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

NOC Outcomes (Nursing Outcomes Classification)

NIC Interventions (Nursing Interventions Classification)

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:
  • Maintain sterility of all eye droppers, tubes of medications, and other items. This reduces the risk of eye infection.
  • Do not share eye makeup.
  • Care for contact lenses as recommended by manufacturer.
  • 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).

Include Rationales?

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