ASSESSMENT DIAGNOSIS RATIONALE PLANNING INTERVENTIONS RATIONALE EVALUATION

Objective: DISTURBED Retinoblastoma is Goal: Independent: After 8 hours of

-Eye is opened in SENSORY a rapidly After 8 hours of Assess ability to To obtain an nursing
horizontal plane PERCEPTION developing cancer nursing speak, hear, overview of intervention, the
related to altered that develops in intervention, the interpret and client’s mental and patient was able to
-Cloudy cornea status of sense the cell of the patient will be able respond to simple cognitive status compensate for
that measures organ (eyes) retina, the light to compensate for commands. and ability to sensory
10mm x 9mm and secondary to detecting tissue of sensory interpret stimuli. impairments.
is edematous retinoblastoma the eye. Therefore impairments.
there is a change Evaluate sensory To assess degree
-Anterior chamber in the amount or Objectives: awareness: of impairment.
is obliterated patterning of -Maintain usual stimulus of
incoming stimuli level of cognition hot/cold,
-Vitreous cavity going to the eyes. dull/sharp, smell,
contains granular -Modify external taste, hearing, and
white material factors that location/function
contribute to of body parts.
-Sclera is alterations in
thickened and sensory abilities Determine To note whether
fibrotic response to response is
-Use resources painful stimuli. appropriate to
-Choroid and focal effectively and stimulus,
area of sclera are appropriately immediate or
diffusely invaded delayed.
by tumor
Provide means of To promote
communication normalization or
and promote response to
stable stimuli.
environment with
continuity of care
by same personnel
as much as
possible. And
reorient to person,
place, time and
events, as
necessary.

Avoid isolation of To prevent sensory

client, physically or deprivation and
emotionally. limit confusion.

Interpret stimuli To assist client to

and offer separate reality
feedback. from fantasy and
altered
perception.

Speak to visually To provide

impaired client auditory
during care. stimulation and
prevent startle
reflex.

Provide tactile Touching is an

stimulation as care important part of
is given. caring and a deep
psychological need
communicating
presence.

Provide safety To prevent injury

measures as and complication.
needed.

Position doors and To aid in

furniture so they maintaining
are out of travel balance.
path for client with
impaired vision.
Collaborative:
Collaborate with To achieve
and involve other maximal gains in
health team function and
members in psychosocial well
providing being.
rehabilitative
therapies and
stimulating
modalities