Nursing Diagnosis for Cataract : Risk for injury related to an increase in intraocular pressure (IOP), hemorrhage, vitreous loss.
Expected outcomes:
- Clients can mention the factors that lead to injury.
- Clients do not do activities that increase the risk of injury.
Intervention:
1. Talk about pain, activity limitation and bandaging the eyes.
R /: Improving cooperation and the necessary restrictions.
2. Put the client on a low bed and recommended to restrict the movement of abrupt or sudden and excessive head move.
R /: Absolute rest was given only a few minutes to one or two hours post-surgery, or one night if there are complications.
3. Assist patients in activity during the resting phase.
R /: Prevent or reduce the risk of injury complications.
4. Teach client to avoid any action that could cause injury.
R /: Measures to increase IOP and cause structural damage to eye post-surgery:
- Straining (Valsalva maneuver)
- Moving the head suddenly
- Bending too long
- cough
5. Observe the condition of the eye: injury protruding, bulging anterior chamber, sudden pain every 6 hours or as needed at the beginning of the operation.
R /: Various conditions such as cuts stand, booth protruding eyes, sudden pain, hyperemia may indicate postoperative eye injury. If sight seeing floating objects (floaters) or dark spots may be attributed retinal detachments.
Nursing Diagnosis for Cataract : Acute Pain related to postoperative wound.
Goal: decrease pain, loss and control.
Expected outcomes:
- Clients demonstrated pain reduction techniques.
- Clients reported pain decreased or disappeared.
Intervention:
1. Assess the degree of pain every day.
R /: Normally pain occurs in less than five days after surgery and gradually disappear. Pain may increase due to increased IOP 2-3 days post-surgery. Pain suddenly showed massive increase in IOP.
2. Instruct to report the development of pain every day, or as soon as an increase in sudden pain.
R /: Improve collaboration; provide security to increase psychological support.
3. Encourage clients to not do any sudden movements that can provoke pain.
R /: Some of the activities the client can increase the pain as sudden movement, bent, rubbed his eyes, coughing, straining.
4. Teach distraction and relaxation techniques.
R /: Reduce stress, reduce pain.
5. Perform collaborative action for topical or systemic analgesic administration.
R /: Reduce pain by increasing pain threshold.
