PLANNING

NURSING
ASSESSMENT IMPLEMENTATION EVALUATION
DIAGNOSIS OBJECTIVE OF
INTERVENTION RATIONALE
CARE

Short Term Goal:  Assess the patient’s  To establish a  Achieving a successful The Intervention
Macular At the end of 1-2 degree of visual baseline of assessment of vision of Only Last for 1
Subjective cues: degeneration hours of nursing impairment. visual acuity the patient. hour and 30
related to diabetic and gain minutes and
intervention, the
retinopathy achieved the desired
 The client has client will be able useful
stated that to: information outcomes:
"Anino nalang  To complete a before  The patient will
ang nakikita ko". Visual acuity modifying the be able to
assessment of patient’s identify the
the patient. environment. potential cause
 The client stated
of the Macular
that she haven’t degeneration
gone to a doctor and accept
 The nurse will  Encourage the  To monitor  Provide education to the
to check her eye patient to have worsening of permanent
sights. be able to patient and their families
regular checkups vision loss and vision changes.
provide health about macular
teaching and with an treat degeneration and
persuade the ophthalmologist at accordingly. suggest/encourage to see  The patient and
Objective cues: least once a year. the significant
patient to visit an ophthalmologist to the
a doctor. nearest clinic. other’s will be
 The client can’t . fully aware of
look directly to the macular
the person who  To avoid and degeneration
she talks to. minimized and will visit a
 Difficulty the risk for doctor to have a
recognizing faces Injuries. further and
 Decreased color  Educate patients and  This includes  Provide education to detailed
family members teaching patients and their families examination.
perception
patients how about fall and Injury
 Client’s age: 59
to use assistive prevention strategies.  The patient and
years old devices his significant
 The client
 diagnosed with properly, others will be
DM type 2, 5 raising fully aware of
years ago awareness the patient’s
about potential environment
lab results: hazards in the and will be
 none environment, ready to ensure
and the patient’s
encouraging safety.
them to report
any changes in  The Patient and
their condition the family will
that may demonstrate
results to risk and exercise
of injuries. behaviours and
lifestyle changes
to reduce risk
 This ensures factors and
that assistance protect self
 Ensure adequate is readily  Provide close supervision from injury
supervision available and and frequent checks for
helps prevent patients who are at high
accidents or risk for falls and Injuries
falls during or traumas.
unsupervised
activities.

 This helps
maintain
stability and  Educate patients about the
 Encourage reduces the importance of wearing
appropriate footwear; risk of slipping proper footwear, such as
Ensure that the floor or tripping. non-slip shoes or slippers
is free of objects that with good traction
can cause the patient
 to slip or fall.  The patient
may not be
 Encourage the able to  Educate patients about the
patient to promote perform importance of sufficient
sufficient lighting at activities of lighting at home to avoid
home. daily living as Risk for injuries.
normal if
he/she cannot
see properly.
Sufficient
lighting also
reduces
the risk for
injury.

Cite Reference/s
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based
guide to planning care. St. Louis, MO: Elsevier.

Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier.

T. Heather Herdman/Shigemi Kamitsuru (Eds), NANDA International, Inc. Norsing Diagnoses: Definitions and Classification 2018-2020,
Eleventh Edition 2017 NANDA International, ISBN 978-1-62623-929-6. Used by arrangement with the Thieme Group, Stuttgart/New
York

NURSING CARE PLAN (NCP)