ASSESSMENT DIAGNOSI INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

S
SUBJECTIVE: Disturbed Increased After 2 hours 1. Determine type and 1. Affects choice of After 2 hours of
visual intraocular of nursing degree of visual loss. interventions and nursing
patient’s future
“Masakit ang mata Sensory pressure intervention 2. Allow expression expectations. intervention.
ko at napansin ko Perception inadequate the patient will of feelings about loss 2. Although early Goal was met,
na lumabo at r/t Altered drainage of and possibility of loss intervention can prevent patient has
ngkaron ng parang sensory aqueous  Participate of vision. blindness, patient faces maintained
ulap ang paningin reception humor from in 3.Implement measure the possibility or may current visual
ko” (I am having the anterior therapeutic s to assist patient to have already field/acuity
pain around my eye chamber of regimen. manage visual experienced partial or without further
and I also noticed the eye limitations such complete loss of vision. loss.
that my vision is  Maintain as reducing clutter, Although vision loss
getting blurred and atrophy of current arranging furniture cannot be restored (even
cloudy) as the optic visual out of travel path; with treatment), further
verbalized by the nerve field/acuity turning head to view loss can be prevented.
patient without subjects; correcting 3. Reduces safety
Disturbed further loss. for dim light and hazards related to
visual problems of night changes in visual fields
Sensory vision. or loss of vision and
OBJECTIVE: 4. Demonstrate papillary
administration of eye accommodation to
 Cloudy pupils drops (counting environmental light.
 Sudden/persistent drops, adhering to 4. Controls IOP,
severe pain or schedule, not missing preventing further loss
pressure in and doses). of vision.
around eye(s) 5. Assist with 5. These direct-acting
 Progressive loss of administration of topical myotic drugs
visual field medications as cause pupillary
 Headache indicated: constriction, facilitating
 V/S taken as .6. Stress the the outflow of aqueous
follows importance of humor and lowering
meticulous IOP. Note: Ocusert is a
T: 36.5 ˚C compliance with disc (similar to a
P: 80 prescribed drug contact) that is placed in
R: 18 therapy. the lower eyelid, where
BP: 110/ 80 7. Chronic, open- it can remain for up to 1
angle glaucoma wk before being
Pilocarpine replaced
hydrochloride (Isopto 6. To prevent an
Carpine, Ocusert increase in IOP,
[disc], Pilopine HS resulting in disk
gel); changes and loss of
vision
.7 [Beta]-blockers
decrease formation of
aqueous humor without
changing pupil size,
vision, or
accommodation. Note:
These drugs may be
contraindicated or
require close monitoring
for systemic effects in
the presence of
bradycardia or asthma.
 ASSESSMENT DIAGNOSI INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
S
SUBJECTIVE: Anxiety After 1 hour of After 1 hour of
related to nursing 1. Establish rapport 1. To gain the trust of nursing
“Napakasakit sa possibility/re intervention 2. Evaluate anxiety the patient intervention
aking damdamin, ality of loss the patient will level, degree of pain 2. These factors affect Goal was met,
paano kung ako ay of vision experienced or the patient’s perception patient appeared
tuluyang mabulag,  Appear suddenness of onset of threat to self, relaxed and
paano na ang araw relaxed and of symptoms, and potentiate the cycle of demonstrate
araw kong demonstrate current knowledge of anxiety, and may ways to reduced
pamumuhay” as ways to the condition. interfere with medical anxiety
verbalized by the reduced 3. Give accurate, attempts to control IOP.
patient anxiety honest information. 3. Lessens anxiety
Discuss the related to unknown or
probability that future expectations, and
careful monitoring provides a factual basis
OBJECTIVE: and treatment can for making informed
prevent additional choices about treatment.
 Cloudy pupils visual loss 4. Provides an
 Sudden/persistent 4. Allow the patient opportunity for the
severe pain or to acknowledge patient to deal with the
pressure in and concerns and express reality of the situation,
 around eye(s) feelings. clarify misconceptions,
 Progressive loss of 5. Use non and problem-solve
visual field therapeutic concerns
 Apprehension, mechanisms 5. Such as watching
uncertainty 6. Provides an movies, listening to
 Expressed concern opportunity for the music to reduce anxiety
regarding changes patient to deal with 6. Provides reassurance
in life events the reality of the that patient is not alone
situation, clarify in dealing with the
misconceptions, and problem.
problem-solve 7. Reassurance is not
concerns helpful for the anxious
7. Avoid unnecessary individual
reassurance