Disturbed Sensory Perception

Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli

accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
Nursing Diagnosis

Disturbed Sensory Perception

May be related to

Altered sensory reception, transmission, integration (neurological trauma or

deficit)

Psychological 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

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.

Nursing Interventions
Review pathology of individual condition.

Rationale
Awareness on the type and areas of
involvement aid in assessing specific deficit
and planning of care.

Nursing Interventions

Rationale

Observe behavioral responses: crying,

inappropriate affect, agitation, hostility,
agitation, hallucination.

Individual responses are variable, but

commonalities such as emotional lability,
lowered frustration threshold, apathy, and
impulsiveness may complicate care.

Establish and maintain communication with

the patient. Set up a simple method of
communicating basic needs. Remember to
phrase your questions so hell be able to
answer using this system. Repeat yourself
quietly and calmly and use gestures when
necessary to help in understanding.

Note: even an unresponsive patient may be

able to hear, so dont say anything in his
presence you wouldnt want him to hear and
remember.

Eliminate extraneous noise and stimuli as

necessary.
Speak in calm, comforting, quiet voice, using
short sentences. Maintain eye contact.
Ascertain patients perceptions. Reorient
patient frequently to environment, staff,
procedures.
Evaluate for visual deficits. Note loss of visual
field, changes in depth perception (horizontal
and/or vertical planes), presence of diplopia
(double vision).
Approach patient from visually intact side.
Leave light on; position objects to take
advantage of intact visual fields. Patch affected
eye if indicated.

Assess sensory awareness: dull from sharp, hot

from cold, position of body parts, joint sense.

Stimulate sense of touch. Give patient objects

to touch, and hold. Have patient practice
touching walls boundaries.
Protect from temperature extremes; assess
environment for hazards. Recommend testing
warm water with unaffected hand.

Reduces anxiety and exaggerated emotional

responses and confusion associated with
sensory overload.
Patient may have limited attention span or
problems with comprehension. These measures
can help patient attend to communication.
Assists patient to identify inconsistencies in
reception and integration of stimuli and may
reduce perceptual distortion of reality.
Presence of visual disorders can negatively
affect patients ability to perceive environment
and relearn motor skills and increases risk of
accident and injury.
Helps the patient to recognize the presence of
persons or objects and may help with depth
perception problems. This also prevents patient
from being startled. Patching the eye may
decrease sensory confusion of double vision.
Diminished sensory awareness and impairment
of kinesthetic sense negatively affects
balance and positioning and appropriateness of
movement, which interferes with ambulation,
increasing risk of trauma.
Aids in retraining sensory pathways to
integrate reception and interpretation of
stimuli. Helps patient orient self spatially and
strengthens use of affected side.
Promotes patient safety, reducing risk of injury.

Nursing Interventions

Rationale

Note inattention to body parts, segments of

environment, lack of recognition of familiar
objects/persons.

Agnosia, the loss of comprehension of

auditory, visual, or other sensations, may lead
result to unilateral neglect, inability to
recognize environmental cues, considerable
self-care deficits, and disorientation or bizarre
behavior.

Encourage patient to watch feet when

appropriate and consciously position body
parts. Make patient aware of all neglected body
parts: sensory stimulation to affected side,
exercises that bring affected side across
midline, reminding person to dress/care for
affected (blind) side.

Use of visual and tactile stimuli assists in

reintegration of affected side and allows
patient to experience forgotten sensations of
normal movement patterns.