San Beda College COLLEGE OF NURSING

P.O. Box 4457 1005 MANILA, PHILIPPINES TELEFAX: 735-6011 to 15 Loc. 4131

ASSESSMENT SUBJECTIVE: Masakit ang mata ko at napansin ko na lumabo at pasakit nang pasakit ung mata ko kada araw eh, lalo na pag umaga as verbalized by the patient

NURSING DIAGNOSIS Disturbed visual Sensory Perception r/t Altered sensory reception

OBJECTIVE: Cloudy pupils Sudden/persiste nt severe pain or pressure in and around eye(s) V/S taken as follows T: 36 C P: 80 R: 18 BP: 110/ 80

SCIENTIFIC RATIONALE Increased intraocular pressure (IOP) is the result of inadequate drainage of aqueous humor from the anterior chamber of the eye. The increased pressure causes atrophy of the optic nerve and, if untreated, blindness.

PLANNING Objective: After 8 hours of nursing intervention the patient will be able to: Reduce risk for injury Regain or maintain usual level of cognition Goal: After the 8 hours nursing intervention the patient will be able to: Improve visual acuity within the limits of individual situations Recognize sensory disturbanc e and compensat e against

INTERVENTION Independent Ascertain type/degree of visual loss

RATIONALE

EVALUATION Goal met, after 8 hours of nursing intervention the patient was able to: - Reduced risk for injury - Regained or maintain usual level of cognition - Improved visual acuity within the limits of individual situations - Recognized sensory disturbance and compensate d against changes.

Affects choice of interventions and patients future expectations

Encourage expression of feelings about loss/possibility of loss of vision

Recommend measures to assist patient to manage visual

Although early intervention can prevent blindness, patient faces the possibility or may have already experienced partial or complete loss of vision. Although vision loss cannot be restored (even with treatment), further loss can be

changes.

limitations, e.g., reducing clutter, arranging furniture out of travel path; turning head to view subjects; correcting for dim light and problems of night vision Collaborative Assist with administration of medications as indicated: Pilocarpine hydrochloride

prevented Reduces safety hazards related to changes in visual fields/loss of vision and papillary accommodati on to environment al light

Timolol maleate

These directacting topical myotic drugs cause pupillary constriction, facilitating the outflow of aqueous humor and lowering IOP

Beta]blockers

Acetazolamide

decrease formation of aqueous humor without changing pupil size, vision, or accommodati on

Carbonic anhydrase inhibitors decrease the rate of production of aqueous humor