NURSING CARE FOR CLIENTS WITH GLUCOMA IN JASMINE ROOM OF

WAHIDIN SUDIRO HOSPITAL

By:
ANDRIANINGTIAS
NIM: 20191276

D-III NURSING PROGRAM STUDY

ACADEMY OF NURSING WORKS OF BAKTI HUSADA
Academic Year 2020/2021
CASE

Mrs. B (35 years old) is currently in the middle of handling complaints of the right orbital pain
when the vision is blurred, even though Mrs.B has used minus 4 glasses in the right and left eye,
one month ago Mrs.B suffered from a thyroid disorder. The client complained of nausea and
vomiting and had no appetite. The client complained of weakness. The client said he lost 3 kg.
Client complaints decreased vision. By an ophthalmologist, an Ofthalmoscope, Tonometry and
visual field measurements were performed. The results of the examination turned out that
Mrs.B had glaucoma. Current vital signs BP: 150/100 mmHg, Pulse: 80x / minute, Temperature:
37oC, Respiration: 20x / minute. Mrs. B did not know why she had glaucoma and she heard
information from people that glaucoma could cause blindness, so Mrs. B was afraid of going
blind.

FOCUS DATA

Data subjektif Data objektif

1. The client complains that the left orbital 1. TTV:

hurts when pressed.
TD: 150/100 mmHg
2. The client complains of blurred vision even
though he has used minus 4 glasses in the N: 80x / minute
right and left eye. S: 37oC
3. The client said one month ago he had a RR: 20x / minute
thyroid disorder.
2. The client is seen wearing glasses.
4. Clients complain of nausea and vomiting.
3. The client is seen holding the head area and
5. The client complains of no appetite. around his eyes.
6. The client complains that his body is weak. 4. The client's pupils appear brownish.
7. The client says he has lost 3 kg 5. There is corneal edema in the client.
8. Clients complain of decreased vision. 6. Client looks nauseous and vomiting.
9. The client does not know why he can 7. The client is seen frowning at the sight.
experience glaucoma
8. Client body weight decreased due to no
10. Clients hear information from people that appetite and only ate makan portion
glaucoma can cause blindness, so clients are
afraid of blindness. P: pain when pressed

Q: blunt

R: left orbita
 S: 6

T: gradually

DATA ANALYSIS

Data fokus Problem Etiologi

DS: acute pain biological injury

agents
· The client complains that the left orbita
hurts when pressed

· The client said two months ago suffering

from a Thyroid disorder

DO:

· Vital sign :

TD: 150/100 mmHg

N: 80x / minute

S: 37oC

RR: 20x / minute.

· The client is seen holding the head area and

around the eyes

· The client is seen frowning at the sight

P: pain when pressed

Q: blunt

DS: risk of falling

· The client complains of blurred vision even

though he has used minus 3 glasses in the
right and left eyes

· The client said experiencing changes in

activity usually due to visual disturbances

· The client complains that the body feels

weak
DO:

· The client is seen wearing glasses

· The client's pupils appear brownish

There is corneal edema in the client

DS: Nutritional imbalance lack of food intake

less than the body's
The client complained of nausea and vomiting needs
· The client complains of no appetite

· Client says his weight has dropped by 3kg

DO:

· The client looks nauseous and vomiting

· Client body weight decreased due to no

appetite and only ate ¼ portion

NURSING DIAGNOSES

1. Acute Pain b.d Biological injury agent

2. Risk of falling

3. Nutritional imbalance less than the body's needs b.d Inadequate food intake

N Nursing diagnoses objectives and outcome intervention

o criteria

Acute Pain b.d After 3 x 24 hours of nursing 1. Perform a comprehensive

Biological injury agent action, acute pain problems pain assessment that includes
can be controlled. With the location, characteristics, onset
result criteria: or duration, frequency,
quality, intensity or severity of
1. The client's extra orbital pain and trigger factors.
does not hurt when pressed
2. Explore with the patient the
2. The client is able to take factors that can reduce or
action to reduce pain aggravate the pain
P: don't feel pain when 3. Control environmental
pressed factors that can affect the
 Q: blunt patient's response to
discomfort
R: left orbita
4. Support adequate rest to
S: 2 reduce pain
Q: rarely 5. Involve the family in pain
reduction modalities, if
possible

Collaboration:

Collaborate with your doctor

in administering analgesics
(diazepam)

Risk of falling After 1 x 24 hours of nursing 1. Identification of behavior

action, the problem of falling and factors that affect the risk
risk can be resolved. With the of falling
result criteria:
2. Review the history of falls
1. Falling doesn't happen with the patient and family

3. Identify the characteristics

of the environment that might
increase the potential for falls

4. Place objects within easy

reach of the patient

5. Teach the patient what to

do if the patient falls to
minimize injury

Nutritional imbalance After 3x24 hours of nursing Nutritional Management:

less than the body's action the client's nutrition is (1100)
needs b.d Inadequate resolved. With the result
food intake criteria: 1. Determine the patient's
nutritional status and the
1. The client does not have patient's ability to meet
nausea and vomiting again nutritional needs

2. The client's appetite 2. Identify any food allergies

increases or intolerances the patient
has.
3. The ideal BB client
3. Determine the patient's
dietary preferences.

4. Intrude the patient

regarding nutritional
requirements

5. Assist the patient in

determining which guidelines
or food pyramid are most
suitable to meet nutritional
needs.

Collaboration:

With nutritionists in the

provision of proper nutrition