Nursing Related Learning Experience Manual

Name of Student Yr & Sec BSN -1B

Clinical Instructor Area
Date of Exposure 7 / 8 / 2020 Hospital NDDU

GORDON’S FUNCTIONAL HEALTH PATTERN

Functional Health Pattern Cue Cluster Inference Diagnostic Statement Priority Rationale
1. Health Perception & Subjective: *She has worn Ineffective Health Ineffective Health Medium Medium because this
Management glasses for reading for the Maintenance Maintenance r/t irregular problem can if not
past 20 years examination of the eye as intervene will cause much
* Mrs. Hira says that she a- manifested by says that she worse problem of the eye
eye examination 4 years ago a- eye examination 4 years may lead to visual
ago impairement.
Objective: *68-year-old
woman

2. Nutrition / Metabolism NA NA NA NA NA

3. Elimination Pattern NA NA NA NA NA

4. Activity / Exercise Subjective: *Can't see as Risk for activity Risk for activity Low Low since the problem is
well as I used to intolerance intolerance r/t altered not yet occur and it can be
* blurring that seems to be visual perception intervene through different
getting worse intervention

Objective: * distant visual

acuity in the right eye (OD)
20/40
* left eye (OS) 20/40
5. Sleep / Rest NA NA NA NA NA

6. Cognitive / Perceptual Subjective: *Can't see as Disturbed Sensory Disturbed Sensory High High 1 because this is the
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well as I used to Perception: Visual Perception: Visual r/t problem that makes client
* blurring that seems to be altered visual perception as to seek health practitioner
getting worse manifested by statement and this problem affects
* She reports progressive “Can't see as well as I used the ADL of the client.
changes in her vision over the to” and reports a halo effect
past 5 months. at night when at lights
*reports a halo effect at night * distant visual acuity in the
when at lights right eye (OD) 20/40
*and she said that she does * left eye (OS) 20/40
not drive much at night
anymore because of this
* She has worn glasses for
reading for the past 20 years
* she a- eye examination 4
years ago

Objective: * distant visual

acuity in the right eye (OD)
20/40
* left eye (OS) 20/40
* The extraocular muscles
are intact
* The visual fields are equal
to the examiners
* The conjunctivae are
smooth and without redness
* The pupils are bilaterally
round, _ = size, and reactive
to light and accommodation
*No nystagmus is noted

7. Self – Perception / Self NA NA NA NA NA

- Concept

8. Role / Relationship Subjective: * Her 71-year-

old husband had a major
stroke 1 year ago, and she is

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 Nursing Related Learning Experience Manual

solely responsible for his care

* Their daughter and her
family live 321.8 km (200
miles) away
* She has been retired from
the telephone company for 30
years
Objective:
9. Sexuality / NA NA NA NA NA
Reproductive

10. Coping – Stress NA NA NA NA NA

Tolerance

11. Value Belief Subjectve: “Mrs. Hira uses NA NA NA NA

for grocery shopping and to
go to church”

PROBLEM IDENTIFICATION

Problem (PES) Date Identified Time Date Resolved

Disturbed Sensory 7 / 8 / 2020 2 : 18 PM 7 / 8 / 2020
Perception: Visual r/t altered visual
perception as manifested by statement
“Can't see as well as I used to” and reports a
halo effect at night when at lights
* distant visual acuity in the right eye (OD)
20/40
* left eye (OS) 20/40

Ineffective Health 7 / 8 / 2020 2 : 18 PM 7 / 8 / 2020

Maintenance r/t irregular examination of
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY
 Nursing Related Learning Experience Manual

the eye as manifested by says that she a-

eye examination 4 years ago

Risk for activity intolerance r/t altered 7 / 8 / 2020 2 : 18 PM 7 / 8 / 2020

visual perception

PRIORITIZATION OF PROBLEMS

Nursing Diagnosis Prioritization Rationale

Disturbed Sensory High High 1 because this is the problem that makes client to
Perception: Visual r/t altered visual perception as seek health practitioner and this problem affects the
manifested by statement “Can't see as well as I used to” and ADL of the client.
reports a halo effect at night when at lights
* distant visual acuity in the right eye (OD) 20/40
* left eye (OS) 20/40

Ineffective Health Medium Medium because this problem can if not intervene will
Maintenance r/t irregular examination of the eye as cause much worse problem of the eye may lead to visual
manifested by says that she a- eye examination 4 years ago impairement.

Risk for activity intolerance r/t altered visual perception Low Low since the problem is not yet occur and it can be
intervene through different intervention

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 Nursing Related Learning Experience Manual

NURSING CARE PLAN

Name of Patient Mrs. Hira Rm/Bed No. 2C 204 Age 68 Chief Complaints Vision distortion
Address General Santos City Admission Date 7 / 8 / 2020 Sex F Diagnosis Disturbed Sensory
Perception: Visual r/t altered visual
perception

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN
Subjective Cues: C Note: Use P-E-S format General Objective Independent Goal was met,
O * Assess the patient’s ability to see and after this
*Can't see as well as I Disturbed Sensory
G Within a week patient perform activities. intervention the
used to N Perception: Visual r/t will be able to regain client can do
* blurring that seems I altered visual perception vision to the maximum Rationale: Provides a baseline for her ADL without
to be getting worse T as manifested by possible extent with the determination of changes affecting the difficulties due
* She reports I statement “Can't see as surgical procedure and patient’s visual acuity. to visual
progressive changes V well as I used to” and will regain optimal vision distortion.
in her vision over the E reports a halo effect at night possible and will adapt to * Encourage patient to see an ophthalmologist
past 5 months. when at lights permanent visual changes at least yearly.
*reports a halo effect P *distant visual acuity in the
at night when at lights E right eye (OD) 20/40 Specific Objective Rationale: Can monitor progressive visual loss
*and she said that she R * left eye (OS) 20/40 or complications. Decreases in visual acuity
does not drive much C * Patient will be able can increase confusion in the elderly patient.
at night anymore E to use adaptive
because of this P Background Knowledge * Provide large print objects and visual aids for
devices to
* She has worn T teaching.
glasses for reading U Disturbed Sensory compensate for visual
for the past 20 years A Perception: Change in the loss.. Rationale: Assists patient to see larger print
* she a- eye L amount or patterning of and promotes a sense of independence.
examination 4 years incoming stimuli * Patient will maintain a
ago P accompanied by a safe environment with no * If surgery is planned, instruct patient and/or
A diminished, exaggerated, injury noted. family regarding procedure, post-procedure

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 Nursing Related Learning Experience Manual

Objective Cues T distorted, or impaired care, and the need for follow-up with the
T response to such stimuli. * Patient will be able to physician. Instruct about complications and
* distant visual acuity E Visual distortions are also deal with the potential for emergency signs and symptoms (flashing lights
in the right eye (OD) R common for the adult client permanent visual loss. with loss of vision, seeing a “veil” falling over
20/40 N due to aging and you need visual field, loss of vision in a specific portion
to be aware of the warning of the visual field, etc.) of which to notify the
* left eye (OS) 20/40 signs of age-related eye physician.
health problems that could
* The extraocular cause vision loss. Many eye Rationale: Prepares the patient for what to
muscles are intact diseases have no early expect, facilitate compliance, and provides
symptoms. They may instruction about potential problems to
* The visual fields are develop painlessly, and you lessen anxiety.
equal to the may not notice the changes
examiners to your vision until the * Provide sufficient lighting for the patient to
condition is quite advanced. carry out activities.
* The conjunctivae
are smooth and Ref Rationale: Elderly patients need twice as much
without redness https://nurseslabs.com/2- light as younger people.
cataracts-nursing-care-
* The pupils are *Encourage the client to use the appropriate
plans/
bilaterally round, _ = eye glasses as prescribe by ophthalmologist
size, and reactive to
light and Rationale: In order for the client to have
accommodation clearer vision.

* No nystagmus is
noted Dependent

* Cataract surgery – In cases of visual

impairment due to cataracts

Rationale: surgery may be opted. Usually an

artificial lens is placed within the eye as a
replacement of the damaged and clouded lens.
This, more often than not restores vision

*Administer medication for Glaucoma 

a. Latanoprost
b. tafluprost
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 Nursing Related Learning Experience Manual

c. travoprost 
Rationale: medications in eye drops are
prescribed to control glaucoma.

ASSESSMENT HEALTH NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS

PATTERN

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 Nursing Related Learning Experience Manual

Name of Student Yr & Sec

Clinical Instructor Area
Date of Exposure Hospital

DIAGNOSTIC EXAMINATIONS
Name of Patient Rm/Bed No. Age Chief Complaints
Address Admission Date Sex Diagnosis

Diagnostic Normal
Date Ordered Result Significance
Examination Values

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY

 Nursing Related Learning Experience Manual

College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY