COLLEGE OF NURSING
Carlatan, San Fernando City, La Union
Objectives
Long term: After 3 weeks of
nursing intervention the patient
will be able to understand the
changes that happens to the eyes
as it gets older.
Short term: After 8 hours of
nursing intervention the patient
will be able to verbalize
understanding of individual factors
that contribute possibility of injury
due to poor visual acuity.
Identified Problems/Concerns
Poor visual acuity
TEACHING PLAN
Activities Evaluation
Student Nurse Client/Family Member
1. Monitors symptoms of vision 1. Provide adequate lighting Long term: Goal met.
deterioration. for increased visibility.
Patient was able to improve visual
Rationale: Regular monitoring and Rationale: To ensure that visual acuity within the limits of individual
frequent evaluation decreases risk to tasks are carried out safely and situations.
long term damage to eyes. enhance security.
2. Assist family in identifying 2. Avoid clutter on floor to
Short term: Goal met.
hazards in home and modifying them. prevent tripping.
Patient was able to verbalize
Rationale: To meet the safety needs of Rationale: Reduces the risk for understanding of individual factors that
the client and reduce risk of injury. injury and to promote clean contribute possibility of injury due to
environment poor visual acuity.
3. Instruct patient to wear
prescription glasses when out of bed 3. Support client when
or when transferring. transferring position to avoid
injury.
Rationale: Visual aids are necessary
to enhance vision. Rationale: To promote safety of
the client

Long term: After 3 months of
nursing interventions, the patient
will be able to demonstrate
understanding of factors that
contributes to impaired skin
integrity
Short term: After 4 hours of
nursing intervention patient will be
able to describe measures to
protect skin and prevent skin
impairment.
4. Established NPI to identify the
needs to enhance knowledge about
caring for the eyes.
Risk for impaired skin integrity 1. Assess the overall condition of
the skin.
Rationale: Provides baseline data for
possible interventions for the nursing
diagnosis Risk for Impaired Skin
Integrity.
2. Assess patient’s nutritional
status, including weight, weight loss,
and serum albumin levels.
Rationale: An albumin level less than
2.5 g/dL is a grave sign, indicating
severe protein depletion and at high
risk of skin breakdown.
3. Encourage adequate nutrition
and hydration.
Rationale: Sufficient hydration and
nutrition help maintain skin turgor,
moisture, and suppleness, which
provide resilience to damage caused
by pressure.
4. Educate patient and caregiver
about the causes of pressure.
1. Clean, dry, and The patient shall be able to display
moisturize skin, particularly bony behaviors such as timely and
prominences, twice daily or as systematic inspection and intervention
to the developing problems thus
indicated by incontinence or
reducing the progression of skin
sweating. Avoid hot water.
breakdown.
Rationale: Smooth, supple skin
is more resistant to injury. These
measures prevent evaporation
away from skin
2. Know signs of itching
and scratching.
Rationale: The patient who
scratches the skin in attempts to
alleviate itching may open skin
lesion and increase risk for
infection.
3. Keep bedclothes dry and
free of wrinkles, crumbs.
Rationale: Reduces/prevents
skin irritation.

Long term: After 2 months of
nursing interventions, the patient
will be able to demonstrate
measures to reduce risk of
impaired physical mobility.
Short term: After 8 hours of
nursing intervention the patient
will be able to identify causative
factors of limited activity
intolerance.
Rationale: This information can assist
the patient or caregiver in finding
methods to prevent skin breakdown.
5. Educate patients and caregivers
about proper skin care.
Rationale: Educating patients and
caregivers methods to maintain skin
integrity enhances their sense of self
efficacy and prevents skin breakdown.
Risk for impaired physical 1. Monitor and record client's 1. Support and work with Long term: Goal met.
mobility ability to tolerate activity and use all
clients during self-care activities
Patient was able to demonstrate
four extremities; note pulse rate, blood
such as eating, bathing,
measures to increase mobility.
pressure, dyspnea, and skin color grooming, dressing, and
before and after activity. transferring rather than having
client be a passive recipient of
Rationale: To provide baseline in care. Short term: Goal met.
identifying interventions.
Patient was able to identify causative
Rationale: To promote
2. Teach client to get out of bed factors of limited activity intolerance.
independence of the client.
slowly when transferring from the bed
to the chair. 2. Utilizing the environment
to prevent injury.
Rationale: To prevent injury
Rationale: Modifying the
3. Teach client relaxation environment reduces the
techniques to use during activity. chances of falls or injury of the
client.
Rationale: To increase efficiency of
task.

Long term: After 2 months of
nursing interventions, the patient
will be able to use the information
gained to develop an individual
plan to meet health needs and
goals.
Short term: After 3 hours of
nursing intervention the patient
will be able to verbalize
willingness to perform the
activities required to care for
herself.
Readiness for enhanced self
health management
4. Teach client to use assistive devices
such as a cane, walker or crutches
Rationale: To increase mobility.
1. Verify client’s level of
understanding of therapeutic regimen.
Rationale: Provides opportunity to
assure accuracy and completeness
of knowledge base for future learning.
2. Acknowledge individual
efforts/capabilities to reinforce
movement toward attainment
of desired outcomes.
Rationale: Provides positive
reinforcement encouraging continued
progress toward desired goals.
3. Assist in implementing
strategies for monitoring
progress/responses to therapeutic
regimen.
Rationale: Promotes proactive problem and concern but does not hinder
solving.
1. Implement measures at Long term: Goal met.
home to promote independence
Patient was able to use the information
but intervene when the patient
gained to develop an individual plan to
cannot function.
meet health needs and goals.
Rationale: An appropriate level
Short term: Goal met.
of assistive care can prevent
injury from activities without Patient was able to verbalize
causing frustration. Nurses can willingness to perform the activities
be key in helping patients accept required to care for herself.
both temporary and permanent
dependence.
2. Family and significant
others will promote autonomy
and support if the patient
becomes tired and not capable
of carrying out task.
Rationale: This displays caring
with patient’s efforts to attain
autonomy.
3. At home, allow the
patient perform self-care
measures as
much as possible to promote
independence.

Rationale:

4. Reinstitutes feeling of
independence and promotes
self-esteem and improves
rehabilitation process.