Assessment Subjective: Nawawalan ako minsan ng gana kumain sa ospital kaya minsan hindi ko nauubos ang pagkain.

Simula ng nagpacheck up ako ditto, ilang beses ako pabalik balik sa optha at operating room dahil sa mata ko kaya dahil din doon namayat ako kasi dati itong pantaloon na suot ko masikip sakin ngayon maluwag na. Malaki ang pinayat ko talaga. Objective: *Weight: 40 kgs. Height: 51 *Body Mass Index of 16.6 *Loss of weight *Presence of decreased subcutaneous fat & muscle mass. *Decrease appetite

Diagnosis Imbalanced Nutrition: Less than body requirements related to inability to procure adequate amounts of food as evidenced by clients verbalization of weight loss, decreased appetite and BMI of 16.6

Planning Short term: After 30 minutes of nursing interventions the client will be able to: a. Verbalize understanding on the importance of proper diet. b.Enumerate foods to be included in her diet. Long-term: After 3 days of nursing interventions, the client will be able to: a. Demonstrate changes in her diet as manifested by proper food selection. b. Have no further weight loss rather increase weight toward goal. c. Demonstrate behaviors, lifestyle changes to regain or maintain appropriate weight.

Intervention Independent 1. Determine clients weight and BMI. 2. Obtain clients nutritional history, ADLs, environment & attitude towards eating.

Rationale 1. Provides baseline data about the client.

2. To obtain etiological factors contributing to the weight loss and reduced nutritional intake of the client. 3. Education provides ample information that the client may not be aware of therefore increasing their learning. 4. For client and significant others be educated on the foods that will help to nourish clients nutrition and through giving the sources of these nutrients helps the client & significant other to easier familiarize as to what foods they may include in the

3. Educate client regarding importance of eating healthy foods.

4. Educate client together with significant others towards the proper selection of foods emphasizing foods that are nutritious and high in calories & protein as well as the need for ample intake of fluids, vitamins and minerals.

Evaluation Short term: After 30 minutes of nursing interventions the client has been able to: Verbalize understanding and demonstrates selection of foods that will help to nourish clients nutrition. Long-term: After 3 days of nursing interventions, the client has been able to: a. Demonstrated changes in her diet as manifested by proper food selection. b. Achieve progressive weight gain. c. Demonstrated behaviors, lifestyle changes to regain or maintain appropriate weight.

to eat. 5. Encourage client with the help of the significant others to make a daily log of food intake & monitor clients weight regularly.

diet. 5. To be able to monitor clients progress.

6. Suggest ways that may assist the client in eating and ensure pleasant environment. Dependent 1. Have the clients physician be informed about clients nutrition. Collaborative 1. Consult dietitian for further assessment and recommendations regarding food preferences & nutritional support.

6. To uplift clients feeling about eating.

1.For physician to be informed and think of necessary actions to help.

1. Dietitians have a greater understanding of the nutritional value of foods.

Nursing Diagnosis Nawalan ako ng Risk for paningin sa Injury kaliwa, at related to; kaunting aninag Visual na lang ang Sensory nakikita ko sa dysfunction kanan kong mata as pagkatapos manifested operahan, Hindi by visual ko na magagawa acuity of yung mga 20/400 OD nakasanayan and total kong gawin nung loss of nakakakita pa ako vision OS. kahit maglakad mag-isa hindi na pwede kasi baka bumangga ako sa pader. . As verbalized by patient. Px is alert, oriented to time, person and place, cooperative, ambulatory with assistance; pupils are round and equal; does not react to light and

Assessment

Planning Objective: After 6 hours of nursing intervention the patient will be able to: Verbalize understanding of individual factors that contribute to possibility of injury Demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from injury Demonstrate behaviours, lifestyle changes to reduce risk factors and protect self from injury Be free from injury

Intervention

Rationale

Evaluation

Perform thorough assessments regarding safety issues when planning for client care and/or preparing for discharge from care.

Failure to accurately assess and intervene or refer these issues can place the client at needless risk and creates negligence issues for the health care practitioner. To prevent injury in home, community, and work setting

Ascertain knowledge of safety needs/injury prevention and motivation Assess mood, coping abilities, personality styles

After 6 hours of nursing intervention the patient: - Reduced risk for injury - Regained or maintain usual level of cognition Goal: After the nursing intervention the patient: - Improved visual acuity within the limits of individual situations - Recognized sensory disturbance and compensate against changes.

That may result in carelessness/increase risk-taking without consideration of consequences To identify risk for falls

Assessed clients muscle strength, gross and fine motor coordination Note socio economic status/availability and use of resources Maintain bed or chair in lowest position with wheels locked

accommodation; Marked redness of the conjunctiva is seen with conjunctivitis; redness of the sclera; Visual acuity of 20/400 OD; OS ; client reads chart by leaning forward; Myopia, impaired far vision Presbyopia, impaired near vision, VS as follows: R: 15 P: 58 BP: 90/60 mmHg

Ensure that pathway to bathroom is unobstructed, and properly lighted. Instruct client to request assistance as needed Monitor environment for potentially unsafe condition and modify as needed Administer medications using 10 rights system Inform and educate client regarding all treatments and medications Develop plan of care with family to meet clients and SOs individual needs. Demonstrate/Encourage use of Techniques to reduce/Manage stress, and vent emotions such as anger and hostility

Nursing Diagnosis Subjective: Disturbed Nawalan ako ng sensory paningin sa kaliwa, perception: at kaunting aninag na visual r/t lang ang nakikita ko altered sensory sa kanan kong mata reception as pagkatapos manifested by operahan. As visual acuity verbalized by patient. of 20/400 OD and total loss of vision OS. Objective: Px is alert, oriented to time, person and place, cooperative, ambulatory with assistance; pupils are round and equal; does not react to light and accommodation; Marked redness of the conjunctiva is seen with conjunctivitis; redness of the sclera; Visual acuity of 20/400 OD; OS ; client reads chart by leaning forward; Myopia, impaired far

Assessment

Planning Objective: After 6 hours of nursing intervention the patient will be able to: - Reduce risk for injury - Regain or maintain usual level of cognition Goal: After the nursing intervention the patient will be able to: - Improve visual acuity within the limits of individual situations - Recognize sensory disturbance and compensate against changes.

Intervention Review results of laboratory test Assist with/review diagnostic studies and sensory/motor neurological testing. Monitor drug regimen

Rationale

Evaluation

To Identify medications with effects or drug interactions that may cause/exacerbate perceptual problems

After 6 hours of nursing intervention the patient: - Reduced risk for injury - Regained or maintain usual level of cognition Goal: After the nursing intervention the patient: - Improved visual acuity within the limits of individual situations - Recognized sensory disturbance and compensate against changes.

Ascertain clients/SOs perception of changes in activities of daily living. Provide means of communication, as indicated. Avoid isolation of client, physically or emotionally Explain procedures or activities, expected sensations, and outcomes. Eliminate extraneous noise To prevent sensory deprivation/limit confusion.

vision Presbyopia, impaired near vision, VS as follows: R: 15 P: 58 BP: 90/60 mmHg

or stimuli, including non essential equipments, alarms or audible monitor signals when possible. Provide undisturbed rest or sleep patterns. Provide safety measures, as needed. To aid in maintaining Raising siderails Maintain bed in its balance. lowest position. Adequate lighting Assistance with walking Position doors and furnitures so they are out of travel path, or strategically place items/grab bars. Speak to visually impaired or unresponsive client during care. Ambulate with assistance/devices. Encourage diversional activities. To provide auditory stimulation and prevent startle reflex. To enhance balance.

Established therapeutic nurse-client relationship Encouraged client to verbalize her feelings