GUADIZ, Yessamin T.

BSN 3 F 1

May 4,
2021 F:
12:00NN Ø Readiness for enhanced therapeutic management related to
willingness to comply to treatment
Ø Readiness for enhanced self-care related to willingness to perform
ADL’s with minimal assistance
Ø Readiness for enhanced coping related to expressed want to
restore vision
D: The patient and significant other requested for discharge. With intact
eye patch and is wearing eye shield. No complaints and denies
discomfort. Minimal redness on the sclera of OD observed. No unusual
discharges with very minimal tearing noted. Verbalized the need for
minimal assistance in performing ADLS. Shows willingness to be taught on
how to administer eyedrops. Verbalized future compliance to medication.
Showed optimism towards discharge and treatment.

A: Educated the patient regarding normal symptoms that may occur a

few days after discharge due to eye surgery, such as itching and mild
discomfort, some fluid discharge, and sensitivity to light. Educated patient
to avoid bending and lifting heavy objects for 3 days. Reminded that
watching TV and reading can be done as long as it is tolerated and
minimal. Reinforced instructions of not rubbing or scratching the affected
eye. Instructed the patient sleep on his back or on the unoperated side.
Demonstrated on how to properly administer eyedrops. Educated the
significant other and patient on how to clean bandage and area around
the affected eye. Reminded patient regarding the follow-up schedule on
May 10, 2021.

R: Patient verbalized understanding of the discharge instructions and

health teachings. Expressed willingness to participate in treatment and
health management.

GUADIZ, Yessamin T. / Ma’am Lorna Saxton

SLU - BSN 3 F 1 BSN 3 Clinical Instructor