Nursing Related Learning Experience Manual

Name of Student Yr & Sec BSN -1B

Clinical Instructor Area
Date of Exposure 7 / 8 / 2020 Hospital NDDU

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Pattern Cue Cluster
1. Health Perception & Subjective: *She has worn
Management glasses for reading for the
past 20 years
* Mrs. Hira says that she a-
eye examination 4 years ago
Objective: *68-year-old
woman
Inference Diagnostic Statement
Ineffective Health Ineffective Health
Maintenance Maintenance r/t irregular
examination of the eye as
manifested by says that she
a- eye examination 4 years
ago
Priority Rationale
Medium Medium because this
problem can if not
intervene will cause much
worse problem of the eye
may lead to visual
impairement.

2. Nutrition / Metabolism NA NA NA NA NA

3. Elimination Pattern NA NA NA NA NA

4. Activity / Exercise Subjective: *Can't see as Risk for activity Risk for activity Low Low since the problem is
well as I used to intolerance intolerance r/t altered not yet occur and it can be
* blurring that seems to be visual perception intervene through different
getting worse intervention

Objective: * distant visual

acuity in the right eye (OD)
20/40
* left eye (OS) 20/40
5. Sleep / Rest NA NA NA NA NA

6. Cognitive / Perceptual Subjective: *Can't see as Disturbed Sensory Disturbed Sensory High High 1 because this is the
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 Nursing Related Learning Experience Manual

well as I used to
* blurring that seems to be
getting worse
* She reports progressive
changes in her vision over the
past 5 months.
*reports a halo effect at night
when at lights
*and she said that she does
not drive much at night
anymore because of this
* She has worn glasses for
reading for the past 20 years
* she a- eye examination 4
years ago
Perception: Visual Perception: Visual r/t problem that makes client
altered visual perception as to seek health practitioner
manifested by statement and this problem affects
“Can't see as well as I used the ADL of the client.
to” and reports a halo effect
at night when at lights
* distant visual acuity in the
right eye (OD) 20/40
* left eye (OS) 20/40

Objective: * distant visual

acuity in the right eye (OD)
20/40
* left eye (OS) 20/40
* The extraocular muscles
are intact
* The visual fields are equal
to the examiners
* The conjunctivae are
smooth and without redness
* The pupils are bilaterally
round, _ = size, and reactive
to light and accommodation
*No nystagmus is noted

7. Self – Perception / Self NA NA NA NA NA

- Concept

8. Role / Relationship Subjective: * Her 71-year-

old husband had a major
stroke 1 year ago, and she is

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 Nursing Related Learning Experience Manual

solely responsible for his care

* Their daughter and her
family live 321.8 km (200
miles) away
* She has been retired from
the telephone company for 30
years
Objective:
9. Sexuality / NA NA NA NA NA
Reproductive

10. Coping – Stress NA NA NA NA NA

Tolerance

11. Value Belief Subjectve: “Mrs. Hira uses NA NA NA NA

for grocery shopping and to
go to church”

PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Disturbed Sensory 7 / 8 / 2020 2 : 18 PM 7 / 8 / 2020
Perception: Visual r/t altered visual
perception as manifested by statement
“Can't see as well as I used to” and reports a
halo effect at night when at lights
* distant visual acuity in the right eye (OD)
20/40
* left eye (OS) 20/40

Ineffective Health 7 / 8 / 2020 2 : 18 PM 7 / 8 / 2020

Maintenance r/t irregular examination of
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
 Nursing Related Learning Experience Manual

the eye as manifested by says that she a-

eye examination 4 years ago

Risk for activity intolerance r/t altered 7 / 8 / 2020 2 : 18 PM 7 / 8 / 2020

visual perception

PRIORITIZATION OF PROBLEMS

Nursing Diagnosis Prioritization Rationale

Disturbed Sensory High High 1 because this is the problem that makes client to
Perception: Visual r/t altered visual perception as seek health practitioner and this problem affects the
manifested by statement “Can't see as well as I used to” and ADL of the client.
reports a halo effect at night when at lights
* distant visual acuity in the right eye (OD) 20/40
* left eye (OS) 20/40

Ineffective Health Medium Medium because this problem can if not intervene will
Maintenance r/t irregular examination of the eye as cause much worse problem of the eye may lead to visual
manifested by says that she a- eye examination 4 years ago impairement.

Risk for activity intolerance r/t altered visual perception Low Low since the problem is not yet occur and it can be
intervene through different intervention

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY


Name of Patient Mrs. Hira
Address General Santos City
ASSESSMENT
PATTERN
Subjective Cues:
*Can't see as well as I
used to
* blurring that seems
to be getting worse
* She reports
progressive changes
in her vision over the
past 5 months.
*reports a halo effect
at night when at lights
*and she said that she
does not drive much
at night anymore
because of this
* She has worn
glasses for reading
for the past 20 years
* she a- eye
examination 4 years
ago
College of Health Sciences Department of Nursing
Nursing Related Learning Experience Manual
NURSING CARE PLAN
Rm/Bed No. 2C 204 Age 68 Chief Complaints Vision distortion
Admission Date 7 / 8 / 2020 Sex F Diagnosis Disturbed Sensory
Perception: Visual r/t altered visual
perception
HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
C Note: Use P-E-S format General Objective Independent Goal was met,
O * Assess the patient’s ability to see and after this
Disturbed Sensory
G Within a week patient perform activities. intervention the
N Perception: Visual r/t will be able to regain client can do
I altered visual perception vision to the maximum Rationale: Provides a baseline for her ADL without
T as manifested by possible extent with the determination of changes affecting the difficulties due
I statement “Can't see as surgical procedure and patient’s visual acuity. to visual
V well as I used to” and will regain optimal vision distortion.
E reports a halo effect at night possible and will adapt to * Encourage patient to see an ophthalmologist
when at lights permanent visual changes at least yearly.
P *distant visual acuity in the
E right eye (OD) 20/40 Specific Objective Rationale: Can monitor progressive visual loss
R * left eye (OS) 20/40 or complications. Decreases in visual acuity
C * Patient will be able can increase confusion in the elderly patient.
E to use adaptive
P Background Knowledge * Provide large print objects and visual aids for
devices to
T teaching.
U Disturbed Sensory compensate for visual
A Perception: Change in the loss.. Rationale: Assists patient to see larger print
L amount or patterning of and promotes a sense of independence.
incoming stimuli * Patient will maintain a
P accompanied by a safe environment with no * If surgery is planned, instruct patient and/or
A diminished, exaggerated, injury noted. family regarding procedure, post-procedure
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Objective Cues T distorted, or impaired
T response to such stimuli.
* distant visual acuity E Visual distortions are also
in the right eye (OD) R common for the adult client
20/40 N due to aging and you need
to be aware of the warning
* left eye (OS) 20/40 signs of age-related eye
health problems that could
* The extraocular cause vision loss. Many eye
muscles are intact diseases have no early
symptoms. They may
* The visual fields are develop painlessly, and you
equal to the may not notice the changes
examiners to your vision until the
condition is quite advanced.
* The conjunctivae
are smooth and Ref
without redness https://nurseslabs.com/2-
cataracts-nursing-care-
* The pupils are
plans/
bilaterally round, _ =
size, and reactive to
light and
accommodation
* Patient will be able to
deal with the potential for
permanent visual loss.
care, and the need for follow-up with the
physician. Instruct about complications and
emergency signs and symptoms (flashing lights
with loss of vision, seeing a “veil” falling over
visual field, loss of vision in a specific portion
of the visual field, etc.) of which to notify the
physician.
Rationale: Prepares the patient for what to
expect, facilitate compliance, and provides
instruction about potential problems to
lessen anxiety.
* Provide sufficient lighting for the patient to
carry out activities.
Rationale: Elderly patients need twice as much
light as younger people.
*Encourage the client to use the appropriate
eye glasses as prescribe by ophthalmologist
Rationale: In order for the client to have
clearer vision.

* No nystagmus is
noted Dependent

* Cataract surgery – In cases of visual

impairment due to cataracts

Rationale: surgery may be opted. Usually an

artificial lens is placed within the eye as a
replacement of the damaged and clouded lens.
This, more often than not restores vision

*Administer medication for Glaucoma 

a. Latanoprost
b. tafluprost
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
 Nursing Related Learning Experience Manual

c. travoprost 
Rationale: medications in eye drops are
prescribed to control glaucoma.

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN

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 Nursing Related Learning Experience Manual

Name of Student Yr & Sec

Clinical Instructor Area
Date of Exposure Hospital

DIAGNOSTIC EXAMINATIONS
Name of Patient Rm/Bed No. Age Chief Complaints
Address Admission Date Sex Diagnosis

Diagnostic Normal
Date Ordered Result Significance
Examination Values

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY