PREGNANCY INDUCED HYPERTENSIONN2-A2

ObjectiveAfter the case presentation/discussion the students will be able to: Understand and acquire knowledge about Pregnancy

Induced Hypertension (Pre-eclampsia) its manifestations including the pathophysiology.

Understand ways of providing holistic nursing care by utilizing the nursing process in the care of a client with Pregnancy Induced Hypertension including her newborn.

Learn about disease condition, its complications , the medical , surgical and pharmacological management of the condition.

Pregnancy Induced Hypertensionis a disease of unknown etiology

occurring after 20th week of gestation characterized by blood pressure more than 140/90mmHg and generalized edema.

PATIENT PROFILENAME : D.F

ADDRESS : BRGY. SOUTHSIDE, MAKATI CITY

AGE : 32

CIVIL STATUS : MARRIED

OCCUPATION : NONE

RELIGION : IGLESIA NI CRISTO

DATE ADMITTED : NOVEMBER 7, 2013

LANGUAGE : ENGLISH AND TAGALOG

SOURCE OF RELIABILITY : PATIENT DF

• Chief Complaint

High Blood pressure reading upon 1 week of admission and confinement at UERM Hospital.

Date Admitted: November 7, 2013

Date Discharged: November 14, 2013

HISTORY OF PRESENT ILLNESS• Patient D.F. after missing her period having positive pregnancy test result decided to seek medical check up from a health center. Multivitamins and Ferrous Sulfate was prescribed. After seeking medical consultation from a private physician, untrasound was done revealing placenta previa totalis. Presence of bilateral led edema was noted. Patient was diagnosed with severe preeclampsia at PGH.

HISTORY OF PRESENT ILLNESS• There was a positive fever, blurring of

vision, slight swelling of fingers, headache, good fetal movements prior to admission. Also, patient is experiencing change in hearing (described as deafness), nausea and frequency of urination.

LMP : FEBRUARY 15 , 2013 Upon admission: 

WEIGHT: 71.1 kgBP: 170/90RR: 24HR: 99Temp 37.0

PAST MEDICAL HISTORY CHILDHOOD DISEASES

Measles Chickenpox Mumps

MAJOR ADULT ILLNESSES none

ALLERGIES (NONE) MENSTRUAL HISTORY

Menarche : 12 y/o Cycle : 30 days (-) dysmenorrhea

PAST MEDICAL HISTORY IMMUNIZATIONS

Tetanus Toxoid (1,2) Rubella Measles Small pox Hepa A and B BCG Mumps Chicken pox

OBSTETRICAL HISTORY G1PO

PAST MEDICAL HISTORY COITARCHE

At 24 years old 1 sexual partner

FAMILY HISTORY GENOGRAM

51

3537

54

32

? ?? ?

S/P CVA

SOCIAL HISTORY Non-smoker Previous occasional alcoholic beverage

drinker (maximum 2 bottles of beer or 2 glasses of wine)

(-) history of illicit drugs

DEVELOPMENTAL NEEDS AND TASKS

As our patient is 32 years old female, she is at young adulthood stage (18-35years) in her life.

According to Diekelmann (1976) there are five developmental tasks of young adulthood and they are:

1. The young adult achieve independence from parental control

2. They begin to develop strong friendships and intimate relationship outside the family

3. They establish personal set of values

4. They develop a sense of personal identity

5.They prepare for life work and develop the capacity for intimacy

In our patient : She achieved independence from parental control

She formed an intimate relationship with her husband

She has her own set of personal values

She has developed a sense of personal identity

She has prepared herself for life and has already built the capacity for intimacy

Gordon’s Functional Health PerceptionPATIENT PROFILE : NAME: FAMINI, DORISADDRESS : 337 PERSING ST. POST PROPER, BRGY. SOUTHSIDE, MAKATI CITYAGE : 32

CIVIL STATUS : MARRIEDOCCUPATION : NONERELIGION : IGLESIA NI CRISTOSOURCE OF MEDICAL CARE : PHILHEALTHDATE ADMITTED : NOVEMBER 7, 2013

DIAGNOSIS: OPERATIVE DELIVERY VIA ‘E’ LTCCS FOR SEVERE PREECLAMPSIA TO A LIVE FULL TERM GIRL BW 2,140g BL 43cm, G1P0

 STUDENT NURSES: ESAGRE, RYAN

VIAJE, DEM CYRILLE P.

Areas of Functional

Pattern

Before Hospitalizatio

n

During Hospitalization Analysis Interpretation Nursing Diagnosis

Health Perception-Health Management

Patient D.F visits the nearby health centre for her monthly pre-natal check-ups. She’s provided with ferrous sulfate as supplement and folic acid too. She decided to see a physician after experiencing uterine contractions several times. However, her BP was 120/80mmHg before pregnancy.

Patient D.F is now hospitalized and realizes the complications of pregnancy she has. She was diagnosed with severe preeclampsia and had undergone caesarean section for her premature baby. She manifests edema, proteinuria and blurring of vision. She is expecting to recover from her present condition with the help and support of her family and health providers attending to her needs. As of this writing, her BP is 160/90mmHg.

Severe Preeclampsia is marked by any or all of the following manifestations:Blood Pressure of 160/110; Proteinuria 3-4+ on a random sample and 5g on a 24-hr sample; Oliguria(500ml or less in 24hrs altered renal function tests; Elevated serum creatinine more than 1.2 mg/dL; Cerebral or visual disturbances (headache or blurred vision); Pulmonary or cardiac involvement; Extensive peripheral edema; Hepatic dysfunction; thrombocytopenia; Epigastric pain. (Maternal and Child Health Nursing Vol. 2, 5th Edition by Adele Pillitteri p. 428)

Patient D.F cannot function well in relation to her severe preeclampsia evidenced by extensive edema and blurring of vision. Patient is also kept monitored for her vital signs esp. blood pressure.

S: “Ako’y nahihilo, nung naramdaman ko na akoy namamanas na agad akong komunsulta sa doctor “ as verbalized by the patient. O: Edema noted on

the lower extremities (grade 2)

Cold, clammy skin noted

BP 170/90mmHg Diagnosis:Ineffective tissue perfusion related to vasoconstriction of blood vessels

Nutrition Metabolic

Patient D.F is living a healthy lifestyle and her appetite is well. She prefers to eat meat than fish and vegetables. Also, she makes sure that she drinks plenty of water every day.

Patient D.F is on her low fat, low salt diet consisting mainly of fish, vegetables and bread that’s being catered in the hospital. She likes the taste and her appetite is very objective.

An individual health status greatly affects eating habits and nutritional status (Fundamentals of Nursing by Kozier p. 1178)

Nutritional and metabolic status of patient D.F has been changed slightly to her confinement and medical condition.

S: ““Mas mahilig ako kumain ng karne kasysa sa mga gulay.” O: Patient -V/S taken as follows: BP:170/90mmHg PR:99bpm RR: Diagnosis:Imbalanced nutrition: risk for more than body requirements

Activity Exercise

Patient D.F has a sedentary lifestyle. She uses to stay inside the house and likes to watch television with her mom.

When a patient is admitted to a health agency, he or she is confronted with stimuli that are different in quality and quantity than that to which he or she is accustomed to. (Fundamentals of Nursing, 5th Edition by Taylor, Lillis, p. 906

There was a gradual progress regarding patient’s activity and exercise. She’s more aware of this time the significance of getting involved and do something.

S:”Mas gusto ko sa loob mg bahay. Di ako masyadong lumalabas”O: Patient has poor posture and gait. Diagnosis:Sedentary Lifestyle 

Cognitive Perceptual

Patient D.F is a 2-year college graduate. She can read and speaks very well and listens attentively.

Patient D.F’s present condition affects her cognitive-perceptual pattern. Her sensory perception is limited to her hospital bed and within hospital area.

When a patient is admitted to a health agency, he or she is confronted with stimuli that are different in quality and quantity than that to which he or she is accustomed to. (Fundamentals of Nursing, 5th Edition by Taylor, Lillis, p. 906

There was a change in cognitive and perceptual pattern in terms of stimuli that is limited only to the environment which is within the hospital area and patient’s room.

S:”Medyo nanlalabo ang mga mata ko “ as verbalized by the patient. O: Blurred vision: OS-2.75; OD -1.75 , near sighted, sclerosisDiagnosis:Disturbed Sensory Perception related to altered sensory transmission

Sleep Rest Patient D.F usually sleeps around 9pm and wakes up early in the morning usually 6am as her daily routine and body clock.

Patient D.F’s sleeping pattern is disturbed due to vital signs taking and other medical procedures.

Illness that causes pain or complication can result in sleep problems. People who are ill require more sleep than normal and normal rhythm and wakefulness is often disturbed. (Fundamentals of Nursing by Kozier, 7th Edition)

Patient D.F’s sleep and rest pattern was changed when she was admitted to the hospital due to her illness and other contributing factors.

S:”Di ako masyadong nakakatulog dito” O: Patient has good attention span and has dark circles around the eyes. Diagnosis:Disturbed Sleep Pattern due to present condition  

ANATOMY AND PHYSIOLOGY OF THE HEART

3 layers of the heartEpicardiumMyocardiumendocardium

ANATOMY AND PHYSIOLOGY OF THE HEART

ANATOMY AND PHYSIOLOGY OF THE HEART

ANATOMY AND PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEMBLOOD VESSELS

The blood vessels are the part of the circulatory system that transports blood throughout the body.

There are three major types of blood vessels: the arteries, which carry the blood away from the heart; the capillaries, which enable the actual exchange of water and chemicals between the blood and the tissues; and the veins, which carry blood from the capillaries back toward the heart.

ANATOMY AND PHYSIOLOGY OF THE CARDIOVASCULAR SYSTEM

ANATOMY AND PHYSIOLOGY OF THE KIDNEY

KIDNEYThe kidneys are part of the urinary system. There are 2 kidneys found in the body. The right kidney is usually lower than the left kidney.

Functions of the Kidney

1)Execatory function :MetabolitesDrugsToxins

2)Homeostatic function :Water balance maintenanceElectrolyte balance maintenanceAcid-base balance maintenance

3)Endocrine (hormonal) secretory function :

Renin by the juxtaglomerular cells Erythropoietin hormone by endothelial cells of peritubular capillaries of renal cortex.Prostaglandins

4)Endocrine (hormonal) metabolic function :

The kidney converts Vitamin D3 active 1,25-dihydroxycholecalciferol by alpha one hydroxylase enzyme in cells of PCT under effect of PTH.

ANATOMY AND PHYSIOLOGY OF THE KIDNEY

Hormones produced by kidney:

- renin- erythropoetin - vitamin D3- aldosterone- ADH

ANATOMY AND PHYSIOLOGY OF THE KIDNEY

REGULATION OF SALT/WATER BALANCEBLOOD LOSS ↓ARTERIAL

PRESSURE↓GFR

↑RENIN RELEASE

↑ANGIOTENSIN

↑ALDOSTERONE

↑THIRST

↑ SALT RETENTION

↑ WATER INTAKE

↑ WATER RETENTION

↑ ADH

PATHOPHYSIOLOGY

Modifiable Diet Lifestyle Occupation Number of pregnancies Socio-economic status

Non Modifiable Age History of diabetes

mellitus

Vasospasm

Vascular effects

Vasoconstriction

Poor Organ Perfusion

Increased blood pressure

Signs & symptoms BP: 170/90

PR : 99RR : 24

Temp : 37.0Increased cardiac

outputBlurring of vision

RBC : 5.0Partial

prothrombine time control :

24.4 secs

Kidney effectsDecreased glomeruli

filtration rate and increased

permeability of glomeruli

membranes.Increased serum

blood urea nitrogen, uric acid

and creatinine.

Decreased urine output and protenuria.Signs & symptoms

Lab result: +2 protein on urine24 hours total

protein : 0.36g/LUrine color :

Amber

Interstitial effectsDiffusion of fluid

from blood stream into

interstitial tissue.

Edema

Signs & symptoms

Edema +2 pittingNuetrophils : 85%Lymphocytes :15

%

Prioritized NURSING DIAGNOSIS

Imbalanced nutrition : more than body requirements related to excessive intake in relationship to metabolic need.Ineffective tissue perfusion related to vasoconstriction of blood vesselsDisturbed visual perception related to altered sensory transmission

Medications

Name of Drug CefuroximeSodium (Zinacef)

Dosage 500mg/tab1 tablet x 7 days – BID

Classification Therepeutic class: Antibiotic Pharmacologic class: Second generation cephalosporin

Indication Gynecologic infections.

Contradiction Hypersensitivity to cephalosporins

Side&Adverse EffectsSide Effects:CNS:SeizuresGI:Diarrhea,cramps,nausea,vomiting.Skin:Rashes Adverse Effects:Uncomplicated UTI, skin infections, uncomplicated pneumonia.

Nursing ResponsibilityTell patient to take drug as prescribed, even after he feels better. If patient has difficulty in swallowing tablets, show him how to dissolve or crush tablets,.

MedicationsName of Drug Ketorolac tromethamine (Toradol)

Dosage 30mg IV x 3 more doses- Q6

Classification Therapeutic class: Nonsteroidal anti-inflammatory agents.

Indication Short term management of pain.

Contradiction May increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke especially with prolonged used.

Side&AdverseEffectsSide Effects:CNS: Drowsiness, abnormal thinking, headache, dizziness.Resp: Dyspnea, asthmaCV: edema pallor Adverse Effect: Increase adverse effect with aspirin , potassium supplements, corticosteroids or alcohol. May decrease effectiveness of diuretics or antihypertensives.

Nursing ResponsibilityInstruct patient to take medication exactly as directed. Take missed doses as soon as remembered if not almost time for next dose. Advise patient to consult health care professional if rashes, itching, visual disturbances.

MedicationsName of drug Tramadol Hydrochloride (Ultram)

Dosage 50mg IV x 3 more doses- Q6

Classification Therapeutic: Analgesics

Indication Moderate to moderately severe pain.

Contradiction Not recommended for use during pregnancy or lactation.

Side&Adverse EffectSide Effect: CNS: dizziness, headache, somnolence, anxiety, confusion.CV: VasodilationGI: Constipation, nausea.Skin: Sweating. Adverse Effect: Blurred Vision, itching, Muscle pain.

Nursing responsibilityEncourage patient to turn, cough, and breathe deeply every 2 hrs. to prevent atelectasis. Instruct patient on how and when to ask for pain medication. May cause dizziness and drowsiness. Caution patient to avoid driving or other activities requiring alertness until response to medication is known. 

MedicationsName of drug Celecoxib (Celebrex)

Dosage 200mg/cap1 cap x 7 days- BID

Classification Therapeutic: Antirheumatic, non steroidal and anti inflammatory agents.Pharmacologic: COX-2 inhibitors

Indication Relief sign and symptoms of different arthritis. Management of acute pain including primary dysmenorrhea.

Contraindication Pre-existing renal disease, heart failure, liver dysfunction, concurrent diuretic or ACE inhibitor therapy (increased rate of renal failure).Should not be used in late pregnancy( may cause premature close of ductus arteriosus.

Side& Adverse EffectsSide Effect: CNS: dizziness, headache, insomniaCV: edemaGI: GI bleeding, abdominal pain, diarrhea, dyspepsia, flatulence, nausea.Skin: rash, expoliative dermatitis.

Nursing Responsibility Instruct the patient to take the medicine exactly as directed. Don’t take more than prescribed. Advise the patient to notify the health care professional promptly if signs and symptoms of GI toxicity(abdominal pain, black stools), skin rash,unexplained weight gain or edema occurs.    

MedicationsName of Drug Metropolol (Lopresor)

Dosage  50mg/ tab- BID

Classification  Therapeutic: Antianginals, antihypertensivenesPharmacologic: Beta blockers

Indication  Hypertension. Angina pectoris.

Contraindication  Uncompensated CHF: Pulmonary Edema: Cardiogenic shock: Bradycardia or heart block

Side& AdverseEffectSide Effect:CNS: fatigue, weakness, anxiety, dizziness, drowsiness.EENT: blurred vision, stuffy nose.Res: bronchospamsm, wheezingCV: Bradycardia, hypotension, pulmonary edema.GI: Constipation, diarrhea, dry mouth, flatulence Adverse Effect:Erectile dysfunction, decreased libido, urinary frequency.

Nursing Responsibility Teach the patient and the family how to check the pulse daily and blood pressure biweekly and to report significant changes to health care professional. Advise patient to change position slowly to minimize orthostatic hypotension. Instruct the patient to take the medicine as directed.

Medications

Name of drug Nifedipine (procardia XL)              

Dosage  30mg/ tab 1 tab- OD

Classification  Therapeutic: Antihypertensive and antianginalis.Pharmacologic: Calcium channel blocker.

Indication  Management of hypertension

Contraindication  Blood pressure <90 mm Hg: coadministration of grapefruit juice. Sick sinus syndrome: 2nd or 3rd degree AV block.

Side& Adverse Effect Side Effect:CNS: headache,abnormal dreams, anxiety, confusion, dizziness, drowsiness.EENT: blurred vision, disturbed equilibriumResp: Cough, dyspneaCV: Peripheral edema.GI: Abnormal liver function studies, constipation, diarrhea. Adverse Effect: Gynecomastia, anemia, thrombocytopenia, weight gain, muscle cramps.

Nursing responsibliity Advise patient to take medication exactly as directed. Instruct patient on how to monitor pulse. Instruct patient to seek for professional health care provider if heart rate is <50bpm. Instruct patient to avoid concurrent use of alcohol medications and natural herbal products. 

MedicationsName of drug MethyldopateHydrochloride (Aldomet)

Dosage 750mg /tab 1 tab-Q6

Classification Therapeutic: Antihypertensive Pharmacologic: Centrally Acting Antiadrenergic

Indication Management of moderate to severe hypertension.

Contraindication Active liver disease: Oral suspension contains alcohol bisulfates and should be avoided in patient with known tolerance.

Side & Adverse EffectSide Effect:CNS: sedation, decreased mental acuity, depression.EENT: Nasal stuffinessCV: MyocarditisGU: Erecticle dysfunction. Adverse Effect:fever

Nursing responsibilityEmphasize the importance of continuing the drug even if feeling well. Encourage patient to comply with additional interventions for hypertension such as weight reduction, low sodium diet, smoking cessation.

MedicationsName of Drug  Magnesium Sulfate (Sulfamag)     

Dosage  10gms

Classification  Therapeutic: mineral and electrolyte replacements/supplementsPharmacologic: minerals/ electrolytes

Indication  Treatment/prevention of hypomagnesemia. Treatment of hypertension.

Contraindication  Hypocalcemia: Anuria: Heart block.

Side & Adverse Effect  Side Effect:CNS: drowsinessResp: decreased respiratory rateCV: bradycardia, hypotension.GI: Diarrhea Adverse Effect:Hypothermia, muscle weakness.

Nursing responsibilty Explain purpose of medication to family of the client.

LABS AND DIAGNOSTICSComplete

Blood Count Reference 11/7/13

Hemoglobin 120-140 g/L 156

Hematocrit 37-47 & 44

RBC 4.0-4.5 x 1012/L 5.0

MCHC 32-37% 35

MCH 27.5-33.2pg 31.0

MCV 80-94 fL 88

RDWa 11-15% 14.3

WBC 5-10 x 109/L 14.1

Neutrophils 40-75% 85

Stabs 3-5%  

Lymphocytes 20-45% 15

Monocytes 2-6%  

Eosinophiles 1-4%  

Basophils 0-1%  

Platelets 150-440 x 109/L 261RBC pathology Normochromic, normocyctic Normochronic, normocytic

LABS AND DIAGNOSTICSPanels Normal Range 11/7/13 11/8/13 11/11/13

Prothrombine time 10-13 sec 9.5 sec     Control   12.0 sec     INR   0.79     % activity   142.6    Partial prothrombine time control 29-34 sec 24.4 sec    

Createnine 44-106 umol/L   62 umol/L  

Urea nitrogen substance 3.2-6.8 mmol/L   3.4 mmol/L  

Uric acid substance 178-440 umol/L   439 umok/L  SGOT 10-30 lu/L   28 lu/L  SGPT 6-37 Iu/L   15 lu/L  Sodium 135-155 mmol/L   139 mmol/L  Potassium 3.5-5.3 mmol/L   3.9 mmol/L  Chloride 103-116 mmol/L   108 mmol/L  

Magnesium 0.65-1.05 mmol/L   0.86 mmol/L  

Calcium 2.1-2.5 mmol/L   2.2 mmol/L  LDH-L 109-193 lu/L   196 lu/L  Glycosylated hemoglobin       5.5%

LABS AND DIAGNOSTICSSpecial Urinalysis

  11/9/13

24 hours total urine 0.36 g/L

Total volume 5100 cc

LABS AND DIAGNOSTICSSpecial Urinalysis

Urinalysis Normal 11/7/13

Color Vary degrees of yellow Amber

Turbidity Clear Turbid

Reaction Variable (usually acidic) Acidic

Specific gravityVariable but 1.023 and above-usually no significant kidney

damage1.030

Protein Negative 2+

Sugar Negative Negative

RBC 0-1/hpf Abundant

WBC 0-5/hpf 5-7/hpf

Cast   None

Bacteria   Rare

Epithelial cells   Few

Mucus threads   None

crystals   None

NURSING CARE PLAN ASSESSMENT

NURSING DIAGNOSIS

PLANNING INTERVENTION RATIONALE EVALUATION

Subjective:“Mas mahilig talaga ako kumain ng karne kaysa sa mga gulay, atsaka maya’t-maya ako kumakain.” As verbalized by the patient Objective:-V/S taken as follows:BP:170/90mmHgPR:99bpmRR: 24bpm Height: 5’3Weight: 71.5kgBMI: 28.0 

Imbalanced nutrition: more than body requirements r/t excessive intake in relationship to metabolic need.

Short Term Goal:-After 4 hours of nursing intervention the client will be able to participate in treatment regimen. Long Term Goal:-After 2 days of nursing intervention the client’s blood pressure will be stabilized and return to its normal range. 

Independent:-Monitor vital signs, particularly blood pressure every 2 hours. -Discuss necessity for decreased caloric intake and limited intake of fats, salt, and sugar as indicated.  -Review usual daily caloric intake and dietary choices. Dependent:-Administer antihypertensive medication as ordered. Collaborative:-Collaborate with nutritionist for appropriate diet program.

 -To identify physical responses associated with medical conditions.-Excessive salt intake expands the intravascular fluid volume and may damage kidneys, which can further aggravate hypertension.-Identifies current strengths/ weaknesses in dietary program. -Antihypertensive help decrease and control blood pressure.  -Helps in avoiding increase of blood pressure through diet.

Goal partially met.

-Patient positively responded to actions and interventions performed.

 

ASSESSMENTNURSING

DIAGNOSISPLANNING INTERVENTION RATIONALE EVALUATION

SUBJECTIVE :“Ako’y nahihilo, nung naramdaman ko na akoy namamanas na agad akong komunsulta sa doctor” as verbalized by the client OBJECTIVE: Edema noted on

lower extremities

(grade 2)  Cold, clammy

skin noted.  capillary refill

within 6 seconds 

BP 170/90

Ineffective tissue perfusion related to vasoconstriction of blood vessels

After 4 hours of nursing intervention, client will be able to manifest increased tissue perfusion as evidenced by: • Bloodpressure within 130/90• Warm and dry skin• Capillaryrefill within normal range(3- 5 seconds)• edema value of +1 or absence of edema

DEPENDENT :•Close monitoring of vital signs particularly blood pressure every 2 hours. • Perform assistive passive range of motion. • Provide quiet and restful environment. COLLABORATIVE :• Administer antihypertensive drugs as ordered. • Administer Magnesium sulfate as ordered.

To identify physical responses associated with medical conditions.  ROM promotes improved blood circulation. It conserves energy/lowers tissue oxygen demand. Antihypertensives help decrease and control blood pressure. Magnesium sulfate prevents or controls seizures in preeclampsia brought about by vasospasm secondary to vasoconstriction of blood vessels.

 GOAL PARTIALLY MET •Blood pressure is slightly above normal range: 130/90 •Skin is warm to touch. •Capillary refill within 4 seconds. •Edema is still present (from grade2 to grade 1)

ASSESSMENT NURSING DIAGNOSIS

PLANNING NURSING INTERVENTION

RATIONALE

EVALUATION

Subjective:“Medyo nanlalabo ang mga mata ko”as verbalized by the patient.  Objective: Blurred

vision:OS-2.75; OD-1.75, near sighted.

Sclerosis  

-V/S BP:170/90 

Disturbed sensory perception related to altered sensory transmission.

After 4 hours of nursing intervention client will: Short term Goal: Patient will be

safe and secured throughout the shift. 

will feel relaxed and comfortable during the shift.  

Long term Goal: patient will

regain visual acuity 

Dependent : -promote a stable environment with continuity of care by same personnel as much as possible. -Provide safety and security by raising the bed side rails.   Independent :- Remind the patient to use with the goal of cataract glasses magnify approximately 25%, peripheral vision and blind spot may exist. - Determine visual acuity, note whether one or both eyes are involved Collaborative :-referral to ophthalmologist

  -so that the patient can remember or recognized the care personnel.   -to prevent further accident of the patient.    -changes in acuity and depth perception can lead to confused vision / boost the risk of injury to the patient learns to compensate.

The patient positively responded to interventions and actions performed.