Student Nurses Community

NURSING CARE PLAN Glaucoma

ASSESSMENT

DIAGNOSI
S

INFERENCE

PLANNING

SUBJECTIVE:

Disturbed
Visual
Sensory
Perception
r/t Altered
Sensory
Reception

Increased
intraocular
pressure

Inadequate
drainage of
aqueous
humor from
the anterior
chamber of
the eye

Atrophy of
the optic
nerve

Disturbed
visual
sensory

After 8 hours of
nursing
intervention the
patient will:

I am having
pain around
my eye and I
also noticed
that my vision
is getting
blurred and
cloudy as
verbalized by
the patient.
OBJECTIVE:
Cloudy pupils
Sudden/persist
ent severe
pain or
pressure in
and around
eye(s)
Headache
V/S taken as
follows:
T: 37 C
P: 80
R: 18

Participate in
therapeutic
regimen.
Maintain
current visual
field/acuity
without
further loss.

INTERVENTION

Independent:
Ascertain
type/degree of
visual loss
Encourage
expression of
feelings about
loss/possibility
of loss of vision
Recommend
measures to
assist patient to
manage visual
limitations, e.g.,
reducing
clutter,
arranging
furniture out of
travel path;
turning head to
view subjects;
correcting for
dim light and
problems of
night vision.

RATIONALE

EVALUATI
ON

Affects choice
of
interventions
and patients
future
expectations
Although early
intervention
can prevent
blindness,
patient faces
the possibility
or may have
already
experienced
complete loss
of, although
cannot be
restored (even
with
treatment),
further loss
can be
prevented
Reduces safety
hazards
related to
changes in
visual
fields/loss of

Goal met,
patient has
maintained
current
visual
field/acuity
without
further loss

Student Nurses Community

BP: 110/80
Collaborative:
Assist with
administration of
medication as
indicated:
Pilocarpine
hydrochloride
Timolol maleate
Acetazolamide

vision and
papillary
accommodatio
n to
environmental
light
These directacting topical
myotic drugs
cause papillary
constriction,
facilitating the
outflow of
aqueous
humor and
lowering IOP
Beta-blockers
decrease
formation of
aqueous
humor without
changing pupil
size, vision, or
accommodatio
n.
Carbonic
anhydrase
inhibitors
decrease the
rate of
production of
aqueous
humor.

Student Nurses Community