanent blindness. Common Labwork/Diagnostics: Common diagnostic tests for glaucoma include tonometry to measure intraocular pressure, visual field testing to assess peripheral vision loss, and ophthalmoscopy to examine the optic nerve head (Story, 2018). Assessment Data: Subjective: Ms. Julia Jones expresses concern about her recent glaucoma diagnosis and her lack of knowledge about the prescribed medication. Objective: Visual acuity test reveals decreased peripheral vision. Intraocular pressure is elevated in both eyes. Health History: Ms. Jones is 68 years old, African American (increased risk for glaucoma), and has no prior experience with eye drop administration. | Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with glaucoma and its treatment regimen. Nursing Diagnosis: Risk for Noncompliance is related to a lack of understanding of the importance of the treatment regimen. Nursing Diagnosis: Impaired Peripheral Vision related to progressive optic nerve damage from glaucoma (Herdman et al., 2021) | SMART Goal: By the end of the teaching session, Ms Jones will correctly demonstrate the proper technique for administering eye drops, verbalize understanding of the purpose of Combigan, and list two potential side effects. SMART Goal: Within one week, Ms Jones will accurately explain the correlation between intraocular pressure and glaucoma, state the importance of consistent medication administration, and commit to following the prescribed regimen. SMART Goal: Over the next month, Ms Jones will independently perform daily activities of living, incorporating strategies to compensate for peripheral vision loss. | Nursing Diagnosis: Deficient Knowledge 1. Intervention: Use visual aids and simple language during the teaching session to explain glaucoma, Combigan’s purpose, administration technique, and potential side effects. Rationale: Visual aids and simple language enhance comprehension for a patient with impaired vision, promoting effective learning and understanding of the treatment regimen. 2. Intervention: Provide written instructions on eye drop administration and a list of potential side effects for Ms Jones to refer back to at home (Katzung et al., 2021). Rationale: Written instructions serve as a visual reminder and resource, reinforcing the learning from the teaching session and minimizing confusion. Nursing Diagnosis: Risk for Noncompliance 1. Intervention: Establish a supportive nurse-patient relationship to address Ms. Jones’s concerns, build trust, and encourage open communication about her fears or uncertainties (Katzung et al., 2021). Rationale: A trusting relationship fosters better patient engagement and communication, enabling the nurse to address barriers to compliance and provide reassurance. 2. Intervention: Collaborate with the ophthalmologist to simplify the medication regimen, if possible, and involve a family member or caregiver in medication reminders and administration (Katzung et al., 2021). Rationale: Simplifying the regimen and involving a support person enhances adherence and ensures consistent medication administration, reducing the risk of vision loss. Nursing Diagnosis: Impaired Peripheral Vision 1. Intervention: Teach Ms. Jones about mobility and safety techniques, such as using a cane or walker, to navigate her environment more confidently (Katzung et al., 2021). Rationale: Providing skills to enhance mobility and safety compensates for peripheral vision loss, minimizing accidents and promoting independence. 2. Intervention: Recommend low-vision rehabilitation services to Ms. Jones, connecting her with specialists who can provide adaptive tools and techniques to optimize her remaining vision (Katzung et al., 2021). Rationale: Low-vision rehabilitation helps individuals maximize their visual capabilities, facilitating better adaptation to their environment and daily activities. |