NURSING CARE PROCESS

Name of Patient:M Age:81 y/o Sex: Female Civil Status: N/A Room/Bed No. N/A
Medical /Surgical Diagnosis: N/A Assessment date: N/A Intervention date: N/A
Prepared by: Mark Austin P. Agustin Section/Grp No.: Section 112/Group 1 CI/Supervisor: Sir Neugene Rowan S. Cu
Cues Nursing Analysis Goals and Implementation Rationale Evaluation
Diagnosis Objective
Long-term Goal: Independent-
Subjective cues: SCIENTIFIC ANALYSIS Supplemental:
“I am just afraid I
might stumble Disturbed People rely so much After 8 hours of nursing Assess the client for Ear and Vision MET. The client was able to
down anytime sensory on their senses such intervention, the client will visual acuity and hearing assessment is part of maintain usual level of
because I perception : as vision and hearing. be able to maintain the use acuity as well as the routine Physical cognition, use resources
sometimes loose Visual and And it is evidently one if cognition and sensory Romberg’s test. Assessment for effectively and appropriately
Hearing RT clients. This is to and be free of injury.
balance.” of the main uses of perception along with its
altered sensory ensure on whether
elderly to perform accessories and resources
reception and any other deviations Despite the existing disturbed
Biochemical activities that they effectively and are present to plan sensory perception, the client
Imbalances need to become appropriately and will be an appropriate care was efficient and has
AEB altered active. Thus, loss of free from injuries. plan to the client. consciousness of her internal
Objective cues: sense of sight and auditory and external environment by
balance/falls perception will make (Weber, 2016) continuously adhering to
BP- 120/90 them more eyeglasses and hearing aid and
PR- 81 dependent to other keeping it updated. She was
RR 17 and might result to a also able to continue to
Temp- 36.5 harder way for them performing ADL and IADL
BMI = 22.2 to enjoy activities without inflicting any injuries.
that they used to do
Independent-
Laboratory results: that may lead to
Supplemental:
motor incoordination. Short-term Goal:
low hemoglobin That might possibly The utilization of - MET. The client continuously
high sodium result to depression after 1 hour of nursing Monitor the client’s adhered to the prescribed
adherence to her prescription lenses
high uric acid that is linked to many intervention, the client will eyeglasses and hearing aid.
prescribed sensory and hearing aids are
normal blood sugar other illnesses, may it maintain the utilization of necessary to
borderline (near be physical or mental such as her prescription accessories. The client was able to
maintain the level of
high) cholesterol) health problems. glasses and hearing aid, and cognition a person consistently adhere to her
low calcium and maintain a good diet for has despite factors glasses and hearing aid in her
potassium (King and Bend, 2018) biochemical balance. such as age. daily living and was not
Chest x-ray is (Planck 2020) Adhering to the involved in any injuries.
normal usage of these
orange to brown SITUATIONAL accessories improve
cerumen in both ANALYSIS: performance of -

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 ears activities and at the-
Urinalysis is 9-10 Based on the same time lowers -
WBC. objective data the risks of -
gathered from the inflicting injuries.
client, she has been
adhering to her (Smart, 2011)
prescription lenses
and to her hearing
aid. However,
laboratory results
indicate electrolyte
imbalance which may Independent-
effect on her sensory Objectives: Developmental:
perception and may
Explain to the client the Senses are a big - MET. The client was able to
cause motor 1. The client should
sensory needs and the part of our lives for verbalize her awareness on her
incoordination or be able to
importance of adhering to it helps us sensory needs.
altered sense of verbalize at least
her prescription lenses understand and feel
balance that she also 3-5 sensory needs
and hearing aid. what's going on in The client had adequate
mentioned during the in 8 minutes
and out of your knowledge on her sensory
assessment. body. However, needs and she appropriately
senses of people used this knowledge
Health Implication: who age is slowly appropriately to maintain her
deteriorating; hence usual cognition.
At an old age, risk the use of assistive
from disturbed devices is essential
sensory perception for their daily -
may possess a life activities to have no
threatening if not barrier and to -
addressed. Such as prevent them from-
inflicting injuries from encountering -
hazards.
fall and the inability
to perform activities
(Wilmot, - 2017)
that will help them
keep active.

Indepenent-
Developmental:
Sufficient - MET. The client has
2. The client should Instruct and demonstrate
knowledge when it demonstrated ways to maintain
be able to to the client the proper
comes to effectiveness of her medical
demonstrate 3-5 usage and maintenance on
maintenance of devices.
ways on how she her prescription lenses
and hearing aid. assistive equipment

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 can maintain is vital for those After the health teaching from
effectiveness of who are using it to the nurse, the client
her medical sustain it from a demonstrated appropriate
devices. potential hazard in cleaning and battery changing
their daily for her glasses and hearing aid
functioning. Proper respectively through which it
cleaning of glasses ensured effective results to
should be known as prevent a lack of sensory
well as proper perception.
cleaning and battery
changing for
hearing aids to
avoid handling it -
negligently.

(Smart-, 2011)

Independent-
Developmental:

External factors are MET. The client was able to

3. The client should Explain to the client related to what is to
be able to external factors recognize and modify
be perceived in a contributing to changes in
recognize and contributing to changes in given situation
modify at least 3 sensory or perceptual sensory or perceptual abilities.
through our senses.
external factors abilities and teach her However, in certain-
contributing to how to modify these She efficiently recognized
situations, external external factors that may affect
changes in factors when needed. factors may
sensory or her perception abilities such as
negatively affect exposure to UV light and loud
perceptual our perceptual
abilities in 15 noises and modified her
ability. Hence, activities to prevent directly
minutes. sufficient encountering these.
knowledge on
maintenance of
good perceptual
abilities and
modification of
some external
factors are needed
to prevent negative
effects to happen.

(Smart, 2011)

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Bibliography
Planck, M. (2020, February 10). Sensory perception is not superficial brain work. (Institute for Human Cognitive and Brain Sciences)
Retrieved from Science Daily: https://www.sciencedaily.com/releases/2020/02/200210112234.htm
Smart, J. (2011). Disability Across Developmental Life Span. Springer Publishing.
Wilmot, K. (2017, june). Understanding Sensory Processing Issues. Retrieved from https://www.understood.org/en/learning-
thinking- differences/child-learning-disabilities/sensory-processing-issues/understanding-sensory-processing-issues
King, E. B. (2018, May 30). HOW DO VISION AND HEARING LOSS AFFECT YOUR LIFE? Retrieved from Charlotte Eye Ear Nose & Throat
Associates P.A: https://www.ceenta.com/news-blog/how-do-vision-and-hearing-loss-affect-your-life
Tang Wing Sze 1, C. Y. (2012). The Effectiveness of Physical Restraints in Reducing Falls Among Adults in Acute Care Hospitals and
Nursing Homes: A Systematic Review. Retrieved from National Library of Medicine:
https://pubmed.ncbi.nlm.nih.gov/27819940/
Beeson, P. (1985, March-April). Alleged susceptibility of the elderly to infection. Retrieved from Yale J Biol Med:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2589900/
WebMD. (2008). Prehypertension: Are You at Risk? Retrieved from WebMD: https://www.webmd.com/hypertension-high-blood-
pressure/guide/prehypertension-are-you-at-risk#1
Boxer, B. (2018). Age-Related Vision Problems. Retrieved from WebMD: https://www.webmd.com/eye-health/age-related-vision#1
Kreimeier, U. (2000, October 23). Pathophysiology of fluid imbalance. Retrieved from US National Library of Medicine National
Institute of Health: ncbi.nlm.nih.gov/pmc/articles/PMC3226173/

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 Nursing Problem/s Rank Justification
Disturbed sensory perception : Visual and Hearing 1st Impaired visual and hearing acuity is common in aging
RT altered sensory reception and Biochemical and it may pose threats such as the inability to clearly
Imbalances AEB altered sense of balance/falls distinguish objects/ environment which may also lead to
motor incoordination. (Boxer, 2018)

The ability to see falls on Physiological Needs on Maslow's

Hierarchy and this is given high priority for there is a slight
chance that the client may not be able to efficiently
perform ADL eventually because on the client’s objective
data it is known that she uses corrective glasses and
hearing aid to lower risks that are related to her age and
existing biochemical imbalances based on her lab results.
This needs prioritization for effective handling to
activities that involves visual and auditory perception is a
key to diminish other possible threats such as motor
incoordination because as mentioned by the client she
feels that she might fall when walking.

Risk for Electrolyte Imbalance RT fluid imbalance 2nd Based on Maslow's Hierarchy of Needs, problems that
(high sodium/ potassium) and aging poses a threat to the Physiologic Needs of client should
be Prioritized. ' Electrolyte balance inside the body is
essential for it plays a vital role to the bodily muscles,
bone health and the central nervous system. It may not
be an existing problem to the client, but it may possibly
be if it persists.
If risk for electrolyte imbalance is not prevented nor given
priority it may put the client to complications such as
decreased cardiac output, hypovolemic shock, metabolic
acidosis, or multisystem failure which we do not want to
happen. (Kreimeier, 2000)

Risk for decreased cardiac RT altered afterload 3rd In elders, diastolic is expected to be as much as possible
lower than 80 and if not, it can already be considered as
prehypertensive. This increases the patient’s risk of heart
attack, stroke, coronary heart disease, heart failure, and
kidney failure. (WebMD, 2008) A decreased cardiac
output may threaten the attainment of physiologic needs

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 (circulation). However, this is only medium priority the
problem is non- existent but I maybe it altered afterload
persists. In addition, the client does not also complain
much of the symptoms.
There's no cure for high blood pressure, but there is
treatment with diet, lifestyle habits, and medications.

Risk for Infection RT inadequate secondary 4th Based on the principles on designation of nursing
defenses (decreased hemoglobin, WBC in urine) priorities, those that poses risk for physiologic needs must
be attained first than other higher levels of needs.
Secondary defenses on the body is essential for the assist
in protecting the body from invaders. (Beeson, 1985)
Yet, these risks are often on the least priority, because it
doesn’t have a direct and actual effect on the client
presently. It is in line with the fact that, according to
Maslow’s hierarchy of needs, maintenance of the body is
essential for survival, and as necessary as the basic
physiological need.

Risk for falls RT age and impaired imbalance 5th Based on the concept of nursing priorities categorization,
those which present a risk to physiological needs must be
achieved first than other higher levels of needs.
Many patients who fall suffer bodily injuries due to the
impact of the fall, such as breaking a hip or internal brain
swelling. (Tang Wing Sze 1, 2012)

In Maslow’s Hierarchy of Needs, Risk for falls poses a

threat on safety for stability. It is given lowest priority for
the problem it is not entirely life threatening but has the
possibility and objective data of the client does not
indicate any difficulties in performance of her ADL thus
risk of its occurrence is low as well.

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