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    NCP - Impaired Tissue Integrity

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    Rene John Francisco
    The document describes a 12-year-old male patient who presented with a painful, red right eye with cloudy streaks on the cornea. The nursing diagnosis was impaired tissue integrity of the eye likely caused by a foreign object. Interventions included educating the patient and family on prevention, administering eye drops, and assessing for signs of impaired wound healing. The patient expressed willingness to participate in treatment but required assistance from his mother to understand due to his young age.

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    NCP - Impaired Tissue Integrity

    Uploaded by

    Rene John Francisco
    5K views3 pages
    The document describes a 12-year-old male patient who presented with a painful, red right eye with cloudy streaks on the cornea. The nursing diagnosis was impaired tissue integrity of the eye likely caused by a foreign object. Interventions included educating the patient and family on prevention, administering eye drops, and assessing for signs of impaired wound healing. The patient expressed willingness to participate in treatment but required assistance from his mother to understand due to his young age.

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    The document describes a 12-year-old male patient who presented with a painful, red right eye with cloudy streaks on the cornea. The nursing diagnosis was impaired tissue integrity of the eye likely caused by a foreign object. Interventions included educating the patient and family on prevention, administering eye drops, and assessing for signs of impaired wound healing. The patient expressed willingness to participate in treatment but required assistance from his mother to understand due to his young age.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    5K views3 pages

    NCP - Impaired Tissue Integrity

    Uploaded by

    Rene John Francisco
    The document describes a 12-year-old male patient who presented with a painful, red right eye with cloudy streaks on the cornea. The nursing diagnosis was impaired tissue integrity of the eye likely caused by a foreign object. Interventions included educating the patient and family on prevention, administering eye drops, and assessing for signs of impaired wound healing. The patient expressed willingness to participate in treatment but required assistance from his mother to understand due to his young age.

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    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

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

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

    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

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

    explore To assess potential 2.Goal partially patient problems that may met. Participated his develop/arise. fairly in the assessment of his condition due to Assess present To prevent very young age and condition such by occurrence of lack of knowledge taking vital signs, complications that regarding the checking the injured could further add complexity of the part, and referring injury to the patient disease. His mother abnormal findings conversed more regarding his Administer Lubricates the eyes, present condition medications as reducing risk of and took action for indicated: lesion formation the treatment of her Moxyfloxacin eye sons health. drops 1 drop Q15 for 3 hours as loading dose, then 1 drop Q1 OU thereafter Assess for and report -to provide due 3.Goal partially signs and symptoms nursing care through met. Demonstrated of impaired wound the presenting signs cooperation on the healing (e.g. treatment regimen increasing periwound by being obedient to swelling and redness, the ones taking

    3. Express willingness to participate in the treatment regimen.

    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.

    care of him and good compliance to medication.

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