Nursing Background INFERENC Goals and Interventions Rationale Evaluation

Diagnosis Study E Objectives

Disturbed Change in GOAL:
Sensory the amount Patient with By the end of my Goal met as
Perception: or patterning Cataract nursing intervention evidenced by
Visual related of incoming of my 8 hour shift , the client was
to altered stimuli the client will be able able to
sensory accompanied to recognize correct recognize
reception by diminish, temporary correct
secondary top exaggerated, Opacity of compensation for temporary
cataract distorted, or the Lens visual sensory compensation
extraction. impaired impairment. for visual
response to sensory
Assessment such stimuli. Independent impairment.
Subjective:
“Malabo ngan OBJECTIVES: Establish rapport
To gain trust
th and stand on the
deri maupay (NANDA 9 Disturbed By the end of my 30 with the client
unaffected side
an ak pangita edition.pp or loss of minutes nursing and so that the
ha ak tuo na 461-465) vision intervention, the client can see
mata kay gin client will be able to: you.
operahan pla Identify self to
 Verbalize patient &
kanina an awareness of To lessen the
encouragehim to
wala,” sensory needs acknowledge visual client anxiety
verbalized by ECCE with  Use alternative impairment.
the client. IOL, OS resources
effectively
Objective:  Be free of Use visual aids. Serve as
+ dressing on injury (Large printed compensation to
the left eye labels showing strengthen
+patched eye Patched directions in the
soaked eye soaked decreased visual
room,large typed
+tilting of the (L) functioning.
printed books and
head magazines.)
+lack of eye to
eye contact.
To provide
Orient the client to
One sided safety when he
proper positon of
vision equipment in his does his ADL.
environment

Maintain bed in low

position with side
rails up.

DEPENDENT
Opthalmic drugs
Wait for physician’s are used to
order in the dilate pupil and
removal of dressing allow more light
and for timely to reach retina
administration of for maximum
Opthalmic Drugs visual function
• Prednisone
acetate1% (NANDA 9th
OD edition pp 461-
• Ofloxacin 465)
Eyedrops
q2h
 Nursing Backgroun INFERENCE Goals and Interventions Rationale Evaluation
Diagnosis d Study Objectives
Deficient Absence or Cataract GOAL:
knowledge related deficiency By the end of my Goal met
to lack of of of nursing intervention as
Vision loss of my 8 hour shift, evidenced
information cognitive
the client will be able by the
regarding post information to understand patient has
operative care. related to knowledge of home able to
specific care he will need understand
Subjective topic Lack ECCE with after surgery, signs knowledge
“Anu an tak mga of specific IOL,OS and symptoms of of home
buruhaton para dali information complication, and care he will
action on it. need after
dayun mag upay necessary
Independent surgery,
nag mobalik for OBJECTIVES: To easily gain signs and
maupay antak clients /SO Lack of By the end of my 30 Establish rapport cooperation form symptoms
pangitaan,” as to make information minutes nursing to the patient the patient of
stated by the informed intervention, the complicatio
client. choices client will be able to: n, and
• Verbalize Ascertain level of To asses action on it.
“Para anu ine nga regarding
Client understanding knowledge readiness to learn
ginhatag ha ak han condition, including
become of home care
doktor” as treatment, apprehensiv instruction anticipatory
verbalized by the and e frequently • Demonstrate needs.
client. lifestyle ask proper usage
changes. questions. of home care Identifies starting
Objective medication. Determine the point.
• Frequent -Nurse’s client most
urgent needs
asking of the Pocket
client Guide 9th To facilitate
• Educational ed. pp 319- learning
Provide
attainment 321. environment
of secondary that is conducive
level to learning.
• First
hospitalizatio
n
• Inaccurate
follow
Provide a written Reinforces
through of information learning process
instruction guidelines
regarding:
Proper usage of
home meds.
 Nursing Background INFERENC Goals and Interventions Rationale Evaluation
Diagnosis Study E Objectives
Sleep Prolonged GOAL:
deprivation periods of AGING and By the end of three Goal met as
related to time without CATARACT days of my nursing evidenced by
sleep intervention, the the client was
aging, and
(sustained client will be able to able to report
restriction of natural,perio report improve sleep improved
lying on the dic pattern. sleep pattern.
post operative suspension Disturbed
side when of relative or loss of OBJECTIVES:
sleeping. consciousnes vision and By the end of 1 hour
s) sleep nursing intervention,
insufficienc the client will be able Independent
th
(NANDA 9 y to:
Assessment Establish rapport.
edition.pp  Verbalize To build client
Subjective:
468-470) understanding trust.
“Dinugang la
of sleep Determine
an kulang tak
disorder presence of
katurog kay To assess
ECCE with  Identify
dire ak physical and
IOL, OS appropriate contributing
nakakakiwa psychological
intervention to factors.
hin maupay factors (advancing
pag gab-i,” promote sleep. age)
verbalized by
 the client. Determine Helps identify
“Masakit an Restriction intervention client appropriate
tak mata of lying on had tried. options.
sanglit dre ak the post
nahihingaturog operative Instruct client bed
,” as side partner to keep a To document
verbalized sleep-wake log. symptoms and
identify factors
that interferes
Objective: Encourage client to with sleep.
develop plan to:
+Awakening at Sleep
night at least 3 deprivation
times
Inability to • Restrict
concentrate caffeine and • Factors
Restlessness alcohol, known to
AGE=68y/o smoking disrupt
Smoking from late sleep.
efternoon.

• Promote • Enhances
adequate energy
exercise expenditur
during day. e so that
client feels
ready to
sleep.
Limit evening fluid
intake. Reduce need for
nighttime
elimination.

DEPENDENT

Administration of
sedatives and Promotes
hypnotics. calming and
sleep.
 (NANDA 9th
edition pp 461-
465)