Patient Initials: JC Date(s) of care: _February 3, 2012 Admitting Diagnosis: Peripheral Pterygium Chief Complaint: Peripheral Pterygium Medications:

amlodipine, aspirin, atenolol, cyclobenzaprine, folic acid, glyburide 5mg/ metformin hcl 500mg, HCTZ 12.5mg/lisinopril 20mg, proparacaine hcl 0.5%, rosuvastatin, sildenafil citrate, tramadol, trazodone, vitamin d Surgery/Procedures: Removal of Pterygium with conjunctival autograph in left eye. February 3, 2012 Data Collection related to nursing diagnosis Objective Data Patient has hx of inaccurate follow-through of instruction -Maintaining glucose levels -Diet restrictions (as evidence by lab values) NANDA Nursing Diagnosis Knowledge deficit r/t deficient knowledge regarding postoperative activity, mediations, and eye care Goal Patient will follow mutually agreed on health care plan throughout surgical site healing time. Nursing Interventions 1. Staff will assess patients understanding of discharge instructions and willingness to comply 2. Conduct patient teaching with mutual goals for health maintenance that the patient paraphrases in own words 3. Include significant other in patient teaching. Have significant other reciprocate teaching as well. Subjective Data: Statement reflecting misconceptions: I think all I got to do is keep it covered up 4. Provide positive reinforcement while conducting patient teaching. Rationale 1. Assessment may lead to discovery of anticipatory learning needs. 2. Patient reciprocating teaching helps to enhance internalization of material, evaluate learning, and promotes a sense of control. 3. Involving significant others in care promotes continuity of care at home.

4. Positive reinforcement enhances cooperation and encourages continuation of effort.

Patient Initials: JC Date(s) of care: _February 3, 2012 Admitting Diagnosis: Peripheral Pterygium Chief Complaint: Peripheral Pterygium Medications: amlodipine, aspirin, atenolol, cyclobenzaprine, folic acid, glyburide 5mg/ metformin hcl 500mg, HCTZ 12.5mg/lisinopril 20mg, proparacaine hcl 0.5%, rosuvastatin, sildenafil citrate, tramadol, trazodone, vitamin d Surgery/Procedures: Removal of Pterygium with conjunctival autograph in left eye. February 3, 2012

Data Collection related to nursing diagnosis Objective Data -Patient cannot see has one eye covered with a patch

NANDA Nursing Diagnosis Risk for Injury r/t impaired vision

Goal Patient will be free of injury related to impaired vision while wearing eye patch As evidenced by no reports of injury from patient of patient family

Nursing Interventions 1. Assess clients balance and mobility skills

Rationale 1. Assessment of patient establishes baseline for patient mobility and starting point for developing interventions/precautions 2. Decreases chance of patient being injured in automobile accident due to impaired vision. 3. -Promotes continuity of care and decreases likelihood of impaired vision related falls at home. -Involves caregiver in health maintenance 4. Promotes patients orientation to surroundings and balance.

2. Staff will ensure that patient has significant other/caregiver to assist patient with driving and ADLs at home. Subjective Data -Patient states Its gonna be a little hard getting around with this patch I really have to watch where I step 3. Staff will provide caregiver a checklist for assessing home environment for threats to safety.

4. Encourage patient to use glasses and assistive devices when ambulating/walking

Patient Initials: JC Date(s) of care: _February 3, 2012 Admitting Diagnosis: Peripheral Pterygium Chief Complaint: Peripheral Pterygium Medications: amlodipine, aspirin, atenolol, cyclobenzaprine, folic acid, glyburide 5mg/ metformin hcl 500mg, HCTZ 12.5mg/lisinopril 20mg, proparacaine hcl 0.5%, rosuvastatin, sildenafil citrate, tramadol, trazodone, vitamin d Surgery/Procedures: Removal of Pterygium with conjunctival autograph in left eye. February 3, 2012

Data Collection related to nursing diagnosis Objective Data

NANDA Nursing Diagnosis Disturbed Sensory Perception: visual r/t -Closing of one eye to see wearing eye patch. -Reaching in front of self to check for closeness of objects

Goal Patient will achieves optimal functioning within limits of visual impairment in the timeframe need for surgical site to heal. As evidenced by ability to care for self, to navigate environment safely, and to engage in meaningful activities

Nursing Interventions 1. Staff will assess current sensory perception and orientation to objects upon intake to the Day Surgery Clinic 2. Evaluate patients ability to function within limits of visual impairment

Rationale 1. Provides baseline for measurement of improvement of sensory perception.

2. Personal appearance and condition of clothing and surroundings are good indicators of the patients adaptation to visual loss. 3. Orientation reduces fear related to unfamiliar 4. Halogen lighting is preferred to improve vision for patients with diminished vision.

3. Orient patient to environment. Subjective Data Yeah, its real hard to get around like I used to. It makes everything around me difficult. 4. Provide adequate lighting