Saturday, August 21, 2010

2 Diabetic Retinopathy Nursing Care Plans

Diabetic retinopathy is retinopathy (damage to the retina) caused by complications of diabetes mellitus, which can eventually lead to blindness. It is an ocular manifestation of systemic disease which affects up to 80% of all patients who have had diabetes for 10 years or more. Despite these intimidating statistics, research indicates that at least 90% of these new cases could be reduced if there was proper and vigilant treatment and monitoring of the eyes.

Altered Sensory Perception
In poorly controlled DM, microcirculatory changes occur rapidly wherein the lining of the retinal blood vessels that supply the retina is blocked within the retina. Visual impairment occurs as a result of this    ischemia which significantly alter the visual perception of the patient.
Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale Expected Outcome
s> the pt. may be verbalize: -change in sensory acuity
-dependency on significant others
-bilateral blindness
-change in usual response to stimuli
-poor concentration
- change in behavior pattern
Altered sensory perception (visual) r/t micro vascular destruction 2° DM Short term: after 1-2 hrs. of NI, the pt. will demonstrate behaviors to prevent accidents that can result due to visual impartment. Long term:
After 2-3 days of NI. The pt. will be free of injury caused by the sensory alterarion.
>establish rapport >monitor and assess V.S
>assess pt’s general physical condition
>listen and respect clients expression of dependency
>reorient to time, place, and staff and events as necessary
>explain procedures / expected sensations and outcomes
>minimize discussion of negatives within clients hearing
>provide rest periods
>arrange bed, personal articles and food trays
>instruct SO not to leave the client unattended
>provide safety measures
>position door s and furniture’s so they are out of travel path
>administer antidiabetic medications as needed
>to gain pt’s. trust and cooperation >to obtain baseline data
>to note for any abnormality
>to encourage verbalization of feelings
>enhances pt’s. well being and sense of importance.
>to promote participation
>pt may misinterpret and believe references are to himself / herself
>to conserve energy
>enhances safety
>to prevent injury
>to aid in maintaining balance
>to treat underlying condition.
The pt shall have demonstrated behaviors to prevent accident / injures. The pt shall have been free of injury caused by the alteration
Risk For Falls
Retina is the most metabolically active structure per weight of tissue in the body. Thus the retina is an inevitable target for micro vascular damage in diabetes mellitus. Diabetic retinopathy appears to be a response to retinal ischemia resulting from blood vessel changes and RBC aggregation. It is the leading cause of blindness. In the case of the pt. retinopathy become a chronic complication that lead to blindness. Blindness increase the pt’s susceptibly to falling that may cause physical harm. This impartment in eyesight may to inability to recognize danger.
Assessment Nursing Diagnosis Objectives Nursing Interventions Rationale Expected Outcome
s> the patient may verbalize: -weakness
-imbalance of stance and posture
-needs  assistance in performing ADLs
-dependent to significant others
-decrease Hgb concentration
-bilateral blindness
-(+) homans sign on both legs
- with  limited ROM
-faintness when turning
-decrease lower extremely strength
-difficulty c̄ gait
Risk for falls r/t eyesight impairment (blindness) Short term: After 1-2 hrs of NI, the pt will be able to demonstrate behaviors to reduce and protect  self from injury.
Long term:
After 2-3 days of NI, the pt will be free of injury from mechanical sources
>establish rapport >monitor and assess V.S
>assess pts general physical condition
>evaluate client’s cognitive status
>provide information regarding clients dse  condition (s) that may result in increase risk of falls.
>review medication regimen and how it affects clients. Instruct in monitoring of side effect.
>ensure safety precautions
>instruct the S.O not to leave the unattended .
>instruct pt. to ask for assistance during ambulation/ transfer
>administer due to meds
>to gain pts trust and cooperation >to obtain  baseline
>to note any abnormality
>affects ability to perceive own limitation and risk for falling
>to instill awareness on the need to promote safety.
>use of pain medication may contribute to weakness and confusion; multiple medications and combinations  may contribute to dizziness or loss of balance
> to prevent falls
>to treat underlying medical condition
The pt shall have demonstrated behaviors to protect self from injury The pt shall have been free for injury.