Retinal detachment happens when the retina pulls away from the back of the eye, and it is an emergency that can cause permanent vision loss. Classic signs are sudden floaters, flashes of light, and a curtain or shadow over part of the vision. Your priorities are getting the client to treatment fast, protecting the eye, and teaching post-op positioning and safety.
Each care plan below follows the nursing process (ADPIE).
Disturbed Sensory Perception (Visual)
- Separation of the retina from its blood supply
- Eye patch or blurred vision after surgery
- Client reports flashes of light and new floaters
- Client describes a curtain or shadow over part of the vision
- Decreased visual acuity
- Client reports any change in vision right away during the hospital stay
- Client moves safely in the room with help as needed within 24 hours
- Client keeps or regains as much vision as possible after treatment
- Client follows all follow-up eye appointments
- Visual acuity and visual field changes
- Onset and progression of symptoms
- Eye pain or pressure after surgery
- Ability to move around safely
| INTERVENTION | RATIONALE |
|---|---|
| Report new or worsening vision symptoms to the provider right away | Fast repair gives the best chance of saving vision. |
| Keep the client calm and limit activity before surgery as ordered | Quick movements may make the detachment worse. |
| Orient the client to the room and keep the call light and needed items within reach | Reduced vision increases the risk of falls. |
| Approach and speak to the client from the side with better vision | This prevents startling the client and helps them feel safe. |
EVALUATION
- Client reports vision changes promptly
- Client moves around the room without injury
- Vision is stable or improving at follow-up
Deficient Knowledge
- New diagnosis and surgery
- Unfamiliar post-op positioning and activity limits
- Client asks questions about care after surgery
- Client is unsure how to position the head or use eye drops
- Client demonstrates the ordered head position and eye drop technique before discharge
- Client follows activity limits and recovers without complications
- Client's current understanding and readiness to learn
- Ability to instill eye drops
- Support at home
- Understanding of warning signs
| INTERVENTION | RATIONALE |
|---|---|
| Teach the exact head position ordered, such as face-down after a gas bubble | The gas bubble must press against the detached area to hold the retina in place. |
| Teach to avoid heavy lifting, bending over, straining, and rubbing the eye as ordered | These raise pressure in the eye and can disrupt healing. |
| Teach no air travel or high altitude while a gas bubble is present | The gas expands at altitude and can sharply raise eye pressure. |
| Teach to report sudden pain, more floaters or flashes, or vision loss right away | These may mean the retina has detached again or pressure is too high. |
EVALUATION
- Client demonstrates correct positioning and eye drop use
- Client states activity limits and warning signs
- Client keeps follow-up appointments
Practice this in This vs That
Tell retinal detachment apart from other eye conditions that cause vision changes.
Play This vs ThatQuick answers
A client reports seeing a curtain over one eye and new flashing lights. What should the nurse do?
Treat it as an emergency. Keep the client calm and still, and notify the provider right away so treatment can start quickly.
Why might a client need to stay face-down after retinal surgery?
A gas bubble placed in the eye floats upward. Face-down positioning keeps the bubble pressing on the retina so it can reattach.
For learning only. Individualize every care plan to your client, and follow your program, current guidelines, provider orders, and facility policy.