NCP Nursing Diagnosis: Disturbed Sensory Perception: Visual Vision Loss; Macular Degeneration; Blindness

Nursing Diagnosis: Disturbed Sensory Perception: Visual
Vision Loss; Macular Degeneration; Blindness
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Visual Compensation Behavior
* Risk Control: Visual Impairment

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Communication Enhancement: Visual Deficit
* Environmental Management
* Self-Esteem Enhancement

NANDA Definition: Change in the amount or patterning of incoming stimuli, accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Visual impairment and/or loss of vision affects more than 100 million Americans. Genetics, aging, and chronic diseases such as diabetes and glaucoma account for the majority of visual impairment. Trauma, usually associated with alcohol use, also accounts for visual impairment or loss to a lesser degree. Some forms of visual impairment can be corrected, either by refraction (glasses, contact lenses), medications (used mainly in the treatment of glaucoma), or surgery (lens implants, keratorefractive procedures). These include myopia (nearsightedness), hyperopia (farsightedness), astigmatism (caused by abnormal corneal curvature), and presbyopia (loss of accommodation as the result of normal, age-related changes in the lens). Other types of visual impairment or loss cannot be corrected. As the American population ages, visual impairment, including noncorrectable loss from progressive macular degeneration, is a growing concern. Nursing interventions in persons with visual impairment are aimed at assisting the individual to cope with the loss and remain functional and safe. Ability to be independent with self-care, especially in the management of medications, may require ongoing supervision and/or institutionalization. This care plan addresses needs of persons who are out of their usual environments (e.g., in outpatient settings, hospitals, or long-term care facilities).

* Defining Characteristics: Lack of eye-to-eye contact
* Abnormal eye movement
* Failure to locate distant objects
* Squinting, frequent blinking
* Bumping into things
* Clumsy behavior
* Closing of one eye to see
* Frequent rubbing of eye
* Deviation of eye
* Gray opacities in eyes
* Head tilting
* Disorientation
* Reported or measured changes in visual acuity
* Anxiety
* Change in usual response to visual stimuli
* Anger
* Visual distortions
* Incoordination
* History of falls, accidents

* Related Factors: Diabetes
* Glaucoma
* Cataracts
* Refractive disorders (myopia, hyperopia, astigmatism, presbyopia)
* Macular degeneration
* Ocular trauma
* Ocular infection
* Retinal detachment
* Conjunctival Kaposi’s sarcoma of acquired immunodeficiency syndrome (AIDS)
* Disease or trauma to visual pathways or cranial nerves II, III, IV, and VI, secondary to stroke, intracranial aneurysms, brain tumor, trauma, myasthenia gravis, or multiple sclerosis
* Advanced age

* Expected Outcomes Patient achieves optimal functioning within limits of visual impairment as evidenced by ability to care for self, to navigate environment safely, and to engage in meaningful activities.

Ongoing Assessment

* Assess age. The incidence of macular degeneration, cataracts, retinal detachments, diabetic retinopathy, and glaucoma increase with aging.
* Determine nature of visual symptoms, onset, and degree of visual loss. Recent loss, loss over a long period, or long-standing loss have different implications for nursing intervention and the patient’s level of adaptation or resource use. Since visual loss may occur gradually, quantification of loss may be difficult for the patient to articulate.
* Review medical history.
* Inquire about patient or family history of systemic or central nervous system (CNS) disease. Family or patient history of atherosclerosis, diabetes, thyroid disease, or hypertension should be investigated as possible cause for visual loss.
* Ask patient about specifics such as ability to read, see television, history of falls, or ability to self-medicate.
* Inquire about history of visual complaints, eye trauma, or ocular pain.
* Assess central vision with each eye, individually and together. Vision loss may be unilateral, bilateral, central, and/or peripheral, and may not affect both eyes to the same extent.
* Assess peripheral field of vision and visual acuity. Glaucoma affects peripheral vision; its onset is insidious, and has no associated symptoms. Macular degeneration affects central vision, is more common among cigarette smokers, and is irreversible.
* Assess eye and lid for inflammation, edema, positional defects, and deviation. These are correctable problems that can negatively affect vision.
* Assess factors or aids that improve vision, such as glasses, contact lenses, or bright and/or natural light.
* Evaluate patient’s ability to function within limits of visual impairment. Personal appearance and condition of clothing and surroundings are good indicators of the patient’s adaptation to visual loss.
* Evaluate psychological response to visual loss. Anger, depression, and withdrawal are common responses. Self-esteem is often negatively affected.

Therapeutic Interventions

* Introduce self to patient, and acknowledge visual impairment. This reduces patient’s anxiety.
* Orient patient to environment. Orientation reduces fear related to unfamiliar environment.

Do not make unnecessary changes in environment. This ensures safety and maintains what the patient has arranged.
* Provide adequate lighting. The use of natural or halogen lighting is preferred to improve vision for patients with diminished vision.
* Place meal tray, tissues, water, and call light within patient’s range of vision or reach. These ensure safety and sense of independence.
* Communicate type and degree of impairment to all involved in patient’s care. This enhances continuity of care.
* Recommend use of visual aids when appropriate. Visual aids such as magnifying glass, large-type printed books, and magazines encourage reading.
* Place food on tray and plate in same place each meal and explain arrangement of food on tray and plate, using clockwise sequence.
* Encourage use of sense of touch. Touch encourages patient to become familiar with unfamiliar objects.
* Explain sounds or other unusual stimuli in environment. Explanations reduce fear.
* Encourage use of radios, tapes, and talking books. Diversional activities should be encouraged. Radio and television increase awareness of day and time.
* Remove environmental barriers to ensure safety. If furniture or wastebaskets are moved, notify patient of changes.
* Discourage doors from being left partially open. Fully open or closed doors reduce the risk for injury among the vision-impaired.
* Maintain bed in low position with side rails up, if appropriate. Side rails help remind patient not to get up without help when needed.

Keep bed in locked position. This prevent falls.
* Guide patient when ambulating, if appropriate. Describe where you are walking; identify obstacles.
* Instruct patient to hold both arms of chair before sitting and to feel for the seat on chairs or sofas without arms. These reduce the risk of falls.
* Consult occupational therapy staff for assistive devices and training in their use.
* Supervise patient when smoking. Supervision prevents accidental fires.

Education/Continuity of Care

* Involve caregiver in patient’s care and instructions. Help patient understand nature and limitations of disease. Patient and family need information to plan strategies for assisting the visually impaired patient to cope.
* Reinforce physician’s explanation of medical management and surgical procedures, if any.
* Teach general eye care:
o Maintain sterility of all eye droppers, tubes of medications, and other items. This reduces the risk of eye infection.
o Do not share eye makeup.
o Care for contact lenses as recommended by manufacturer.
o Do not rub eyes.
* Demonstrate the proper administration of eye drops or ointments; allow for return demonstration by patient and/or caregiver.
* Help family or caregiver identify and make arrangements at home. These provide for patient’s safety and sense of independence, as indicated.
* Make appropriate referrals to home health agency for nursing and social service follow-up.
* Reinforce need to use community agencies, if indicated (e.g., Lighthouse for the Blind [check local listings] or American Foundation for the Blind, 15 West 16th Street, New York, NY 10011).