Nursing Diagnosis Actual Abnormal Acute Pain related to Cues: tissue injury of Patient the eye verbalized Ga secondary

y to sakit akun mata, mechanical ga hapdi kag daw trauma as may ma guwa evidenced by inflammatory Pain Scale of 7 process, facial out of 10 grimacing, and (moderate to guarding severe pain) behavior Tenderness, swelling and redness of the right eye Feeling of warmth under the eyes upon palpation Facial maskgrimacing and crying Exhibited guarding behavior of the Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset

Assessment

Rationale Predisposing Factors: Unknown/ unidentified foreign object entered the eye causing irritation

Desired Outcome After 8 hours of nursing intervention the patient will be able to: 1.Follow prescribed pharmacological regimen

Nursing Intervention Independent and Collaborative Interventions:

Justification

Evaluation After 8 hours of nursing intervention the patient was able to: 1.Goal met. Demonstrated good compliance to prescribed medication by taking it at the right schedule.

-Administer analgesics as -To maintain indicated such as acceptable level Paracetamol 200mg/ of pain IVTT/ Q4 -Monitor vital signs -Usually altered in acute pain

Precipitating Factors: Lifestyle Attitude Parental Guidance Age=12 (tend to be active) Gender- Male 2.Demonstrate use of relaxation skills and diversional activities as indicated for individual situation

Mechanical trauma penetrating the orbital area causing tissue inflammation Release of pain and inflammatory mediators

-Teach the use of nonpharmacologic techniques (e.g. relaxation, guided imagery, music therapy, distraction, and massage) before, after, and if possible during painful activities; before pain occurs or increases; and along with other pain relief measures.

-The use of noninvasive pain relief measures can increase the release of endorphins and enhance the therapeutic effects of pain relief medications.

2. Goal partially met. Actively participates in the relaxation techniques lead by the student nurse as well as in other play activities prepared based on pts developmental stage.

affected eye when being inspected Elevated WBC level of 17.7 (normal is 4.5 to 13.5) 10^9/L

of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

(bradykinin, prostaglandin) Nociceptors send signals to the brain of the intensity of the pain by increasing the frequency of signals sent to specialized areas within the CNS Pain signals travel through the spinal cord into the dorsal horn Pain signals are sent up, Adelta nociceptor and Cnociceptor fibers in the ascending pathways to the brain facial mask, grimace, feeling of warmth in the eye, tenderness, guarding behavior, increase vital signs Acute Pain Source: Atlas of Pathophysiology, 3rd Ed. Lippincott -Instruct or encourage use of relaxation exercises, such as focused breathing -Encourage adequate rest periods 3.Verbalize methods that provide relief -Provide comfort measures such as change in position, use of heat or cold compress to the affected site -Assess level of pain as of the moment -to provide non pharmacological pain management 3. Goal partially met. Verbalizes specific positions such as lying down in supine position and procedures that alleviates pain such as play activity and provides relief through medication administration.

Source: Doenges, M.E, Strengths: Good family et. Al. Nurses Pocket Guide support Edition 11. Good compliance F.A. Davis to treatment Company. Philadelphia, regimen Pennsylvania. 2008.

-to provide due care in alleviating the suffering of the patient -to assist client to explore methods for alleviation/ control of pain -to prevent fatigue

4.Show a positive behavior in the relief of present condition

-Evaluate the effectiveness of the pain control measures used thorough ongoing assessment of pain experience.

-Research shows that the most common reason for unrelieved pain is failure to routinely assess pain and pain relief. Many

5. Goal partially met. Demonstrated positive behavior towards present condition by participating in the treatment regimen provided for him.

clients silently tolerate pain if not specifically asked about it. -Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, severity, and precipitating or aggravating factors -Pain is a subjective experience and must be described by the client in order to plan effective treatment to assess precipitating contributory factors

Assessment Data Actual Abnormal Cues: - Patient verbalized, Gasakit akun mata, gahapdi kag daw may ma guwa - Whitish to cloudy streak appearance in the cornea of the right eye - Tenderness, swelling and erythema of the right eye

Nursing Diagnosis Impaired Tissue Integrity related to alterations of protective mechanisms of eye as evidenced by whitish to cloudy streak appearance of the cornea in the right eye, marked inflammation and localized erythema.

Rationale

Desired Outcome After 4 days of nurse-client interaction, the patient will be able to:

Nursing Intervention Independent Collaborative Interventions: and

Justification

Evaluation After 4 days of nurse-client interaction, the patient was able to:

Predisposing Factors:

Unknown/ unidentified foreign object entered the eye causing irritation

Precipitating Factors: Lifestyle Attitude Parental Guidance Age=12 (tend to be active) Gender- Male

1. Describe the Discuss with the etiology and patient the prevention predisposing and measures. precipitating factors that lead to his condition.

Definition: The state in which an individual experiences or is at - Feeling of warmth risk for altered - under the eyes integumentary, upon palpation corneal, or mucous membranous tissues - Pain scale of 7 out of the body. of 10 (moderate to severe pain) Source: Handbook of Nursing Diagnosis Strengths: th Good family 13 Ed by Moyet pp. 340-344 support

-To educate the 1.Goal partially met. Stated patient for better towards the student nurse on how understanding in he acquired such disease by order to gain verbalizing Ginkalot ko bi kay cooperation. kakatol. The patient seen nodding upon discussing the health teaching plan towards him Instruct patient not to -To avoid further and to the folks concerned scratch affected eye injury indicates understanding on his current condition including Encourage to wash -Prevents possible factors which might have hands and have a microorganisms from lead to the worsening of his good hygiene invading open skin condition. injury

Foreign body irritating the protective barrier of the eye causing inflammatory process

2. Participate in Talk and risk with the assessment. regarding condition.

explore To assess potential 2.Goal partially met. Participated patient problems that may fairly in the assessment of his his develop/arise. condition due to very young age and lack of knowledge regarding the complexity of the disease. His Assess present To prevent mother conversed more regarding condition such by occurrence of his present condition and took

 Good compliance to treatment regimen

Body compensating with the injury (cornea) by altering the structures making it prone to breakage of integrity Whitish to cloudy streaks of the cornea, marked inflammation, and localized erythema Impaired Tissue Integrity Source: Atlas of Pathophysiology, 3rd Ed. Lippincott

taking vital signs, checking the injured part, and referring abnormal findings Administer medications as indicated: Moxyfloxacin eye drops 1 drop Q15 for 3 hours as loading dose, then 1 drop Q1 OU thereafter 3. Express willingness to participate in the treatment regimen.

complications that could further add injury to the patient Lubricates the eyes, reducing risk of lesion formation

action for the treatment of her sons health.

Assess for and report -to provide due 3.Goal partially met. signs and symptoms nursing care through Demonstrated cooperation on the of impaired wound the presenting signs treatment regimen by being healing (e.g. obedient to the ones taking care increasing periwound of him and good compliance to swelling and redness, medication. pale or necrotic tissue in wounds healing by secondary primary intention). Establish a To gain patients therapeutic and cooperation. trusting relationship between you and the patient.

Assessment Risk Related Factors: Whitish to

Diagnosis Risk for Injury related to damage vision/ sensory impairment

Rationale Predisposing Factors: Unknown/ unidentified foreign object entered the eye causing irritation Precipitating Factors: Lifestyle Attitude Parental Guidance Age=12 (tend to be active) Gender- Male

Desired Outcome After four (4) days of nursing care, the client will be able to: 1. Verbalize

Intervention

Justification

Evaluation After four (4) days of nursing care, the client was able to: 1. Goal partially met. The patient, since he was a child, nods and listens while being taught on how to compensate to changes in ADLs due to impaired vision with the help of the SO in communicating and emphasizing important information.

Independent Interventions Independent Interventions

cloudy streak appearance in the cornea of the right eye

Definition: Unable to see Risk for injury as a result of environmental conditions interacting with the Facial maskgrimacing and crying individuals adaptive and defensive resources. Strength: Good family support willingness to get well Source: Doenges, M.E, et. Al. Nurses Pocket Guide Edition 11. Trauma to the eye leading to alteration on the protective barrier clearly due to abscess formation of the affected eye

Perform thorough assessments regarding understanding of safety issues when planning individual factors for client care. that contribute to possibility injury. of Note clients age, gender, developmental stage, decision-making ability, level of competence.

-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.

Discuss importance of self monitoring of condition or emotion that can contribute to injury.

-Understanding about condition and self monitoring of emotion can prevent contribution to injury

Encourage use stress -This will help the patient management techniques relax and avoid injury

F.A. Company. Philadelphia,

Davis Marked inflammation and altered appearance of the eye

Pennsylvania. 2008. Presence of cloudy to streak appearance of the cornea 2. Show Impairing vision

Evaluate individuals emotional and behavioral -May affect clients view of response to violence in and regard for own safety. environmental surroundings

Maintain bed or chair in lowest position, side rails attentiveness in up and with wheels locked. behaviors for lifestyle changes Ensure that pathway to to reduce risk bathroom is unobstructed and properly lighted. factors and protect self from injury. Monitor environment for potential unsafe conditions and modify as needed.

Risk for Injury

-to prevent falls due to 2. Goal partially restlessness of the client met. Patient listened to the directions of the -To have easy access while SO since he has being assisted and avoid limited movement injury due to his condition.

-To note for potential barriers that cause harm to the patient

3. Modify environment

Evaluate environment for potential safety hazards as based on age of child and

-School age children tends 3. Goal partially to be active and sometimes met. Patient due to it may precipitate avoids rooming

indicated enhance safety.

to degree of impairment.

Eliminate safety hazards and protect the client from exposure.

them to danger. Monitoring around the area their surroundings can be a and frequently preventive tool asks SO to accompany/ assist -To promote safety to him in bathing, patient toileting etc.