996 UNIT IX / Promoting Psychosocial Health

EvaluatingUsing the measurable desired outcomes developed during theplanning stage as a guide, the nurse collects data needed tojudge whether client goals and outcomes have been achieved.

Examples of client outcomes and related indicators are shownin the earlier Identifying Nursing Diagnoses, Outcomes, and In-terventions and in the Nursing Care Plan. If outcomes are notachieved, the nurse and client, and support people if appropri-ate, need to explore the reasons before modifying the care plan.

NURSING CARE PLAN Sensory-Perception Disturbance

ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*

Nursing AssessmentJulia Hagstrom is an 80-year-old widow who has recently be-come a resident of an extended care facility. Just prior to her ad-mission she underwent surgery for the removal of cataracts andalso experienced more difficulty with hearing. Her children wereconcerned about her physical safety and lack of socialization andurged her to enter a nursing home. Mrs. Hagstrom had cared forherself independently for 15 years in her own home. Three daysafter admission the nurse finds the client somewhat confusedand disoriented to place, and time. She appears restless andwithdrawn. She states, “I’m afraid of all of these strange crea-tures in this orphanage.”

Disturbed Sensory Perception(Sensory Overload) related tochange in environment, andhearing loss (as evidenced bydisorientation to time andplace; restlessness; and alteredbehavior)

Cognitive Orientation[0901] as evidenced by notcompromised:■ Identifies significant

other(s)■ Identifies current place■ Identifies correct season

Hearing CompensationBehavior [1610] as evidencedby often demonstrated:■ Positions self to advantage

hearing■ Reminds others to use

techniques that advantagehearing

■ Eliminates backgroundnoise

■ Uses hearing supportive devices

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Reality Orientation [4820]

Provide a consistent physical environment and a daily routine.

Provide access to familiar objects, when possible.

Provide a low-stimulation environment for Mrs. Hagstrom becausedisorientation may be increased by overstimulation.

Provide for adequate rest, sleep, and daytime naps.

Use a calm and unhurried approach when interacting with Mrs. Hagstrom.

Speak to the client in a slow, distinct manner with appropriate volume.

Engage Mrs. Hagstrom in concrete “here and now” activities (thatis, ADLs) that focus on something outside the self that is concreteand reality oriented.

Routine eliminates the element of surprise, overstimulation, andfurther confusion.

Familiarity helps reduce confusion.

A disruption in the quality or quantity of incoming stimuli can af-fect a person’s cognitive status. Sensory overload blocks outmeaningful stimuli.

Reduces overstimulation and fatigue, which may be contributingfactors to confusion.

Promotes communication that enhances the person’s sense ofdignity.

The client who has difficulty hearing will be better able to lip readand comprehend speech.

Assists the individual to differentiate between own thoughts andreality..

Physical Examination

Height: 160 cm (5′3′′)Weight: 55.3 kg (122 lb)Temperature: 37°C (98.6°F)Pulse: 72 BPMRespirations: 18/minute Blood Pressure: 128/74 mm HgRinne test: negative

Diagnostic Data

Chest x-ray, CBC, and urinalysisall negative

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NURSING CARE PLAN Sensory-Perception Disturbance continued

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Hearing can be enhanced if the volume is appropriate and thehearing aid is consistently used.

Effective listening is essential in a nurse–client relationship. Poor listening skills can undermine trust and block therapeuticcommunication.

Using simple terms and short sentences facilitates understandingand minimizes anxiety.

Gaining the attention of a client with a hearing impairment is anessential first step toward effective communication. However, theclient’s personal space should be respected and permission totouch should be obtained.

Communication Enhancement: Hearing Deficit [4974]

■ Facilitate use of hearing aids, as appropriate.

■ Listen attentively.

■ Use simple words and short sentences, as appropriate.

■ Obtain Mrs. Hagstrom’s attention through touch.

EVALUATION

Outcomes met. Mrs. Hagstrom identifies her primary nurse by sight and name on the third day. She is aware that Christmas is 3 weeksaway and is anxious to go shopping with the group. Her daughter has brought new batteries for her hearing aid, which she wears during the day.

*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or intervention.Outcomes, interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for eachclient.

CRITICAL THINKING CHECKPOINT

Mrs. Dodd is a 51-year-old client who is being cared for in the criticalcare unit following an automobile accident in which she suffered ex-tensive traumatic injuries. Mrs. Dodd is connected to several monitor-ing devices, has an intubation tube and ventilator to assist her withrespirations, and is receiving various pain and other medications.

1. Identify factors that place Mrs. Dodd at risk for the developmentof sensory deprivation or overload.

2. What assessment findings would alert you to Mrs. Dodd’s expe-riencing sensory overload as opposed to sensory deprivation?

3. How can you intervene to help Mrs. Dodd during this stressful event?4. How might the care of a client in the home setting differ from the

care of a client such as Mrs. Dodd who is receiving care in a crit-ical care unit?

See Critical Thinking Possibilities in Appendix A.

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