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;

Assessment

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. To prevent injury in home, community, and work setting

Ascertain knowledge of safety needs/injury prevention and motivation Assess mood, coping abilities, personality styles

After 6 hours of nursing intervention the patient: - Reduced risk for injury - Regained or maintain usual level of cognition Goal: After the nursing intervention the patient: - Improved visual acuity within the limits of individual situations - Recognized sensory disturbance and compensate against changes.

That may result in carelessness/increase risk-taking without consideration of consequences To identify risk for falls

Assessed clients muscle strength, gross and fine motor coordination Note socio economic status/availability and use of resources Maintain bed or chair in lowest position with wheels locked

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 clients and SOs individual needs. Demonstrate/Encourage use of Techniques to reduce/Manage stress, and vent emotions such as anger and hostility