ASSESSMENT Subjective:

DIAGNOSIS

PLANNING After 8 hours of nursing interventions, the patient will identify ways to use resources effectively and appropriately

INTERVENTION Reviewed laboratory test results Assisted with diagnostic studies and sensory testing Monitored drug regimen

RATIONALE

EVALUATION After 8 hours of nursing interventions, the patient was able to identify ways to use resources effectively and appropriately

Disturbed sensory Hindi ako makakita perception ng maayos sa mata ko (visual) sa kaliwa, parang related to anino lang ang eye injury nakikita ko. Objective: (-) CF on left eye (-) Hand movement distinction on left eye VS T 35.6 PR 82 R.R. 21 BP 130/90

To identify medications with effects or drug interactions that may cause sensory perceptual problems

Acertained client's perception of problem in activities of dailuy living. Listen to and respect client's expressions od deprivation and took these into consideration in planning care Provided means of To prevent sensory communication, as indicated. deprivation/limit confusion Avoided isolation of client, physically or emotionally. Explained procedures/activities, expected sensations, and outcomes.

Eliminated extraneous noise/stimuli. Provided undisturbed rest/sleep periods. Provided diversional activities. Provided safety measures as needed. Assisted client to learn effective ways of coping with sensory disturbances anticipating safety needs according to sensory deficit Identify and encourage use of resources/prosthetic devices Instructed patient to cover eye with an eye shield or avoid leaning forward or sleeping on affected side, Instruct the patient to move the eyes as little as possible. Useful for augmenting senses To avoid irritation and increase of pressure on affected part