Dry Eye: Nursing Diagnosis and Care Plan

Assessment

Objective

The patient is characterized by the decreased vision in the left eye.

Painful feelings resulting from the attempts to move the left eye.

The absence of any discomfort while resting.

A patient is not able to determine colors.

The general state of the patient is satisfactory.

The sclera is white, conjunctivae clear.

The patient is unable to assess visual fields on the left side.

Pupils response to light is diminished.

There are no other visual signs of the deterioration of the patients health.

Subjective

The patient denies fever, chills, night sweats, weight loss, fatigue, headache, changes in hearing, sore throat, nasal or sinus congestion, neck pain or stiffness, chest pain or palpitations, shortness of breath or cough, abdominal pain, diarrhea, constipation, dysuria, vaginal discharge, swelling in the legs, polyuria, polydipsia, and polyphagia. She also denies the usage of drugs and alcohol abuse.

Resting on the patient’s words, she might feel some relief being in a cool and air-conditioned environment.

Diagnosis

The patient could be diagnosed with the risk for dry eye (NANDA, n.d.) as she has the symptoms peculiar to it. It could be supported by the symptom called a foreign body sensation when a patient feels pain while trying to move the eye. Furthermore, blurred vision and sore eyes could also prove the diagnosis (Adler, n.d.). Additionally, the patient might also be diagnosed with the deficient diversional activity (NANDA, n.d.) as being the math teacher she performs the same activity every day.

Planning

It is crucial to initiate the recovery process to help the patient and mitigate the negative symptoms of the disease. The consultation with a therapist is vital to obtain a clear image and create a plan for further actions aimed at the improvement of the state of a patient. In the course of treatment, complete recovery could be expected.

Intervention

Examine the patient to discover the signs of the deterioration or improvement of her state and assess the patients ability to see.

Encourage the patient to visit an ophthalmologist to determine the nature of the problem.

Inform the patient about the possible reasons for the deterioration of the state of her eye.

Provide beneficial conditions for the functioning of a patient.

Explain the basic rules and knowledge for patients suffering from the problem of this sort.

The given set of interventions is aimed at the improvement of the state of a patient and the initiation of the recovery process.

Evaluation

The state of the patients eye could serve as the main indicator of the general state of the problem.

The absence of painful feelings could evidence the significant improvement of the state of the patient.

The restoration of the previous reactions will prove the efficiency of the applied measures.

The ability to determine colors should also be renewed in the course of the treatment.

Finally, if the patient does not have any discomfort or symptoms signalizing the development of the disease, the complete recovery could be stated.

Teaching Plan

Regarding the character of the patients job, it is crucial to explain the basic concerns of a healthy lifestyle and highlight the necessity of preventive activity to stop the development of discomfort and decrease the possibility of relapse (Hughes, 2008). She should be provided with the information related to the exercises needed to promote the health of her eyes. Finally, it important to explain the necessity o the creation of a positive environment at home and at the working place.

References

Adler, R. (n.d.). Web.

Hughes, R. (2008). Patient Safety and Quality. Rockville, MD: Agency for Healthcare Research and Quality

NANDA. (n.d.). The Complete list of NANDA Nursing Diagnosis for 2012-2014, with 16 new diagnoses. Web.

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