Assessment Diagnosis Planning Intervention Evaluation

Subjective:
“nahihirapan ako magbasa o
kahit manuod lang ng TV.
Yung mga kulay hindi ko na
madistinguish. Nahihirapan
din akong makakita sa dilim
at doble na ang paningin ko.”
As verbalized by the patient
Objective:
Px is alert, oriented to time,
person and place,
cooperative, ambulatory;
pupils are round and equal;
reacts briskly to light and
accommodation;
conjunctivae are pink; sclera
is white in color; visual
acuity of 20/150
OD (right eye) and 20/50 OS
(left eye) with corrective
lenses.
VS as follows:
T: 35.9 C
R: 18 bpm
P: 86 bpm
BP: 130/70 mmHg
Disturbed sensory
perception: visual r/t altered
sensory reception / status of
sensory organs as manifested
by visual distortions
Objective:
After 6 hours of nursing
intervention the patient will
be able to:
- Reduce risk for
injury
- Regain or maintain
usual level of
cognition
Goal:
After the nursing intervention
the patient will be able to:
- Improve visual
acuity within the
limits of individual
situations
- Recognize sensory
disturbance and
compensate against
changes.
- Assessed the level of After the nursing intervention,
cognition of the the patient was able to:
patient
- Provided a safe
environment
- Established
therapeutic nurse-
client relationship
- Encouraged client to
verbalize her feelings
- Assisted patient in
mobilizing
- Determined visual
acuity, note whether
one or two eyes
involved.
- Oriented clients to
the environment
- Observed signs of
disorientation
- Reduced risk for
injury
- Regained or maintain
usual level of
cognition
- Improved visual
acuity within the
limits of individual
situations
- Recognized sensory
disturbance and
compensated against
changes.