00219 Risk Of Ocular Dryness

Domain 11: security/protection
Class 2: physical injury
Diagnostic Code: 00219
Nanda label: ocular dryness risk
Diagnostic focus: ocular dryness
Approved 2010 • Revised 2013, 2017, 2020 • Evidence level 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « Risk of dry ocularity is defined as: susceptible to inadequate lacrimal film, which can cause discomfort and/or injury of the ocular surface, which can compromise health.

Risk factors

  • Air conditioning
  • Environmental pollution
  • Coffee consumption
  • Decrease in flicker frequency
  • Excessive air
  • Insufficient knowledge of modifiable factors
  • Inappropriate use of contact lenses
  • Inappropriate use of fans
  • Inappropriate use of the hair dryer
  • Lack of attention to passive smoker
  • Insufficient fluid intake
  • Low environmental humidity
  • Deficiency of omega-3 fatty acids
  • smoking
  • Sun exposure
  • Use of products with Benzalconium chloride preservatives
  • Vitamin A

Risk population

  • Contact lens bearer
  • People who experience prolonged stays in intensive care units
  • People with a history of allergy
  • Older adults
  • Women

Associated problems

  • Artificial breathing
  • Autoimmune diseases
  • Chemotherapy
  • Decrease in the level of consciousness
  • Hormonal changes
  • Incomplete closure of the eyelids
  • Leukocytosis
  • Metabolic diseases
  • Neurological lesion with sensory loss or motor reflexes
  • Neuromuscular block
  • Oxygen therapy
  • Pharmacological preparations
  • Proptosis
  • Radiation therapy
  • Reduction of the volume of tears
  • Surgical procedures

Suggestions of use

  • When the discomfort is caused by dry eyes, it may be necessary to use the risk diagnosis of comfort -related comfort deterioration. The diagnosis of Nanda-I is for the potential problem of dry eye risk; There is no diagnosis for the real problem.

Suggested alternative diagnostics

  • Comfort, deterioration of

NOC Results

  • Noc results have not yet been associated with this diagnosis, although the following could be useful:
  • Neurological status: Consciousness: Activation, orientation and attention to the environment
  • Tissue integrity: skin and mucous membranes: Structural integrity and normal physiological function of the skin and mucous membranes
  • Comfort deterioration level: gravity of the mental or physical discomfort observed or reported

Evaluation objectives and criteria

  • The patient does not suffer from dry eyes, demonstrated by a level of discomfort and tissue integrity of skin and mucous membranes within the expected range for the individual
  • Demonstrates a level of discomfort from mild to null, which is manifested by the following indicators: (Specify from 1 to 5: severe, substantial, moderate, light or none): pain, anxiety, complaints or blows
  • Other examples

    • Sclerotic and wet eyelids without injuries
    • The patient will be alert, active and oriented in time, place and person

    NIC Interventions

    • NIC interventions have not yet been associated with this diagnosis, although the following could be useful:
    • Contact lenses care: eye injury prevention and impairment lenses through proper use
    • Eye care: prevention or reduction of threats to the eyes or to visual integrity

    Nursing Activities

    • In general, nursing activities for dry eye risk focus on the surveillance of risk factors (such as level of consciousness) and dry eye symptoms (pain), as well as measures for decrease risk factors, and thus prevent dry eye.

    Valuations

    • Assess risk factors such as allergies and smoking. Pay special attention to older adults, patients with assisted ventilation and those of low level of consciousness
    • If there are risk factors, monitor them regularly
    • Monitor the humidity, color and drainage of sclerotics and conjunctiva, and assess whether redness and abrasions are observed

    Patient and family education

    • Teach the proper handling, withdrawal and storage of the contact lenses

    Collaboration activities

    • Apply ointment or eye drops on the lower eyelid, as prescribed

    Others

    • Provide eye care every 2 to 4 hours to unconscious patients, to those who do not have a flickering reflection or those who are seriously ill
    • If there are risk factors (for example, coma):
      • Lubricate your eyes with saline solution or artificial tears
      • Use eye protector to keep them closed