Name of Student: Mary Claire Joy Pescadero Section and Group number: BSN4C G4

Assessment Nursing Diagnosis (Rationale)

NURSING CARE PLAN
Desired Outcome Nursing Intervention Justification Evaluation
Cues Pathophysiologic /
Schematic Diagram
Subjective: Acute Pain related to Predisposing Factors: After 8 hours of Independent Interventions: After 8 hours of
cataract extraction Age: 75 years old Nursing 1. Monitor vital signs of the 1. This will serve as baseline Nursing
Patient verbalized
surgery as evidenced by Gender: Female Intervention, the patient patient. data of the patient. Intervention, the
“kasakit gd sang
client description of pain will be able to: 2. Monitor pain scale of the 2. This will tell the intensity patient was able to:
akon mata ah”
which is as deep within patient. of pain the patient felt.
the eye and 8/10 pain Precipitating Factors: A. Patient describes 3. Position the patient flat, or in 3. Reduce pressure on the A. The patient was
scale. Diabetic satisfactory pain control low Fowler’s or on unoperative operative side. able to verbalize a
Environment at a level less than 4 to 5 side for 3-4 weeks; avoid sleeping pain scale of 5 out of
Lifestyle on a rating scale of 0 to on 10. Goal Met.
Objective: 10. operative side
Pain scale of 8/10 4. Instruct patient to avoid 4. This could help the patient B. Patient shown less
Vital signs:
Definition:
Denaturation and abnormal B. Patient displays activities that will increase IOP. reduce pain. of facial grimaces and
Temp: 37.0 degrees structural changes to lens improvement in mood, 5. Instruct patient to wear eye able to interact with
Unpleasant sensory and
Celsius crystalline proteins coping. shield at night; eye glasses in the 5. Strong light causes significant others.
emotional experience
HR: 90 bpm morning for 1-4 weeks post-op. discomfort after use of eye Goal Met.
arising from actual or
RR: 20 cpm drops dilator.
potential tissue damage
BP: 110/80 mmHg Increased density, stiffening and C. Patient displays Dependent Interventions: C. Patient’s vital signs
or described in terms of
Restlessness pigmentation of lens material improved well-being such 1. Give medications to control are temp of 36.5
such damage
Facial grimace as baseline levels for pain such as Can C (N-alpha degrees Celsius, a
(International Association
pulse, BP, respirations, acetylcarnosine (NAC) eye drops 1. Use of medication will heart rate of 75 bpm,
for the Study of Pain)
Opafication of crystalline lens and relaxed muscle tone and the IOP as prescribed. reduce pain and the IOP and a respiratory rate of
or body posture. increase comfort. 16 cpm and a blood
pressure of 120/80
Strength : Source/
Cataract Formation mmHg. The patient
Responsive also showed a relax
Expressive Reference posture. Goal Met.
Nurse’s Pocket Guide. Loss of transparency of natural
lens
Edition 11 by Marilynn
Doenges, Mary Frances
Moorhouse and Alice
Hardening of central lens
Murr
nucleus
 Scattering of light

Hyper-mature enlarged cataract

Cataract extraction surgery

S/S:
• Seeing halo around lights -
earliest symptoms
• Painless, blurry vision
• Reduced contrast sensitivity
• Sensitivity to glare
• Distorted or absent red reflex
in direct observation
ophthalmoscope
• Eye pain

Acute Pain related to cataract

extraction surgery as evidenced
by client description of pain
which is as deep within the eye
and 8/10 pain scale.

Reference:
The Calgary Guide to
Understanding Disease. (nd).
Cataract: Pathogenesis and
Clinical Findings. Retrieved from
https://
calgaryguide.ucalgary.ca/
cataract-pathogenesis-and-
clinical-findings/

Name of CI: Miss Dora Ontiveros RN, MN Area of Exposure: St. Vincent’s Home of the Aged