NUR2356 Module 07 Assignment – Sensory Perception Disorder Care Map

Module 07 Assignment – Sensory Perception Disorder Care Map Purpose of the Assignment 1. Identify the importance of client compliance with a treatment regimen to prevent a permanent disability. 2. Describe the purpo ...

Module 07 Assignment – Sensory Perception Disorder Care Map Purpose of the Assignment 1. Identify the importance of client compliance with a treatment regimen to prevent a permanent disability. 2. Describe the purpose of the treatment regimen in preventing complications of the disease process. Course Competency • Strategies for safe, effective multidimensional nursing practice when providing care for clients experiencing sensory and perception disorders. Instructions Ms. Julia Jones, a 68-year old African American woman, has just been diagnosed with primary open-angle glaucoma. Her ophthalmologist has explained the pathophysiology of the disease to her, but is trying to select the best treatment option for her. You are the nurse working with the ophthalmologist, and Ms. Jones has asked you about the eye drops the doctor has recommended. Mrs. Jones's physician has recommended Combigan, one drop in the right eye every 12 hours. Your client has never administered eye drops and she does not know anything about the medication her ophthalmologist has prescribed. She is interested in how the medication works, the side effects, how it is administered, and why it is so important in the treatment of her glaucoma. Develop a nursing care plan using template directly after these instructions to address Ms. Julia Jones concerns. Use at least two scholarly sources to support your care plan. Be sure to cite your sources in- text and on a reference page using APA format. You can find useful reference materials for this assignment in the School of Nursing guide: https://guides.rasmussen.edu/nursing/referenceebooks Have questions about APA? Visit the online APA guide: https://guides.rasmussen.edu/apa Subjective Subjective Subjective Objective Objective Objective Diagnostic Diagnostic Diagnostic Subjective: Patient Subjective: Verbalizes Subjective: Changes in expresses fear of falling lack of knowledge and sensory acuity such as due to impaired vision & confusion about diagnosis photosensitivity, sensory age, patient states she & medications, inquires distortions, hazy/blurry bumps into furniture about the importance of vision, seeing halos often, experiences medication in the around bright lights, hazy/blurry vision, & sees treatment of glaucoma sudden sight loss, severe halos around bright lights Objective: Patient intracranial pressure, Objective: changes in demonstrates lack of slow visual changes, gait, visual difficulties, knowledge by incorrectly hallucinations & loss of sensory deficits, impaired administering eyedrops, peripheral vision peripheral vision during but expresses motivation Objective: changes in confrontation test, to learn & identifies sensory acuity & in usual disease-related perceived learning needs response to stimuli, symptoms, rubbing eyes for condition, & impaired peripheral vision constantly, holds hands demonstrates confusion during confrontation test, out when walking to when performing the task squints to see words & prevent bumping into Diagnostic: Tonometry objects, redness of the things, & Snellen chart to measure intraocular sclera, rubbing eyes score indicates changes pressure (IOP) above 22 constantly, & Snellen in vision. mm Hg, pupil dilation, chart score indicates Diagnostic: Tonometry visual field testing changes in vision. to measure intraocular (perimetry), visual acuity Diagnostic: Tonometry pressure (IOP) above 22 test to determine the to measure intraocular mm Hg, pupil dilation, ability to discern the pressure (IOP) above 22 visual field testing shapes & details of mm Hg, pupil dilation, (perimetry), visual acuity images & letters, visual field testing test to determine the pachymetry to measure (perimetry), visual acuity ability to discern the the thickness of the test to determine the shapes & details of cornea, ophthalmoscopy ability to discern the images & letters, to examine the shape & shapes & details of pachymetry to measure color of the optic nerve, images & letters, the thickness of the gonioscopy to examine pachymetry to measure cornea, ophthalmoscopy the angle in the eye the thickness of the to examine the shape & where the iris meets the cornea, ophthalmoscopy color of the optic nerve, cornea, optic nerve to examine the shape & gonioscopy to examine imaging to evaluate any color of the optic nerve, the angle in the eye damage from high IOP, gonioscopy to examine where the iris meets the (Glaucoma Research the angle in the eye cornea, optic nerve Foundation, 2019). where the iris meets the imaging to evaluate any cornea, optic nerve damage from high IOP, imaging to evaluate any Snellen chart score to damage from high IOP, access vision; optimal Snellen chart score to score is 20/20, (Glaucoma Research Foundation, 2019). access vision; optimal score is 20/20, (Glaucoma Research Foundation, 2019). Nursing Diagnosis Nursing Diagnosis Nursing Diagnosis Risk for falls r/t sensory Deficit knowledge r/t Disturbed sensory deficits (vision unfamiliarity with perception: visual r/t impairment) as evidenced resources and materials visual impairment as by changes in gait for treatment as evidenced by loss of evidenced by asking peripheral vision questions & voicing lack of knowledge/education on subject SMART Goal SMART Goal SMART Goal Specific: Patient will not Specific: Patient will Specific: Patient will sustain an injury or fall, verbalize understanding maintain visual acuity compromising her health, of the condition, field without further loss. patient will verbalize prognosis, & treatment. Patient will recognize & understanding of risk Patient will identify the correct or compensate for factors that contribute to relationship of sensory impairments, the possibility of falls, signs/symptoms to the verbalize awareness of demonstrates behaviors disease process. Patient sensory needs & and lifestyle changes to will verbalize the presence of deprivation, reduce risk factors and understanding of identify & modify external protect self from injury treatment needs & factors that contribute to Measurable: The perform necessary alterations in sensory or patient’s risk for falls will procedures & explain perceptual abilities, use be assessed at each reasons for the actions. resources effectively & appointment by using the Patient will demonstrate appropriately, & be free Morse Fall Risk ability to deal with health from injury. Assessment situation & remain in Measurable: Achievable: This goal is control of life. Patient Assessment of the realistic and achievable shows motivation to learn patient’s ability to learn, by initiating fall risk & identifies learning remember, & perform precautions and needs. desired health-related encouraging the patient Measurable: Patient will care (eyedrop to ask for assistance and demonstrate proper use administration) because use handrails and other of the medicated vision impairment can assistive devices when eyedrops through compromise learning & ambulating to prevent education & explain the must be considered when falls and injuries. The reasoning for this designing the educational nurse, ophthalmologist, procedure. approach, such as bolder, physical therapist, & Achievable: This goal is larger fonts for written patient will collaborate in achievable by material. Patient will achieving this goal. determining the patient’s demonstrate proper use Relevant: Initiating fall learning style & is of the medicated precautions and patient tailored to patient- eyedrops & explain the education on how to centered education so reasoning for this utilize her assistive that the patient is able to procedure for glaucoma, devices or calling for understand & apply the patient’s IOP should be assistance will decrease information towards her assessed every 6 months the likelihood of the plan of care & treatment. to ensure pressure has patient being free from Relevant: This goal is not increased sustaining a fall or injury. important as it ensures Achievable: This goal is Timely: The goal will be that the patient has the realistic & achievable by achieved when the appropriate knowledge, assessing, evaluating, & patient does not sustain a education, & documenting the fall during the entire understanding on how to patient’s ability to period of treatment for properly apply eyedrops ambulate & function glaucoma. to her eye. This ensures within limits of visual (Ackley & Ladwig, 2008) that the patient has a impairment at every & (Gulanick & Myers, level of independence in appointment to 2014) her treatment. determine any visual Timely: This goal will be changes throughout care achieved after the patient & treatment. The nurse, is educated on how to ophthalmologist, & properly care for and patient will collaborate in apply the eyedrops in her achieving this goal. eye & she can Relevant: This goal is demonstrate effectively important because it sets on the application of the up the patient for visual & medication. She will also sensory acuity as well as express & verbalize assess the risk for falls & understanding of the injuries due to medication, what its impairment purpose is for in the Timely: This goal will be treatment of glaucoma, achieved when the as well as the side effects patient can effectively that may occur, maintain visual acuity (Ackley & Ladwig, 2008) without further vision loss & (Gulanick & Myers, due to glaucoma. This will 2014) be an ongoing goal for as long as the patient is alive, (Ackley & Ladwig, 2008) & (Gulanick & Myers, 2014) Nursing Interventions Nursing Interventions Nursing Interventions * Fall prevention: * Stress the importance * Communication instituting special of glaucoma screening. enhancement: vision precautions with patient An annual tonometric deficit- use of strategies at risk for injury from examination should be augmenting falling, such as wearing performed to measure communication nonslip shoes and socks the hydrostatic pressure capabilities for a person when ambulating, use of within the eyeball. with diminished vision handrails, removal of rugs * Review pathology & * Peripheral Sensation that can cause slips and falls * Ensure appropriate room lighting, especially at night. * Environmental management: safety: monitoring and manipulation of the physical environment to promote safety by removing all dangers that may injure the patient and cause the patient to fall * Orientation: Orient the patient to the environment to prevent falls * Collaboration with other health care team members to evaluate the patient’s medications that contribute to falling, as well as polypharmacy that can lead to risk for falls * Collaborate with physical & occupational therapy to assist with gait techniques & provide the patient with assistive devices for transfer & ambulation as well as tools to help guide the patient around their home in a safe manner, such as handrails. This improves stability & balance when ambulating. * Assess the patient every shift (or appointment) with the Morse fall risk score, (Morse, 2009) * Educate the client on how to safely ambulate at prognosis of the condition & lifelong need for treatment. This provides the opportunity to clarify misconceptions & present condition as manageable. * Demonstrate proper technique for administration of eye drops. Have the patient perform a return demonstration. The enhances the effectiveness of treatment and provides an opportunity for the patient to show competence & ask questions, if necessary. * Review the importance of maintaining a drug schedule for the eye drops & discuss the medications that should be avoided. This disease can be controlled, not cured, and maintaining a consistent medication regimen is vital to control. * Identify potential side effects & adverse reactions of treatment, such as decreased appetite, nausea, fatigue, syncope, etc. These problems require medical evaluation & a possible change in therapeutic regimen. * Encourage patient to make necessary changes in lifestyle to support diagnosis & reduce further deterioration * Explain the importance of attending routine checkups to monitor and maintenance of disease management: Prevention or minimization of injury or discomfort in the patient with altered sensation * Hallucination and/or delusion management: promoting the comfort, safety, and reality orientation of the patient experiencing hallucinations * Environmental management: Manipulation of the patient’s surroundings for therapeutic benefit, sensory appeal, and psychological well-being * Assess and record the visual acuity at every appointment * Assess functional description & evaluate the patient’s ability of what can be seen & what cannot be seen at every appointment & before & after application of medicated eyedrops * Environment assessment & alteration with the ability to adjust the vision quality * Orient patient on the environment: Provide adequate lighting, avoid glare, put patient’s frequently used belongings within outreach vision and return belongings in same place, provide reading materials with great writing * Advise on alternative forms of stimulation such as the radio, audiobooks, home to help relieve to prevent further loss of & television instead of relying solely on vision * Turn on sound on the clock to keep patient aware of time * Safety: Place corner guards on tables and other surfaces to prevent injuries on body if patient bumps into surfaces due to poor vision * Visual acuity test will be conducted every 12 months to ensure further visual deterioration is not occurring, (Doenges, Moorhouse, & Murr, 2019). anxiety & fear at home to vision. decrease the risk of falls during ambulation, (Doenges, Moorhouse, & Murr, 2019). * Inform patient to immediately report severe eye pain, inflammation, increased photophobia & lacrimation, changes in the visual field, veil-like