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Assessment Nursing
Diagnosis
Rationale Desired Outcome Nursing Intervention Justification
Evaluation
Actual Abnormal
Cues:
Patientverbalized Gasakit akun mata,ga hapdi kag daw
may ma guwa
Pain Scale of 7out of 10
(moderate tosevere pain)
Tenderness,swelling and
redness of theright eye
Feeling ofwarmth
under the eyesupon palpation
Facial mask-grimacing andcrying
Exhibitedguardingbehavior of the
Acute Pain
related totissue injury of
the eye
secondary tomechanicaltraumaas
evidenced by
inflammatory
process, facialgrimacing, and
guardingbehavior
Definition:
Unpleasant
sensory andemotionalexperience
arising fromactual or
potential tissuedamage or
described interms of such
damage(International
Association for
the Study ofPain); suddenor slow onset
Mechanical trauma
penetrating the orbital areacausing tissue inflammation
Release of pain andinflammatory mediators
After 8 hours of
nursing interventionthe patient will be able
to:
1.Follow prescribedpharmacological
regimen
2.Demonstrate use of
relaxation skills anddiversional activitiesas indicated for
individual situation
Independent and
Collaborative
Interventions:
-Administer analgesics asindicated such as
Paracetamol 200mg/IVTT/ Q4
-Monitor vital signs
-Teach the use of
nonpharmacologictechniques (e.g.relaxation,
guided imagery, musictherapy, distraction, and
massage) before,after, and if possible
during painful activities;before pain occurs or
increases; and along withother pain relief
measures.
-To maintainacceptable level
of pain
-Usually altered
in acute pain
-The use of
noninvasive painrelief measurescan increase the
releaseof endorphins and
enhance thetherapeutic
effects of painrelief
medications.
After 8 hours of nursing
intervention the patient was ato:
1.Goal met. Demonstrated gcompliance to prescribed
medication by taking it at theright schedule.
2. Goal partially met. Activ
participates in the relaxationtechniques lead by the studennurse
as well as in other play
activities prepared based on pdevelopmental stage.
Predisposing
Factors:
Unknown/unidentified foreign
object entered the
eye causing irritation
Precipitating
Factors:
Lifestyle Attitude Parental
Guidance
Age=12 (tendto be active)
Gender- Male
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affected eyewhen being
inspected
Elevated WBClevel of 17.7
(normal is 4.5 to13.5) 10^9/L
Strengths:
Good familysupport
Good complianceto treatment
regimen
of any intensityfrom mild to
severe with ananticipated or
predictable endand a duration
of less than 6months
Source:
Doenges, M.E,
et. Al. Nurses
Pocket GuideEdition 11.
F.A. DavisCompany.
Philadelphia,Pennsylvania.
2008.
(bradykinin, prostaglandin)
Nociceptors send signals to
the brain of the intensity ofthe pain by increasing the
frequency of signals sent tospecialized areas within the
CNS
Pain signals travel through
the spinal cord into thedorsal horn
Pain signals are sent up, A-
delta nociceptor and C-nociceptor fibers in the
ascending pathways to thebrain
facial mask, grimace,
feeling of warmth in theeye, tenderness, guarding
behavior, increase vitalsigns
Acute Pain
Source:Atlas ofPathophysiology, 3
rdEd.
Lippincott
3.Verbalize methodsthat provide relief
4.Show a positive
behavior in the reliefof present condition
-Provide comfortmeasures such as change
in position, use of heat orcold compress to the
affected site
-Assess level of pain asof the moment
-Instruct or encourageuse of relaxation
exercises, such asfocused breathing
-Encourage adequate restperiods
-Evaluate the
effectiveness of the paincontrol measures used
thorough ongoingassessment of pain
experience.
-to provide nonpharmacological
pain management
-to provide duecare in alleviating
the suffering ofthe patient
-to assist client toexplore methods
for alleviation/control of pain
-to preventfatigue
-Research shows
that the mostcommon reason
for unrelievedpain is failure to
routinely assesspain and pain
relief. Many
3. Goal partially met.Verbalizes specific positions
such as lying down in supineposition and procedures that
alleviates pain such as playactivity and provides relief
through medicationadministration.
5. Goal partially met.Demonstrated positive behavtowards present
condition by
participating in the treatmentregimen provided for him.
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-Perform acomprehensive
assessment of pain toinclude location,
characteristics,onset/duration,
frequency, quality,severity, and
precipitating oraggravating factors
clients silentlytolerate pain if
not specificallyasked about it.
-Pain is asubjective
experience andmust be described
by theclient in order to
plan effectivetreatment to
assessprecipitating
contributoryfactors
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Assessment Data Nursing Diagnosis Rationale Desired Outcome
Nursing
Intervention
Justification Evaluation
Actual Abnormal
Cues:
-Patient verbalized,Gasakit akunmata, gahapdi kag
daw may maguwa
-Whitish to cloudystreak appearancein the cornea of the
right eye
-Tenderness,swelling anderythema of theright eye
-Feeling of warmth-under the eyesupon palpation
-Pain scale of 7 outof 10 (moderate tosevere pain)
Strengths:Good family
support
Impaired Tissue
Integrity related toalterations of
protectivemechanisms of eyeas evidenced by
whitish to cloudystreak appearance of
the cornea in theright eye, marked
inflammation andlocalized erythema.
Definition:The state in which anindividual
experiences or is atrisk for altered
integumentary,corneal, or mucous
membranous tissuesof the body.
Source:
Handbook of
Nursing Diagnosis13
thEd by Moyet pp.
340-344
Foreign body irritatingthe protective barrier of
the eye causing
inflammatory process
After 4 days of
nurse-clientinteraction, the
patient will beable to:
1.Describe theetiology and
preventionmeasures.
2.Participate inriskassessment.
Independent and
CollaborativeInterventions:
Discuss with thepatient the
predisposing andprecipitating factors
that lead to hiscondition.
Instruct patient not to
scratch affected eye
Encourage to washhands and have a
good hygiene
Talk and explore
with the patientregarding his
condition.
Assess presentcondition such by
-To educate thepatient for better
understanding inorder to gain
cooperation.
-To avoid further
injury
-Preventsmicroorganisms from
invading open skininjury
To assess potential
problems that maydevelop/arise.
To preventoccurrence of
After 4 days of nurse-client
interaction, the patient was able
1.Goal partially met. Sttowards the student nurse on
he acquired such disease verbalizing Ginkalot ko bi
kakatol. The patient nodding upon discussing
health teaching plan towards and to the folks conce
indicates understanding on
current condition inclupossible factors which might hlead to the
worsening of
condition.
2.Goal partially met. Participfairly in the assessment
ofcondition due to very young
and lack of knowledge regar
the complexity of the disease.mother conversed more regarhis
present condition and
Predisposing
Factors:
Unknown/
unidentified
foreign object
entered the eye
causing irritation
Precipitating
Factors:
Lifestyle Attitude Parental
Guidance
Age=12 (tend tobe active)
Gender- Male
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Good complianceto treatment
regimen
Body compensatingwith the injury (cornea)
by altering thestructures making it
prone to breakage ofintegrity
Whitish to cloudystreaks of the cornea,
marked inflammation,and localized erythema
Impaired Tissue
Integrity
Source:Atlas of
Pathophysiology, 3rd
Ed. Lippincott
3.Expresswillingness to
participate in
the treatmentregimen.
taking vital signs,checking the injured
part, and referringabnormal findings
Administer
medications asindicated:
Moxyfloxacin eyedrops 1 drop Q15 for
3 hours as loadingdose, then 1 drop Q1
OU thereafter
Assess for and report
signs and symptomsof impaired wound
healing (e.g.increasing periwound
swelling and redness,pale or necrotic
tissue in woundshealing by secondary
primary intention).
Establish a
therapeutic andtrusting relationship
between you and thepatient.
complications thatcould further add
injury to the patient
Lubricates the eyes,
reducing risk oflesion formation
-to provide due
nursing care throughthe presenting signs
To gain patients
cooperation.
action for the treatment of sons health.
3.Goal partially Demonstrated cooperation ontreatment regimen by
b
obedient to the ones taking of him and good complianc
medication.
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Assessment Diagnosis Rationale Desired Outcome Intervention
Justification Evaluation
Risk Related Factors:
Whitish tocloudy streak
appearance in the
cornea of the right eye
Unable to seeclearly due to abscess
formation of the
affected eye
Facial mask-grimacing and crying
Strength:
Good familysupport
willingness toget well
Risk for Injury
related to damage
vision/ sensory
impairment
Definition:
Risk for injury as a
result of
environmental
conditions
interacting with the
individuals adaptive
and defensive
resources.
Source:
Doenges, M.E, et. Al.
Nurses Pocket
Guide Edition 11.
Trauma to the eye
leading to alteration
on the protective
barrier
After four (4) days of
nursing care, the
client will be able to:
1. Verbalizeunderstanding of
individual factors
that contribute to
possibility of
injury.
Independent Interventions
Perform thorough
assessments regarding
safety issues when planning
for client care.
Note clients age, gender,
developmental stage,
decision-making ability,
level of competence.
Discuss importance of self
monitoring of condition or
emotion that can contribute
to injury.
Encourage use stress
management techniques
Independent Interventions
-Failure to accurately assess
or intervene or refer these
issues can place the client at
needless risk and creates
negligence issues for
healthcare practitioner.
-Affects clients ability to
protect self and influences
choice of interventions and
teaching.
-Understanding about
condition and self
monitoring of emotion can
prevent contribution to
injury
-This will help the patient
relax and avoid injury
After four (4)
of nursing care
client was able
1. Goal part
met. The pat
since he wa
child, nods
listens while b
taught on how
compensate
changes in A
due to impavision with
help of the SO
communicating
and emphasi
important
information.
Predisposing
Factors:
Unknown/unidentified
foreign objectentered the eye
causing irritation
Precipitating
Factors:
Lifestyle
Attitude Parental
Guidance
Age=12 (tendto be active)
Gender- Male
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F.A. Davis
Company.
Philadelphia,
Pennsylvania. 2008.
Marked inflammation
and altered
appearance of the eye
Presence of cloudy to
streak appearance of
the cornea
Impairing vision
Risk for Injury
2. Showattentiveness in
behaviors for
lifestyle changes
to reduce risk
factors andprotect self from
injury.
3. Modifyenvironment as
Evaluate individuals
emotional and behavioral
response to violence in
environmental surroundings
Maintain bed or chair in
lowest position, side rails
up and with wheels locked.
Ensure that pathway to
bathroom is unobstructed
and properly lighted.
Monitor environment for
potential unsafe conditions
and modify as needed.
Evaluate environment forpotential safety hazards
based on age of child and
-May affect clients view of
and regard for own safety.
-to prevent falls due to
restlessness of the client
-To have easy access while
being assisted and avoid
injury
-To note for potential
barriers that cause harm to
the patient
-School age children tendsto be active and sometimes
due to it may precipitate
2. Goal part
met. Pa
listened to
directions of
SO since he
limited movem
due to
condition.
3. Goal partmet. Pa
avoids room
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indicated to
enhance safety.
degree of impairment.
Eliminate safety hazards
and protect the client from
exposure.
them to danger. Monitoring
their surroundings can be a
preventive tool
-To promote safety to
patient
around the
and freque
asks SO
accompany/ a
him in bath
toileting etc.
