Sensory Perception Disorder Care Map

 
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: 

Raised intraocular pressure and changes in the optic nerve head cause central visual field loss (Mahabadi et al., 2022).

 

 

 

 

 

 

 

Common Labwork/Diagnostics:

Complete blood count.

Erythrocyte sedimentation rate.

Fundus photography.

Scanning laser polarimetry.

Serology for syphilis.

Assessment Data (consider subjective, objective, and health history):

Personal data: Vision changes, double vision, visual loss, painful eyes, itchy eyes, blurry vision, light sensitivity, and headache (Dietze et al., 2022).

Objective data: Vision, blood pressure, heart rate, weight, height, BMI, SPO2, and temperature.
Nursing Diagnosis: 

Deficient knowledge related to a new diagnosis of primary open-angle glaucoma as evidenced by patients on side effects, mechanism of action, and administration of eye drops.

 

 

 

 

 

Nursing Diagnosis:

Altered visual sensory perception is related to decreased vision, as evidenced by a diagnosis of primary open-angle glaucoma (Mahabadi et al., 2022).

 

 

 

Nursing Diagnosis

Risk for injury related to vision loss as evidenced by a decrease in vision (Mahabadi et al., 2022).
SMART Goal: 

The patient understands her diagnosis and treatment.

 

 

 

 

 

 

 

 

 

 

SMART Goal:

To prevent further vision loss (Mahabadi et al., 2022).

 

 

 

 

 

 

 

 

SMART Goal:

Ensure the patient stays in a safe environment and is free of injury.
1.      Educate the patient on open-angle glaucoma using a language and terms that the patient understands to ensure she understands her diagnosis. 

 

 

2. Educate the patient on her prescribed medication. Inform the patient on class, side effects, use, and mechanism of action of the eye drop (Fineide et al., 2022). Ensure the patient demonstrates how to administer the drug. Medication education is done to improve patient compliance and self-administration (Aremu et al., 2022).

 

 

 

1. Compliance with prescribed eye drops to prevent further vision loss (Aremu et al., 2022).

2. Educate the patient on the possibility of complete or partial vision loss to ensure the patient is mentally prepared and visits the hospital in case of further vision loss.

 

1. Educate the patient, her family, and her caregiver on safety measures, such as ensuring the patient’s house is well-lit and ensuring there are no things on the floor to prevent injury.

2. Encourage the patient to use spectacles to increase visual acuity and prevent falls and accidents.



 References
Aremu, T. O., Oluwole, O. E., Adeyinka, K. O., & Schommer, J. C. (2022). Medication Adherence and Compliance: Recipe for Improving Patient Outcomes. Pharmacy (Basel, Switzerland), 10(5), 106. https://doi.org/10.3390/pharmacy10050106.

Dietze, J., Blair, K., & Havens, S. J. (2022). Glaucoma. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK538217/.

Fineide, F., Lagali, N., Adil, M. Y., Arita, R., Kolko, M., Vehof, J., & Utheim, T. P. (2022). Topical glaucoma medications – Clinical implications for the ocular surface. The ocular surface, 26, 19–49. Advanced online publication. https://doi.org/10.1016/j.jtos.2022.07.007.

Mahabadi, N., Foris, L. A., & Tripathy, K. (2022). Open Angle Glaucoma. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441887/.