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    Assessment Nursing Diagnosis Background Knowledge Planning Nursing Intervention Rationale Evaluation

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    Maye Arugay
    The patient has left facial paralysis manifested by difficulty closing her left eye. The nursing diagnosis is risk of disturbed visual sensory perception related to neuromuscular impairment. The plan is for the patient to remain free from harm after 1 hour of nursing interventions which include establishing rapport, monitoring vitals, assessing knowledge and identifying changes, with rationales of gaining trust and allowing evaluation. The evaluation showed the interventions were effective in keeping the patient free from visual disturbances.

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    Assessment Nursing Diagnosis Background Knowledge Planning Nursing Intervention Rationale Evaluation

    Uploaded by

    Maye Arugay
    28 views2 pages
    The patient has left facial paralysis manifested by difficulty closing her left eye. The nursing diagnosis is risk of disturbed visual sensory perception related to neuromuscular impairment. The plan is for the patient to remain free from harm after 1 hour of nursing interventions which include establishing rapport, monitoring vitals, assessing knowledge and identifying changes, with rationales of gaining trust and allowing evaluation. The evaluation showed the interventions were effective in keeping the patient free from visual disturbances.

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    Ncp-cayco

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    The patient has left facial paralysis manifested by difficulty closing her left eye. The nursing diagnosis is risk of disturbed visual sensory perception related to neuromuscular impairment. The plan is for the patient to remain free from harm after 1 hour of nursing interventions which include establishing rapport, monitoring vitals, assessing knowledge and identifying changes, with rationales of gaining trust and allowing evaluation. The evaluation showed the interventions were effective in keeping the patient free from visual disturbances.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    28 views2 pages

    Assessment Nursing Diagnosis Background Knowledge Planning Nursing Intervention Rationale Evaluation

    Uploaded by

    Maye Arugay
    The patient has left facial paralysis manifested by difficulty closing her left eye. The nursing diagnosis is risk of disturbed visual sensory perception related to neuromuscular impairment. The plan is for the patient to remain free from harm after 1 hour of nursing interventions which include establishing rapport, monitoring vitals, assessing knowledge and identifying changes, with rationales of gaining trust and allowing evaluation. The evaluation showed the interventions were effective in keeping the patient free from visual disturbances.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    ASSESSMENT NURSING BACKGROUND PLANNING NURSING RATIONALE EVALUATION

    DIAGNOSIS KNOWLEDGE INTERVENTION

    BP is a peripheral INDEPENDENT INDEPENDENT


    SUBJECTIVE Risk of disturbed facial paralysis, After 1 hour of
    visual sensory there’s have no After 1 hour of 1.Establish rapport 1.To gain the level of nursing
    Mother’s reports that substantial nursing trust with the patient. interventions the
    perception related to
    she has difficulty with researches have interventions patient patient was able
    neuromuscular
    left eye closure. proven the etiology 2.monitor patient’s 2.allow the evaluation to remain free
    impairment as will remain free
    of it. vital sign of any neurological harm resulting
    manifested by loss of from harm resulting complication such as from visual
    protective eye closure. Ineffective agent from visual abnormal. disturbances.
    OBJECTIVE disturbances.

    Left Facial Asymmetry Inflammation and


    subsequent 3.assess patient’s 3.the level of response
    swelling of one knowledge of change is related to the
    BP - 90/50
    facial nerve. in structure of perceived value or
    function of the body importance that the
    PR -100 bpm part. patient’s places on the
    Blockage of normal affected body part.
    neural activity

    4.assist patient to 4.patient may


    Loss of innervation identify actual perceive changes that
    to one side of the changes. are not actually
    face present.

    5.encourage the 5.allow to examine if


    Difficulty with left patient to report theirs have present of
    eye closure.. immediately any infection.
    pain experienced
    around the eye.
    6.place an eye patch 6.to protect the eye
    on the affected eye. from scratch. And
    keep the eye closed
    and moist during
    night.

    DEPENDENT

    1. administer 1.artificial tear or


    artificial tears or ophthalmic ointment
    ophthalmic is used to prevent the
    ointment as eye from dryness.
    ordered.

    2. Administer 2. anti-inflammatory
    prednisone initiated to reduce
    (corticosteroid). inflammation in
    vascular compression
    and permits
    restoration of blood
    circulation to the
    nerve.

    3. Administer 3.analgesic is an agent


    analgesic to moist heat in
    involved side of the
    face.

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