ASSESSMENT Objective: -Eye is opened in horizontal plane -Cloudy cornea that measures 10mm x 9mm and is edematous -Anterior

chamber is obliterated -Vitreous cavity contains granular white material -Sclera is thickened and fibrotic -Choroid and focal area of sclera are diffusely invaded by tumor

DIAGNOSIS DISTURBED SENSORY PERCEPTION related to altered status of sense organ (eyes) secondary to retinoblastoma

RATIONALE Retinoblastom a is a rapidly developing cancer that develops in the cell of the retina, the light detecting tissue of the eye. Therefore there is a change in the amount or patterning of incoming stimuli going to the eyes.

PLANNING Goal: After 8 hours of nursing intervention, the patient will be able to compensate for sensory impairments. Objectives: -Maintain usual level of cognition -Modify external factors that contribute to alterations in sensory abilities -Use resources effectively and appropriately

INTERVENTIO NS Independent: Assess ability to speak, hear, interpret and respond to simple commands.

RATIONALE To obtain an overview of clients mental and cognitive status and ability to interpret stimuli.

EVALUATION After 8 hours of nursing intervention, the patient was able to compensate for sensory impairments.

Evaluate sensory To assess awareness: degree of stimulus of impairment. hot/cold, dull/sharp, smell, taste, hearing, and location/functio n of body parts. To note Determine whether response to response is painful stimuli. appropriate to stimulus, immediate or delayed. Provide means of communication and promote stable environment with continuity of care by To promote normalization or response to stimuli.

same personnel as much as possible. And reorient to person, place, time and events, as necessary. Avoid isolation of client, physically or emotionally. Interpret stimuli and offer feedback.

To prevent sensory deprivation and limit confusion. To assist client to separate reality from fantasy and altered perception. To provide auditory stimulation and prevent startle reflex. Touching is an important part of caring and a deep psychological need communicating presence. To prevent injury and complication.

Speak to visually impaired client during care.

Provide tactile stimulation as care is given.

Provide safety measures as needed.

Position doors and furniture so they are out of travel path for client with impaired vision. Collaborative : Collaborate with and involve other health team members in providing rehabilitative therapies and stimulating modalities

To aid in maintaining balance.

To achieve maximal gains in function and psychosocial well being.