Care Plan: I need to know if this nursing diagnosis is legit

  1. 1 I am assigned do make a Care Plan for a long term facility patient who has a history of Diabetes Mellitus type 2. He is self-sufficient... does all ADL's on his own, walk with a walker d/t his vision is not so great. He has myopia and has recently been diagnosed with nuclear sclerosis cataract. This is the nursing diagnosis I have come up with:
    Disturbedsensory perception related to impaired visual reception as evidencedby decreased vision with the need to use corrective lenses to see.

    I am just very unsure if this "works" or not. The patient does have glasses, but he claims that he does not wear them all the time. I think the route I am wanting to go has to do with safety. I have my patient goal as being


    Maintainsafe optimal functioning within limits of visual impairment

    Any suggestions/comments would be very appreciated!
  2. Visit  smit6843 profile page

    About smit6843

    29 Years Old; Joined Mar '13; Posts: 7; Likes: 2.

    14 Comments so far...

  3. Visit  MendedHeart profile page
    0
    Does he have any falls or injury history? What kind a meds is he taking..how active is he?
  4. Visit  JRDeeRN profile page
    0
    Is his eyesight bad related to the disease process of diabetes ?? That would be a good one a lot diabetics have eye problems because of uncontrolled diabetes ... Just a thought !
  5. Visit  MendedHeart profile page
    1
    Your patients goal needs to be measurable. How would you measure this? What is WNL?
    jimithing112 likes this.
  6. Visit  JRDeeRN profile page
    0
    Ex. Risk for injury related to disturbed sensory perception secondary to disease process
  7. Visit  MendedHeart profile page
    0
    Quote from JDuganRN
    Ex. Risk for injury related to disturbed sensory perception secondary to disease process
    Thats two NDs

    Both would work. .I was wondering if he has had any injuries r/t his vision
  8. Visit  JRDeeRN profile page
    0
    Oh lol I used those kind of NDs in school all the time but maybe they weren't as strict about them at my school as long as it got the point across lol nevermind then
  9. Visit  Floridatrail2006 profile page
    0
    I'm wondering if his safety is in jeopardy here. I wonder if there is another ND that can address this patient's safety as well as address his visual issues. You can consider that as well.

    Your diagnosis seems to work. I wonder if there are others that you could consider too that maybe hit on safety.
  10. Visit  Esme12 profile page
    1
    Quote from smit6843
    I am assigned do make a Care Plan for a long term facility patient who has a history of Diabetes Mellitus type 2. He is self-sufficient... does all ADL's on his own, walk with a walker d/t his vision is not so great. He has myopia and has recently been diagnosed with nuclear sclerosis cataract. This is the nursing diagnosis I have come up with:
    Disturbedsensory perception related to impaired visual reception as evidencedby decreased vision with the need to use corrective lenses to see.

    I am just very unsure if this "works" or not. The patient does have glasses, but he claims that he does not wear them all the time. I think the route I am wanting to go has to do with safety. I have my patient goal as being


    Maintainsafe optimal functioning within limits of visual impairment

    Any suggestions/comments would be very appreciated!

    Care plans are all about the assessment OF THE PATIENT. What you have here is a history of what he has.....nuclear sclerosis cataract, DM type 2. He uses a walker and doesn't wear his glasses.

    But...what is YOUR assessment of the PATIENT? What do they need? What is their complaint? Have they fallen and injured themselves?

    What exactly is a nuclear sclerosis cataract........what so these patient need?

    Nuclear Sclerosis Cataract
    Definition: An opacity in the nucleus of the lens, for which the key histologic criterion is melding or homogenization of lens fiber cells.
    Incidence/Prevalence: It is the most common form of cataract and is especially common in older individuals. Subject prevalence for nuclear lens changes is about 3 fold higher than for posterior subcapsular opacities
    Etiology: There are many associations with nuclear cataract. The biochemical changes involve aggregation of lens crystallins as a predominant feature.
    Clinical Findings: Symptoms include decreased vision and glare. The patients may experience progressive myopia as the refractive power of the lens accompanies the increased size of the cataractous lens.
    What treatment do these patients need? Will corrective lenses help this patient?

    Is this your first care plan? What semester are you? Do you understand the nursing process???? What care plan book do you have?
    Mr.FutureDNP23 likes this.
  11. Visit  GrnTea profile page
    2
    I'm looking in my NANDA-I 2012-2014 and there is no such nursing diagnosis as "disturbed sensory perception." None. Nada. Zip. Zilch. Therefore, in answer to your question, it is not an aceptable nursing diagnosis. I know, I know how sexy it sounds, but without a NANDA-I -approved nursing diagnosis, you're out of luck on that one.

    So, while he may very well have "disturbed" (!!) vision, (how about we call it, "impaired" or "decreased"?) and need glasses, your nursing assessment should give you ideas about what problems that may make for him. Can he read his medication bottle labels? Patient teaching materials? Can he get around without falling? Can he cook safely? Cross a street? If he can't drive, how does he compensate for that, and why does he need to? Look elsewhere for the nursing diagnoses that would describe the problems he has related to his visual impairment, and that will suggest things you, the nurse, can do to help him. (HINT: Domain 11, Safety/Protection, for starters...and there are others) (you're welcome)

    A nursing diagnosis statement translated into regular English goes something like this: "I think my patient has ____(diagnosis)_____________ . He has this because he has ___(related factor(s))__. I know this because I see/assessed/found in the chart (as evidenced by) __(defining characteristics)________________."


    "Related to" means "caused by," not something else. In many nursing diagnoses it is perfectly acceptable to use a medical diagnosis as a causative factor. For example, the NANDA-I nursing diagnosis "acute pain" includes as related factors "Injury agents: e.g. (which means, "for example") biological, chemical, physical, psychological."




    To make a nursing diagnosis, you must be able to demonstrate at least one "defining characteristic." Defining characteristics for all approved nursing diagnoses are found in the NANDA-I 2012-2014 (current edition). $29 paperback, $23 for your Kindle at Amazon, free 2-day delivery for students. NEVER make an error about this again---and, as a bonus, be able to defend appropriate use of medical diagnoses as related factors to your faculty. Won't they be surprised!


    If you do not have the NANDA-I 2012-2014, you are cheating yourself out of the best reference for this you could have. I don’t care if your faculty forgot to put it on the reading list. Get it now. Free 2-day shipping for students from Amazon. When you get it out of the box, first put little sticky tabs on the sections:
    1, health promotion (teaching, immunization....)
    2, nutrition (ingestion, metabolism, hydration....)
    3, elimination and exchange (this is where you'll find bowel, bladder, renal, pulmonary...)
    4, activity and rest (sleep, activity/exercise, cardiovascular and pulmonary tolerance, self-care and neglect...)
    5, perception and cognition (attention, orientation, cognition, communication...)
    6, self-perception (hopelessness, loneliness, self-esteem, body image...)
    7, role (family relationships, parenting, social interaction...)
    8, sexuality (dysfunction, ineffective pattern, reproduction, childbearing process, maternal-fetal dyad...)
    9, coping and stress (post-trauma responses, coping responses, anxiety, denial, grief, powerlessness, sorrow...)
    10, life principles (hope, spiritual, decisional conflict, nonadherence...)
    11, safety (this is where you'll find your wound stuff, shock, infection, tissue integrity, dry eye, positioning injury, SIDS, trauma, violence, self mutilization...)
    12, comfort (physical, environmental, social...)
    13, growth and development (disproportionate, delayed...)


    Now, if you are ever again tempted to make a diagnosis first and cram facts into it second, at least go to the section where you think your diagnosis may lie and look at the table of contents at the beginning of it. Something look tempting? Look it up and see if the defining characteristics match your assessment findings. If so... there's a match. If not... keep looking. Eventually you will find it easier to do it the other way round, but this is as good a way as any to start getting familiar with THE reference for the professional nurse.
    AnimalRescueNurse and KelRN215 like this.
  12. Visit  smit6843 profile page
    0
    Thank you all for you input. My college did not require us to have this NANDA- 2012-2014 book I keep reading about, but I will probably be investing in one very soon. They required us to have a Nursing Care Plan book that I do not find is much help to me. Esme12-- I am a second semester student and do understand the nursing process. I did end up completely throwing out this ND and came up with one that made much more sense and could definetely be applied to my patients situation. GrnTea-- FYI, I actually found "disturbed sensory perception" on the nanda website... so it wasnt something I pulled out of no where. Thank you
  13. Visit  Esme12 profile page
    0
    I didn't want to repeat stuff you already grasp. Which care plan book do you have I use Ackley: Nursing Diagnosis Handbook, 9th Edition and Gulanick: Nursing Care Plans, 7th Edition even if your college didn't require the NANDA-I it is the bible for nursing diagnosis.


    • Disturbed Sensory Perception: Auditory: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli
      Hearing loss is common among older adults but may also occur as the result of congenital exposure to virus; during childhood after frequent ear infections or trauma; and during adulthood as the result of trauma, infection, or exposure to occupational and/or environmental noise. Conductive hearing loss is associated with problems affecting the outer ear and middle ear. These problems include impacted cerumen and infection. Sensorineural hearing loss occurs with inner ear disorders or impaired function of cranial nerve VIII. Aging, noise exposure, and ototoxicity from some drugs contribute to this type of hearing loss. When hearing loss is profound and precedes language development, the ability to learn speech and interact with hearing peers can be severely impaired. When hearing is impaired or lost later in life, serious emotional and social consequences can occur, including depression and isolation. Some causes of hearing loss are surgically correctable. Many hearing assistive devices and services are available to help hearing-impaired individuals. Nursing interventions with the hearing impaired are aimed at assisting the individual in effective communication despite the loss of normal hearing.
    • Disturbed Sensory Perception: Visual: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli
      visual impairment affects a significant number of people across the life span. Refractive errors are the most common form of visual problem. These correctable visual impairments include myopia, hyperopia, presbyopia, and astigmatism. Correction occurs with glasses, contact lenses, or surgery. Chronic diseases such as diabetes mellitus, glaucoma, and macular degeneration cause visual impairment that is not correctable and may lead to blindness. Cataracts contribute to visual impairment that may be corrected through surgery and lens replacement. Infections, trauma, drugs, and diseases of the brain may also cause visual impairment. Changes in visual acuity may interfere with the person's activities of daily living and productivity at work, school, or home. Loss of vision threatens the safety of the individual and puts the person at risk for falls and other injuries. Visual impairment may affect the person's psychological, emotional, and social well-being as he or she copes with adapting to the loss while attempting to remain independent. Dependence on devices to correct or adapt to visual impairment may affect the person's body image and self-concept.

    You are right they Are both a NANDA diagnosis. YOur life will be much easier when you have hte right tools. Good Luck!
  14. Visit  GrnTea profile page
    1
    Quote from smit6843
    Thank you all for you input. My college did not require us to have this NANDA- 2012-2014 book I keep reading about, but I will probably be investing in one very soon. They required us to have a Nursing Care Plan book that I do not find is much help to me. Esme12-- I am a second semester student and do understand the nursing process. I did end up completely throwing out this ND and came up with one that made much more sense and could definetely be applied to my patients situation. GrnTea-- FYI, I actually found "disturbed sensory perception" on the nanda website... so it wasnt something I pulled out of no where. Thank you

    "Disturbed sensory perception" was retired from the list of approved diagnoses in the 2012-2014 edition. The rationale they give for this (pages 490-491) is" "Focus areas within the diagnosis should be separated into individual concepts (i.e., visual sensory perception deficit, auditory sensory perception deficit, etc.), with defining characteristics and related factors specific to each focus clearly identified." Thanks for the opportunity to clarify that.
    KelRN215 likes this.


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