Assessment
Nursing
Diagnosis
“Nawalan ako ng Risk for
paningin sa
Injury
kaliwa, at
related to;
kaunting aninag
Visual na lang ang
Sensory
nakikita ko sa
dysfunction
kanan kong mata as
pagkatapos
manifested
operahan, Hindi
by visual
ko na magagawa acuity of
yung mga
20/400 OD
nakasanayan
and total
kong gawin nung loss of
nakakakita pa ako vision OS.
kahit maglakad
mag-isa hindi na
pwede kasi baka
bumangga ako sa
pader.” .” As
verbalized by
patient.
Px is alert,
oriented to time,
person and place,
cooperative,
ambulatory with
assistance; pupils
are round and
equal; does not
react to light and
accommodation;
Planning
Objective:
After 6 hours of
nursing intervention the
patient will be able to:
- Verbalize
understanding of
individual
factors that
contribute to
possibility of
injury
- Demonstrate
behaviours,
lifestyle changes
to reduce risk
factors and
protect self from
injury
- Demonstrate
behaviours,
lifestyle changes
to reduce risk
factors and
protect self from
injury
- Be free from
injury
Intervention
Rationale
Evaluation
Perform thorough
assessments regarding
safety issues when
planning for client care
and/or preparing for
discharge from care.
Failure to accurately
assess and intervene or
refer these issues can
place the client at
needless risk and creates
negligence issues for the
health care practitioner.
Ascertain knowledge of
safety needs/injury
prevention and
motivation
To prevent injury in
home, community, and
work setting
After 6 hours
of nursing
intervention
the patient:
- Reduced risk
for injury
- Regained or
maintain usual
level of
cognition
Assess mood, coping
abilities, personality
styles
That may result in
carelessness/increase
risk-taking without
consideration of
consequences
Assessed client’s muscle
strength, gross and fine
motor coordination
To identify risk for falls
Note socio economic
status/availability and
use of resources
Maintain bed or chair in
lowest position with
wheels locked
Goal:
After the
nursing
intervention
the patient:
- Improved
visual acuity
within the
limits of
individual
situations
- Recognized
sensory
disturbance
and
compensate
against
changes.
Marked redness
of the conjunctiva
is seen with
conjunctivitis;
redness of the
sclera; Visual
acuity of 20/400
OD; OS ; client
reads chart by
leaning forward;
Myopia, impaired
far vision
Presbyopia,
impaired near
vision,
VS as follows:
R: 15
P: 58
BP: 90/60 mmHg
Ensure that pathway to
bathroom is
unobstructed, and
properly lighted.
Instruct client to request
assistance as needed
Monitor environment for
potentially unsafe
condition and modify as
needed
Administer medications
using 10 rights system
Inform and educate client
regarding all treatments
and medications
Develop plan of care
with family to meet
client’s and SO’s
individual needs.
Demonstrate/Encourage
use of Techniques to
reduce/Manage stress,
and vent emotions such
as anger and hostility