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A Case Study Edwin Quilab Fabro Sr.


Cataract Mature, OD
Submitted to:

Ms. Vivasceni L.C. Magtajas, RN

Clinical Instructor

As Partial Requirement for NCM501202

Submitted by:

Ramyr R. Ociones Charmaine Marie France G. Samonte

January 26, 2008 I. Introduction a. b. c. Overview of the Case Objective of the Study Scope and Limitation of the Study

II. Health History a. b. c. Profile of Patient Family and Personal Health History Chief Complain III. Developmental Data IV. Medical Management a. b. Medical Orders and Rationale Drug Study V. Pathophysiology with Anatomy & Physiology VI. Nursing Assessment (System Review & Nursing. Assessment II) VII. Nursing Management a. b. Ideal Nursing Management (NCP) Actual Nursing Management (SOAPIE) VIII. Health teachings IX. Prognosis X. Evaluation XI. References

Overview of the Case

A cataract is a lens opacity or cloudiness that develops in the crystalline lens of the eye or in its envelope. Cataract is painless and unaccompanied by inflammation. Cataracts rank only behind arthritis and heat disease as a leading cause of disability in older adults. Early on in the development of age-related cataract the power of the crystalline lens may be increased, causing nearsightedness (myopia) and the gradual yellowing and opacification of the lens may reduce the perception of blue colors. Cataracts typically progress slowly to cause vision loss and are potentially blinding if untreated. Moreover, with time the cataract cortex liquefies to form a milky white fluid in a Morgagnian Cataract, and can cause severe inflammation if the lens capsule ruptures and leaks. Untreated, the cataract can cause phacomorphic glaucoma. Very advanced cataracts with weak zonules are liable to dislocation anteriorly or posteriorly. Such spontaneous posterior dislocations (akin to the historical surgical procedure of couching) in ancient times were regarded as a blessing from the heavens, because it restored some perception of light in the bilaterally affected patients.

Cataract derives from the Latin cataracta meaning "waterfall" and the Greek kataraktes and katarrhaktes, from katarassein meaning "to dash down" (kata-, "down"; arassein, "to strike, dash"). As rapidly running water turns white, the term may later have been used metaphorically to describe the similar appearance of mature ocular opacities. In Latin, cataracta had the alternate meaning, "portcullis", so it is also possible that the name came about through the sense of "obstruction".

b. Objective of the Study The objective of this study is to find a case relating to our concept surgery. Rule-out blurred vision and later on diagnosed as positive for cataract mature was the condition of my patient Edwin Quilab Fabro Sr.. As a nursing student, I have to do interventions for my patient and to provide care which is relevant to her condition. Considering that my patient needs systematic care to restore her normal vision that is lost from her condition. And one goal is that to provide a good patient outcome and prevent conflicts to restore my patients normal state. In the case of our patient who is suffering from cataract mature the etiology is to determine, it is said that unlike other eye disorders, cataract is the most leading cause of blindness especially among the older adults. It is caused blindness by obstructing passage of light, but the patient can distinguish light from darkness. As an NCM501202 students, this care study helps us not just to pass this said requirement but also to evaluate our efficacy upon rendering our services in the optimum capacity or the ability to care to a patient suffering this kind of illness. These studies also provide information on actual handling, caring and an overview of the patients vision status with cataract mature.

c. Scope and Limitation of the Study Our concept is about Surgery. At Tagoloan Polymedic General Hospital, Misamis Oriental, we have to find a case which is relevant to the concept. At the Surgical Ward where we are assigned, there are cases of cataracts and one of them is our patient Edwin Quilab Fabro Sr. For two days, from January 9-10, 2008, our duty time is limited from 8-4pm. On the first day I have assessed my patient and up to the last day of confinement of my patient and did some interventions like providing preoperative and postoperative care of the patient and teaching patients self-care to return her normal vision. Questions were being answered by the patient himself. The actual nursing interventions were all carried out with the supervision of a clinical instructor and limited to those which were permitted or allowed by agency protocol. This study was completed altogether by both research using different references and actual hands-on exposure and interaction with the patient.

a. Profile of Patient Patients Name: Birth Date: Birthplace: Age: Sex: Height: Weight: Status: Religion: Nationality: Address: Allergy: Date of Admission: Time of Admission: Chief Complaints: Admitting Diagnosis: Vital Signs: Temperature: Pulse Rate: Respiratory Rate: BP: 36.5 C 80 bpm 20 cpm 150/100 mmHg Edwin Quilab Fabro Sr. August 10, 1956 Butuan City 51 years old Male 57 150 lbs Married Roman Catholic Filipino Barangcot Dangcagan, Butuan City None January 9, 2008 10 AM Blurred Vision Cataract Mature, OD

b. Family and personal health history Mr. Edwin Quilab Fabro Sr., 51 years old, a Carpenter is the wife of Mrs. Flora Fabro. Presently residing at Barangcot Dangcagan, Butuan City and belong to a middle class family. Mr. Fabro had a family health history of Hypertension and Diabetes. Most previous illnesses were fever, cough and flu and uses over the counter medication such as Paracetamol Biogesic, Neozep, Dimetapp, Cotrimoxazole, Mefenamic acid. They also used Herbal medicine as there alternatives when over the counter is not available. c. History of Illnesses Our patient was Edwin Quilab Fabro Sr., he was admitted last January 9, 2008 and his condition started a day prior to admission as onset of vision & blurring. d. Chief Complaints A case of our patient, Edwin Quilab Fabro Sr., was due to blurred vision.

Developmental Task
ROGER GOULDS ADULTHOOD THEORY Adult continues to change over the period of time considered to adulthood and developmental phase maybe found during the adults span of life. Personalities are seen as set. Time is accepted as


finite. Individuals are interested in social activities with friends and This is the period of transformation with realization of

mortality and concern for health.

ERIK ERIKSONS STAGES OF DEVELOPMENT Integrity vs. Despair Acceptance of worth and uniqueness Acceptance of death

DOCTORS ORDER January 9, 2008 > Pls. admit under Dr. Romero - To provide appropriate treatment for the patient. > Consent to care and for cataract extension - To let the patient know what procedure maybe than for the treatment of his illness. The patient has the right to refuse the treatment. > Monitor vital signs every 4 hours > Meds: Captopril 25 mg 1 tab P.O BID > Will inform AP - To lower down blood pressure. - To know if the patient is capable to undergo surgery. >Refer accordingly - To check any alterations of the patients health status thus provide appropriate treatment. > IVF PNSS 1L @ KVO rate - To provide a route for the drug to be administered. - To provide a baseline data for the patients health status. RATIONALE

Dosage Name of drug Date Order ed Classificatio n / Freque ncy Route Capto pril (Capot in) Janua ry 9, 2008 Ace Inhibitor, Antihyperten sive 25 mg 1 Blocks ACE tab P.O BID from converting to angiotensin vasoconstric tor, leading to decreased BP, decreased aldosterone secretion, a small increase in serum potassium levels, and sodium and fluid loss; increased prostaglandi n synthesis also may be involved in the antihyperten sive action. 10 Treatmen t of Contraindicat with allergy to captopril, history of angioedema, second or third trimester of pregnancy. - Use cautiously in patients with impaired renal function; CHF; salt or volume depletion, lactation. CV: tachycardia, angina pectoris, MI, CHF, salt or volumedepleted patients. Dermatologic: rash, scalded mouth sensation, pemphigoidlike reaction, exfoliative dermatitis, alopecia. GI: gastric irritation, aphthous ulcers, peptic ulcers, dysgeusia anorexia, constipation. GU: proteinuria, renal insufficiency, renal failure, - Take drug 1 hour before meals; do with food. Do not stop taking drug without consulting your health provider. - Be careful of drop in blood pressure (occurs most often with diarrhea, sweating, vomiting, or dehydrati on); if lightheadedne Mechanism of Action Specific Indication Contraindicat ions Side Effects/Toxic Effects Nursing Precautio n

hypertens ed in patients or in combinati thiazidetype diuretics

angiotensin I ion alone

hypotension in not take

II, a powerful on with

Structure of the Eye The amount of light entering the eye (right) is controlled by the pupil, which dilates and contracts accordingly. The cornea and lens, whose shape is adjusted by the ciliary body, focus the light on the retina, where receptors convert it into nerve signals that pass to the brain. A mesh of blood vessels, the choroid, supplies the retina with oxygen and sugar. Lacrimal glands (left) secrete tears that wash foreign bodies out of the eye and keep the cornea from drying out. Blinking compresses and releases the lacrimal sac, creating a suction that pulls excess moisture from the eyes surface. .


Eye Movement Eye movement is controlled by six muscles that are directly attached to the eyeball. The four rectus muscles form a relatively straight line from their points of origin, while the two oblique muscles approach the surface of the eye at an angle. All the muscles combine to keep the eyeball in nearly constant motion in order to maximize human vision, which is capable of focusing on about 100,000 distinct points in the visual field. These muscles also enable both eyes to focus on the same point simultaneously, thereby creating effective depth perception.


Anatomy & Physiology

The entire eye, often called the eyeball, is a spherical structure approximately 2.5 cm (about 1 in) in diameter with a pronounced bulge on its forward surface. The outer part of the eye is composed of three layers of tissue. The outside layer is the sclera, a protective coating. It covers about five-sixths of the surface of the eye. At the front of the eyeball, it is continuous with the bulging, transparent cornea. The middle layer of the coating of the eye is the choroid, a vascular layer lining the posterior three-fifths of the eyeball. The choroid is continuous with the ciliary body and with the iris, which lies at the front of the eye. The innermost layer is the light-sensitive retina. The cornea is a tough, five-layered membrane through which light is admitted to the interior of the eye. Behind the cornea is a chamber filled with clear, watery fluid, the aqueous humor, which separates the cornea from the crystalline lens. The lens itself is a flattened sphere constructed of a large number of transparent fibers arranged in layers. It is connected by ligaments to a ringlike muscle, called the ciliary muscle, which surrounds it. The ciliary muscle and its surrounding tissues form the ciliary body. This muscle, by flattening the lens or making it more nearly spherical, changes its focal length. The pigmented iris hangs behind the cornea in front of the lens, and has a circular opening in its center. The size of its opening, the pupil, is controlled by a muscle around its edge. This muscle contracts or relaxes, making the pupil larger or smaller, to control the amount of light admitted to the eye. Behind the lens the main body of the eye is filled with a transparent, jellylike substance, the vitreous humor, enclosed in a thin sac, the hyaloid membrane. The pressure of the vitreous humor keeps the eyeball distended.


The retina is a complex layer, composed largely of nerve cells. The light-sensitive receptor cells lie on the outer surface of the retina in front of a pigmented tissue layer. These cells take the form of rods or cones packed closely together like matches in a box. Directly behind the pupil is a small yellow-pigmented spot, the macula lutea, in the center of which is the fovea centralis, the area of greatest visual acuity of the eye. At the center of the fovea, the sensory layer is composed entirely of cone-shaped cells. Around the fovea both rod-shaped and coneshaped cells are present, with the cone-shaped cells becoming fewer toward the periphery of the sensitive area. At the outer edges are only rod-shaped cells.





Direct destruction Edema


Disorder in move component

Decreased visual search and scanning

Failure to orient



Herniation Failure of inhibitory component of spatial orientation

Metabolic derangement

Orient when should not



Name: Edwin Quilab Fabro Sr. Vital Signs: Pulse: 80 bpm Height: 57 Bp: 150/100 mmHg Weight: 150 lbs. RR: 20 cpm Temp: 36.5 C Date: 01-09-08

EENT [x] impaired vision [x] blind [ ] pain redden [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] burning [ ] edema [ ] lesion [ ] teeth [ ] assess eyes ears nose [ ] throat for abnormality [ ] no problem RESP: [ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [ ] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [ ] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic Assess resp. rate, rhythm, pulse blood breath sounds, comfort [x] no problem CARDIOVASCULAR: [ ] arrhythmia [ ] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate rhythm, pulse, blood pressure, circ., fluid retention, comfort [x] No problem GASTROINTESTINAL TRACT: [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidity [ ] pain assess abdomen, bowel habits, swallowing, bowel sounds, comfort [x] no problem GENITO URINARY AND GYNE [ ] pain [ ] urine [ ] color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nucturia Assess urine frequency, control, color, odor, [ ] gyne bleeding [ ] discharge [x] no problem NEURO: [ ] paralysis [ ] stuporus [ ] unsteady [ ] seizure [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip Assess motor, function, sensation, LOC, grip, gait, coordination, speech [x] no problem MUSCULOSKELETAL and SKIN: [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] rashes [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [ ] poor turgor [ ] cool [ ] flushed [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic Assess mobility, motion gait, alignment, skin color, texture, turgor, integrity [x] no problem

impaired vision & pain at the surgical site


a. Ideal Nursing Management (NCP)

NURSING DIAGNOSIS: Sleep Pattern Disturbances Risk factors may include Internal factors: illness, psychologic stress, inactivity External factors: environmental changes, facility routines Changes in activity pattern Possibly evidenced by Reports of difficulty in falling asleep/not feeling well-rested Interrupted sleep, awakening earlier than desired Change in behavior/performance, increasing irritability DESIRED OUTCOMES/EVALUATION CRITERIA CLIENT WILL: Sleep (NOC) Report improvement in sleep/rest pattern. Verbalize increased sense of well-being and feeling rested.

ACTIONS/INTERVENTIONS Sleep Enhancement (NIC) Independent Provide afghan. Establish new sleep comfortable bedding and Increases






some of own possessions; e.g., pillow, physiologic/psychologic support.

routine When new routine contains as

incorporating old pattern and new many aspects of old habits as environment. Match with roommate possible, stress and related anxiety who has similar sleep patterns and may be reduced, enhancing sleep.


nocturnal needs.

Decreases likelihood that night owl roommate may delay clients falling asleep or create interruptions that cause awakening.

Encourage some light physical Daytime activity can help client activity during the day. Make expend energy and be ready for sure client stops activity several nighttime hours before bedtime individually appropriate. bedtime may sleep; act as however, stimulant, as continuation of activity close to delaying sleep. Promotes Promote bedtime comfort regimens; effect. e.g., warm bath and massage, a glass of warm milk, wine/brandy at bedtime. Helps induce sleep. Instruct in relaxation measures. Provides atmosphere conductive to Reduce noise and light. sleep. Repositioning in turning. May heave fear of falling because of Lower bed and position one side change in size and height of bed. against wall when possible. Collaborative May be given to help client alters areas of a relaxing, soothing

Encourage position of comfort, assist pressure and promotes rest.

Administer sedatives, hypnotics sleep/rest during transition period with caution as indicated. from home to new sitting.


NURSING DIAGNOSIS: Visual Sensory Perception, disturbed May be related to Altered sensory reception, transmission, integration (neurologic trauma) Psychologic stress (narrowed perceptual fields caused by anxiety) Possibly evidenced by Disorientation to time, place, person Change in behavior pattern/usual response to stimuli; exaggerated emotional responses Poor concentration, altered thought processes/bizarre thinking Reported/measured change in sensory acuity: hypoparesthesia; altered sense of taste/smell Inability to tell position of body parts (proprioception) Inability to recognize/attach meaning to objects (visual agnosia) Altered communication patterns Motor incoordination DESIRED OUTCOMES/EVALUATION CRITERIACLIENT WILL: Cognition (NOC) Regain/maintain usual level of consciousness and perceptual functioning. Acknowledge changes in ability and presence of residual involvement. Demonstrate behaviors to compensate for/overcome deficits. ACTIONS/INTERVENTIONS Sleep Enhancement (NIC) Independent Review condition. pathology of individual Awareness involvement planning care. of aids type/area in of RATIONALE


for/anticipating specific deficits and


Observe behavioral responses, e.g., Individual responses are variable, hostility, crying, inappropriate affect, but agitation, hallucination commonalities lability, such as emotional lowered

frustrations threshold, apathy, and impulsiveness may complicate care. Eliminate extraneous noise/stimuli as Reduces anxiety and exaggerated necessary. emotional responses/confusion associated with sensory overload. Speak in calm, quiet voice, using short Client may have limited attention sentences. Maintain eye contact. span can or help problems client attend with to comprehension. These measures communication. Ascertain/validate clients perceptions. Assists Reorient client frequently environment, staff, and procedures. integration reduce reality. Evaluate for visual deficits. Note loss Presence of visual disorders can of visual field, changes in depth negatively affect clients ability to perception (horizontal/vertical planes), perceive environment and relearn and presence of diplopia (double motor skills and increase risk of vision). accident/injury. client of to identify and may or

to inconsistencies in perception and stimuli perceptual distortion

Approach client from visually intact Provides for recognition of the side. Leave light on; position objects presence of persons/objects; may


to take advantage of intact visual help fields. Patch affected eye encourage wearing of prism glasses if being indicated.


depth prevents

perception client from may

or problems;



decrease the sensory confusion of double vision, and prism glasses may enhance vision across midline, decreasing neglect of affected side.

NURSING DIAGNOSIS: Risk for Injury/Trauma Risk factors may include Inability to recognize/identify danger in environment, impaired judgment Disorientation, confusion, agitation, irritability, excitability Weakness, muscular incoordination, balancing difficulties, disturbed perception Seizure activity Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis] DESIRED OUTCOMES/EVALUATION CRITERIA CLIENT WILL: Physical Injury Severity (NOC) Be free of injury

ACTIONS/INTERVENTIONS Sleep Enhancement (NIC) Independent Assess degree of impairment presence in Identifies


potential and




ability/competence impulsive behavior.

of environment alert 22 to

heightens Clients

awareness of risks so caregivers more dangers.

demonstrating impulsive behavior are at increased risk of injury because they are less able to control their own behavior/actions. Assist SO to identify that may any Visual-perceptual deficits increase be

risks/potential hazards and visual- the risk of falls. perceptual present. Eliminate/minimize identified hazards A person with cognitive impairment in the environment. and perceptual disturbances is prone to accidental injury because of the inability to take responsibility for basic safety needs or to evaluate the unforeseen consequences. deficits


Actual Nursing Management (SOAPIE)



Sakit akong isa ka mata tungod sa pag opera as verbalized by the patient. Facial grimace Guarding Restlessness

Risk for injury related to impaired vision Long term: At the end of 1 week, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situation. Short term: At the end of 24 hours, the patient will be able to verbalize understanding of individual factors that contribute to possibility of injury and take steps to correct situation. Provide information regarding disease/condition that may result in increased risk of injury. o To prevent/avoid injury and take preventive actions. Identify interventions/safety devices. o To promote safe physical environment and individual safety.

Demonstrate/encourage use of techniques to reduce/ manage stress and emotions, such as anger, hostility. o These factors can lead to higher risk for injury.

Discuss importance of self-monitoring of conditions/emotions that can contribute to occurrence of injury. o To assist client to reduce or correct individual risk factors.

After rendering nursing intervention, the patient was able to understand E individual factors that contributed to possibility of injury and took steps to correct situation.


Sagabal kau akong isa ka mata, dili kau ko ka tarong og tan-aw as verbalized by the patient. Facial grimace Guarding Restlessness

Impaired physical mobility r/t sensory-perceptual impairment Long term: At the end of 1 week, the patient will be able to verbalize understanding of situation or risk factors and individual treatment regimen and safety measures. Short term: At the end of 24 hours, the patient will be able to verbalize understanding of situation or risk factors and individual treatment regimen and safety measures. Provide for safety measures as indicated by individual situation, environmental segment, and full prevention. o To reduce risk for injury. Encourage adequate intake of fluids/nutritious foods. o Promotes well being and maximizes energy production.

Instruct patient/significant others to provide a safer environment. (e.g., rearrange furniture, removal of sharp objects). o To produce a safer environment.

Encourage patient to verbalize feelings/emotions regarding the problem. o Feeling of frustrations and anxiety may impede attainment of goals.

After rendering nursing intervention, the patient was able to understand the E risk factors and individual treatment regimen and safety measures as evidenced by nodding as a sign of understanding and clarifications.



> Patient was advised to take Captopril when his blood pressure increases. > Do not give patient more than 5 doses of antihypertensive drugs in 24 hours unless prescribed by physician.


> Take some rest to prevent stress and other complications. > Patient was advised to keep activity light (e.g walking, reading, watching television). Resume the following activities only as directed by the physician: driving, sexual activity, unusually strenuous activity.


> Patient was advised to continue for compliance of medication regimen as prescribed by his physician. > Patient instructed to wear sunglasses during the day because the eye is sensitive to light.

OUT-PATIENT (Check-up)

> Patient instructed to have a return checkup with her attending physician. > Patient instructed to call her physician immediately unusualities. if he experiences any


> Encourage the patient to eat rich in high protein such as meat, fish, and eggs for early wound healing



To allow continuous monitoring of the patients healing progress, patient was encouraged to consult her doctor 2 weeks after discharge for follow-up check up of her general condition. This will ensure thorough follow up of her condition and prevention of potential complications. Apart from this, patient was advised to wear eyeglasses during the day and a metal shield worn at night for 1 to 4 weeks, thus, this is to prevent accidental rubbing or poking of the eye, and make sure that proper hand washing is always priorities before touching or cleaning the postoperative eye.



Patients with cataract usually progress especially when it is not yet to its mere complication. The rate of progression depends on the underlying diagnosis, on the successful implementation of secondary preventative measures, and on the individual patient. If the patient is untreated the prognosis becomes worst and poor. In the case of our patient, as he undergone tough Petrobulbar Blocked method of surgery at Polymedic General Hospital, his prognosis is considered as good. As evidenced by tolerating slowly vision gradually improves as the eye heals.



At the end of my hospital duty, we as a student nurse were able to render care to my patient to help him resolve his problem regarding health. Through observing the patients status, we were able to identify some problems during our assessment. Because of a couple of interventions or health teachings applied and imparted to the patient, we were able to render his needs on his problem; alleviated pains felt by the patient due to the effects of the eye surgery and even have improved his sleeping/resting pattern. Patient was willing to pursue his medical therapy just to promote health and wellness for the betterment of his condition. During the treatment, the patient was able to developed or enhanced health awareness on his disease and with this knowledge instilled to his mind, he was then aware on how the disease was occur and what are the proper ways or interventions done just to minimize or prevent this disease from getting worst. We have also made the patient realized the importance of completing the course of therapy by taking the medicines prescribed or ordered to him by his physician. In addition, eating healthy or nutritious foods that were prescribed to him by the health providers was further been explained to him especially the benefits he will gain in eating these nutritious foods. In general, the patient was very cooperative to what health measures administered to him by the health providers. Moreover, these several interventions given to the patient made his body functions different than as before.



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