ASSESSMENT: SUBJECTIVE: Parang may ulap akong nakikita kapag dumidilat ako.as verbaized by the patient.

(+) floaters described as clouds present in her vision. (+) tinnitus (+) diplopia Objective: Fundoscopy: bilateral papillaedeme secondary to an increased intracranial pressure. (+) noted alteration in usual daily activities; prefers to sleep most of the time and asks for assistance when changing positions.

DIAGNOSIS: Disturbed sensory perception related to compression of cranial nerve II (Optic) and VIII (Abducens) and increased turbulent flow on the intracranial vessels secondary to increased intracranial pressure

PLANNNG: After 8hours of nursing care, the patient will be able to: a) verbalize awareness of sensory needs. b) Identify/ modify factors that contribute to alterations in sensory. c) Be free of injury.

IMPLEMENTATION: Independent: 1. 2. 3. Establish rapport. Monitor vital signs Observe for behavioural responses (anxiety). 4. Provide a stable environment with continuity of care. 5. Explain procedures activities prior to its implementation 6. Provide undisturbed rest periods 7. Provide diversional activities. 8. Provide safety measures (side rails up, assistance when ambulating, placing call bell within reach). 9. Instruct patient to avoid sudden movement, straining, bending, and lifting heavy objects. 10. Involve family members and client in the plan of care and stress importance of eye assessment?? Collaborative: 1. 2. referral to a opthamologist: Dr. Francisco. Administration of medications that help decrease intracranial pressure (acetazolamide) Lumbar tap (dates)

EVALUATION: Goal met. The patient was able to: a) Verbalize awareness of her sensory needs as evidenced by her description of floaters in her line of vision and ringing in her ears. b) Identify/ modify factors that contribute to alteration in the field of her vision by enumerating activities that may trigger increase ICP. c) Be free from injury; no incidence of fall noted.

3.

Keep background noise to a minimum. Turn off television and radio when communicating with client. Determine degree of visual and auditory impairment. Stand or sit directly in front of client when communicating. Avoid chewing gum or covering mouth or