ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE: - Assess your

DISTURBED After 8hrs of ability to To obtain an - After 8 hours
“can’t see as SENSORY nursing communicate, overview of the of nursing
well as I used PERCEPTION intervention the hear, interpret, client's mental intervention the
to.”  Related to altered patient will be and respond to cognitive status patient was able
status of sense able to simple and ability to to compensate
“blurring that
organ (eyes) compensate for commands. interpret stimuli. for sensory
seems to be
getting worse” secondary to sensory impairments
(as verbalized retinoblastoma imparement - Evaluating - To determine
by the patient) sensory the level of
awareness: impairment
OBJECTIVE: hot/cold stimuli,
dull/sharp, smell,
distant visual taste, hearing,
acuity in the and
right eye (OD) location/function
20/40
of body parts.
 in the left eye
(OS) 20/40
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Risk for falls After the 8- hour - Monitor vital signs - To assess the Goals were met after 8
“- She states, she has related to present shift, the client will as well as the client's cognitive hours of care. The patient
worn glasses for eye condition be able to patient's health status in relation to was able to reestablish
reading for the past specifically blurring demonstrate condition. the client's current safety measures
20 years. She denies of the left eye due to behavior and lifestyle condition.
eye pain, swelling, aging process. changes that will
excessive tearing, or reduce the risk factor -Assess mood, - To identify
discharge. – and allow the client coping abilities, and physiologic factors
to establish safety personality styles. that may influence
“She states that she measures. the risk of an
has never accident (falls).
experienced any
trauma to her eyes or
head and has never
had any serious eye
problems or
surgery.”

OBJECTIVE:

- No excessive
tearing or blinking is
noted -The
conjunctivae are
smooth and without
redness. –

The pupils are

bilaterally round,
equal in size, reactive
to light and
accommodation
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“- She states that she Risk for Injury After 1 hour of Independent: - Identify basic After 1hour of nursing
is experiencing some (suffocation) related nursing interventions - Learn about the resource intervention the patient
pain across the to contact with the patient will be nature of the requirements and was able to avoid a
bridge of her nose. – chemical pollutants able to avoid a emergency, mishap, assist staff in lifethreatening condition
or poisonous agents. lifethreatening or tragedy. planning an
She has no difficulty condition appropriate degree
swallowing, but the of response based on
sores are painful typical injuries.
when she eats,
especially when she
eats citrus fruits.” - Prepare the area - Assist in the
and equipment, as provision of safe
(as verbalized by the well as inspect and medical and nursing
patient) replenish supplies. care in the event of
an emergency.
OBJECTIVE:

-The findings in the

rest of the oral
examination are
within normal limits.

- The nasal
examination reveals
a slightly reddened
color of the nose,
with some
tenderness noted
across the bridge of
the nose.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
Risk for acute pain - After 8 hours of Independent: - - To identify the - After 8 hours of
“- She states that she related to severe nursing intervention Breathing exercises factors of sensation nursing intervention
is experiencing some medical procedures the patient will be or pulmonary of not being able to the patient was be
pain across the can all cause pain able to breath clearly rehabilitation. get enough air. able to breath
bridge of her nose. clearly.
- As well as physical - In the event of an
- She has no difficulty interventions such as emergency, assist to
swallowing, but the mobility aids or the safe medical and
sores are painful exercise, are nursing care.
when she eats, examples of activity
especially when she and rehabilitation
eats citrus fruits.” interventions

OBJECTIVE:

- The findings in the

rest of the oral
examination are
within normal limits.
- The nasal
examination reveals
a slightly reddened
color of the nose,
with some