ASSESSMENT NURSING

DIAGNOSIS
PLANNING NURSING
INTERVENTION
RATIONALE EVALUATION
Subjective Cues:
Hindi ko makita
ang dinadaanan
ko lalo na pag
gabi may
nagpapatay ng
ilaw nahihirapan
akong magpunta
sa banyo. Yung
isang mata ko
hindi na
nakakakita. Sabi
nila may katarata
daw ako pero
hindi na nila ako
pinaopera dahil
baka hindi na
daw kayanin ng
katawan ko,as
verbalized by the
patient.

Objective Cues:
-Opacity in the
lens of the eyes
-Blurring of vision
-Disorientation to
time, place and
person.
VS:
BP-130/80
PR-78
RR-20
T-36.6
Risk for injury
related to
decreased in
visual acuity
secondary to
aging process as
manifested by
reported blurring
of vision.
Short term:
In 8 hours of
nursing
intervention the
patient will:
1. Verbalize
understanding of
individual factors
that contribute to
possibility of
injury.
2. Demonstrate
behaviors to
reduce risk
factors and
protect self from
injury.

Long Term
1. Be free from
injury.
Independent:
1. Assess the
ability of the
visual fields of
both eyes.

2. Assess mood,
coping abilities,
personality style
that may result in
carelessness.

3. Assess the
environmental
factors that may
lead to injury.

4. Orient client to
environment.
Assess ability to
use side rails, and
bed controls.


5. Ensure that
pathway to
bathroom is
unobstructed and
properly lighted.

6. Teach the
client how to use
assistive devices
and place it
within reach.


7. Encourage
participation in
social activities
and diversion
whenever
possible


8. Administer
medications as
ordered by the
doctor using the
10 Rights
system.

1. To determine
the ability of each
eye.


2. To determine
the level of
cooperation.



3. To determine
causes of injury.



4. These
measures will
help the client to
cope with an
unfamiliar
environment.

5. To promote
clients safety.




6. To promote
independence
and lower the risk
of injury.



7. Social isolation
and leisure time
for too long can
cause negative
feelings.
After 8 hours of
nursing
intervention the
patient:
1. Verbalized
understanding of
individual factors
that contribute to
possibility of
injury.
2. Demonstrate
behaviors to
reduce risk
factors and
protect self from
injury such as
using side rails
and assistive
devices.

Long term
1. Patient was
free from injury.
ASSESSMENT NURSING
DIAGNOSIS
PLANNING
NURSING
INTERVENTION
RATIONALE
EVALUATION
Subjective:

Objective:
Patient may
manifest:
Weakness
Restlessness
Physical
inactivity
Increase
respiratory
rate
Fatigue
Low hgb
count
Low hct count
Activity intolerance
related to
generalized
weakness AEB
limited physical
activity.

Short Term:
After 4 hours of
nursing
interventions
the patient will
identify negative
factors affecting
activity
intolerance and
eliminate or
reduce their
effects.
Long Term:
After 1-2 days of
nursing
interventions, the
patient will report
activity tolerance
with enhance
energy and the
patient will
participate
willingly in
necessary or
1. Monitor and
record vital
signs
2. Provide health
teaching on
the client
regarding the
organization
and time
management
technique to
prevent while
on activity
3. Provide
enough air
coming from
the electric fan
or from the
window
4. Develop and
adjust simple
activity like
brushing his
teeth
5. Assist client
with activity
6. Promote
1. To obtain
the baseline
data
2. To provide
adequate
knowledge
on the client
3. To enhance
patient
ability to
participate
in activity
4. To monitor
patients
respond to
activities
5. To prevent
overexertion
6. To protect
patient from
injury
7. To prevent
over-
exhaustion
8. To
determine
current
Short Term:After
4 hours of nursing
interventions the
patient shall have
identified
negative factors
affecting activity
intolerance and
eliminate or
reduce their
effects.
Long Term:
After 1-2 days of
nursing
interventions, the
patient shall
reported activity
tolerance with
enhance energy
and the patient
will participate
willingly in
necessary or
desired activities.



desired activities.

comfort
measures on
the activity
7. Cluster nursing
care
8. Ascertain
ability to stand
and move
about degree
of assistance
9. Encourage
complete bed
rest
status and
needs
9. For patient
recuperation
and recovery