ASSESMENT S: Paputol-putol nga yung tulog ko ditto dahil sa ingay saka maliwanag. As verbalized by the patient.

O: Presence of eye bag Yawning Interrupted hour of sleep from a total of 8-9 hrs to 6 hrs

NURDING DIAGNOSIS Disturbed sleep pattern related to excessive stimulation (noise and lighting)

BACKGROUND KNOWLEDGE
Nois Lighti

PLANNING Long Term Goal: Within 1 day of nursing intervention, the patient will be able to achieve optimal amount of sleep Short Term Goal:

INTERVENTION Independent: - Ask the SO to tell the other patient the ward to minimize noise during the time of sleep. -Request SO to ask visitors to leave during sleeping hours. -Encourage to listen to soft music when trying to sleep. -Encourage the use of eye mask or pillow to minimize stimulation from light. -Provide educational information about discouraging long periods of sleep during day and refraining from caffeine before

RATIONALE

EVALUATION After 1 day of nursing intervention, goal to achieve optimal amount of sleep was: ____Met ____Partially Met Unmet After 1 hour of nursing intervention, goals to: Identify ways and pattern in having a quiet environment was: met _Partially met Unmet Determine comfort measures that can help in promoting uninterrupted sleep was: met _Partially met Unmet

Stimulation of patients wakefulness and awareness

-To allow quiet environment thus prevent interruption of sleep -To provide a quiet environment

Decrease function of pineal gland

Within 30 minutes to 1 hour of nursing intervention, the patient will be able to: A. Indentify ways and pattern in having a quiet environment B. Determine comfort measures that can help in promoting uninterrupted sleep.

-To promote stimulation of sleep -To promote stimulation of sleep

Suppression of melatonin production

Disturbed Sleeping Pattern

-To promote uninterrupted sleep

C. Indentify individually appropriate interventions to promote sleep.

sleeping. -Encourage usual bedtime routine such as washing face and hands; urinate before bedtime and drinking milk. -Encourage SO to provide bedtime care such as straightening bed sheets, back massage and ensure good ventilation. -To promote physical comfort

Identify individually appropriate interventions to promote sleep was: met _Partially met Unmet

-To promote physical comfort

Reference: NANDA by Marilyn Doenges pages 775-777

NURDING DIAGNOSIS S: Halos di na ko Disturbed sensory makakita sa perception related to kaliwang mata ko. clouding of the lens As verbalized by the in the left eye patient. O: Clouding of the left eye 20/40 eye vision

ASSESMENT

BACKGROUND KNOWLEDGE
Possible traumatic cause

PLANNING Short Term Goal: Within 1 to 2 hours of nursing intervention the patient will be able to: A. Improve visual acuity within the limits of individual situations. B. Identify ways to reduce risk of injury. C. Determine possible intervention to regain normal level of cognition.

INTERVENTION Independent:

RATIONALE

EVALUATION After 1 hour of nursing intervention, goals to:

Structure of lens protein are altered

-Recommend -Enhances patients patient the measures visual field and to manage visual acuity limitations, e.g. turning head to view subjects and problem with night vision. -Ask the SO to assist the patient in doing activities requiring normal level of cognition. -Encourage patient to engage only in simple physical activities or tasks. -Instruct SO to always orient the patient about the environment new to the patient. -Provide information about ways and

Clumping and aggregation of lens protein

Clouding of the lens

Improve visual acuity within the limits of individual situations was: met _Partially met -To prevent possible Unmet injury Identify ways to reduce risk of injury was: met -To prevent possible _Partially met injury Unmet Determine possible intervention to regain normal level of cognition was: met _Partially met Unmet

Blockage of some light from reaching retina

-To help the patient familiarized in the new environment, thus preventing injury -To motivate patient in managing visual impairment

Cloudy area in lens may get larger over time

intervention to improve level of cognition like cataract glasses and engagement to surgery. Reference: NANDA by Marilyn Doenges pages 739-742

Disturbed sensory perception

NURSING CARE PLAN NURDING DIAGNOSIS S: Wala pa po ako Ineffective tissue masyadong perfusion related to nararamdaman, pero increased vascular mataas BP ko. As vasoconstriction. verbalized by the patient. O: Vital signs taken: T-36.5 P-80bpm R-17cpm BP-160/100mmHG ASSESMENT BACKGROUND KNOWLEDGE
Smoking, sedentary lifestyle, high intake of sodium Kidney release rennin in the bloodstream

PLANNING Short Term Goal: Within 3 to 4 hours of nursing intervention, the patient will: A. Participates in activities that reduce cardiac overload or maximize circulation. B. Maintains blood pressure within acceptable range. C. Determine the behavior and lifestyle changes to maintain and maximize circulation.

INTERVENTION Independent: -Provide periods of undisturbed rest and calming environment (minimizing noise) -Maintain activity restriction and asked so as to assist patient with self care activities. -Provide comfort measures; i.e. evaluation of head -Encourage relaxation techniques like guided imagery and prevent distraction. -Discuss modifiable risk factors related to the patient: -Encourage

RATIONALE

EVALUATION After 3 hours of nursing intervention, goals to: Participate in activities that reduce cardiac overload was: Met _Partially met Unmet Maintain blood pressure within acceptable range was: Met _Partially met Unmet

-To reduce myocardial work load

-To reduce physical stress and stimuli that affect the blood pressure -Decreases discomfort and may reduce sympathetic stimulation -Helps reduce stressful stimuli, thereby decreases blood pressure

Angiotensinogen stimulation

Angiotensin I convert to Angiotensin II Aldosterone: causes sodium retention

Determine behavior and lifestyle changes to client and maximize -To assist client in circulation was: understanding those Met area in which he can _Partially met take actions or make Unmet

Retained sodium causes water retention increasing blood volume Vasocontriction of arteries Increases blood pressure

smoking cessation, healthy heart offering information choices. about smokingcessation aids and programs -encourage client to engage in regular exercise -discuss coping and stress tolerance Dependent: Administer antihypertensive agent as ordered -To decrease blood pressure level.

Ineffective tissue perfusion

Reference: NANDA by Marilyn Doenges pages 614-618

NURSING PRIORITIZATION PRIORITY NO. 1 NURSING DIAGNOSIS Ineffective Tissue Perfusion JUSTIFICATION This is our first priority because it involves the circulation in the ABC of life and an actual problem the patient experienced during the data gathering. This is our second priority because it is a problem involving one of the most important senses needed for the accomplishment of patients ADL and a problem when managed can satisfy the safety needs in Maslows hierarchy of needs. This is our third priority because it involves the physiologic needs in Maslows hierarchy of needs, and a problem when managed may help the alleviation of our patients blood pressure in problem No. 1.needs. A problem that can be carried out when the third priority is managed. Risk problems are always prioritized next to an actual problem.

Disturbed Sensory Perception (Visual)

Disturbed Sleep Pattern

4 5

Ineffective Self Health Management Risk-Prone Health Behavior