Assessment 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

Diagnosis Disturbed sensory perception: visual r/t altered sensory reception / status of sensory organs as manifested by visual distortions

Planning 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.

Intervention - Assessed the level of cognition of the 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

Evaluation After the nursing intervention, the patient was able to: - 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.