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996 UNIT IX / Promoting Psychosocial Health

Evaluating Examples of client outcomes and related indicators are shown

in the earlier Identifying Nursing Diagnoses, Outcomes, and In-
Using the measurable desired outcomes developed during the terventions and in the Nursing Care Plan. If outcomes are not
planning stage as a guide, the nurse collects data needed to achieved, the nurse and client, and support people if appropri-
judge whether client goals and outcomes have been achieved. ate, need to explore the reasons before modifying the care plan.

NURSING CARE PLAN Sensory-Perception Disturbance

ASSESSMENT DATA NURSING DIAGNOSIS DESIRED OUTCOMES*
Nursing Assessment Disturbed Sensory Perception Cognitive Orientation
Julia Hagstrom is an 80-year-old widow who has recently be- (Sensory Overload) related to [0901] as evidenced by not
come a resident of an extended care facility. Just prior to her ad- change in environment, and compromised:
mission she underwent surgery for the removal of cataracts and hearing loss (as evidenced by ■ Identifies significant
also experienced more difficulty with hearing. Her children were disorientation to time and other(s)
concerned about her physical safety and lack of socialization and place; restlessness; and altered ■ Identifies current place
urged her to enter a nursing home. Mrs. Hagstrom had cared for behavior) ■ Identifies correct season
herself independently for 15 years in her own home. Three days
Hearing Compensation
after admission the nurse finds the client somewhat confused
Behavior [1610] as evidenced
and disoriented to place, and time. She appears restless and
by often demonstrated:
withdrawn. She states, “I’m afraid of all of these strange crea-
■ Positions self to advantage
tures in this orphanage.”
hearing
■ Reminds others to use
Physical Examination Diagnostic Data
techniques that advantage
Height: 160 cm (5′3′′) Chest x-ray, CBC, and urinalysis hearing
Weight: 55.3 kg (122 lb) all negative ■ Eliminates background
Temperature: 37°C (98.6°F) noise
Pulse: 72 BPM ■ Uses hearing supportive
Respirations: 18/minute devices
Blood Pressure: 128/74 mm Hg
Rinne test: negative

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Reality Orientation [4820]

Provide a consistent physical environment and a daily routine. Routine eliminates the element of surprise, overstimulation, and
further confusion.

Provide access to familiar objects, when possible. Familiarity helps reduce confusion.

Provide a low-stimulation environment for Mrs. Hagstrom because A disruption in the quality or quantity of incoming stimuli can af-
disorientation may be increased by overstimulation. fect a person’s cognitive status. Sensory overload blocks out
meaningful stimuli.

Provide for adequate rest, sleep, and daytime naps. Reduces overstimulation and fatigue, which may be contributing
factors to confusion.

Use a calm and unhurried approach when interacting with Promotes communication that enhances the person’s sense of
Mrs. Hagstrom. dignity.

Speak to the client in a slow, distinct manner with appropriate The client who has difficulty hearing will be better able to lip read
volume. and comprehend speech.

Engage Mrs. Hagstrom in concrete “here and now” activities (that Assists the individual to differentiate between own thoughts and
is, ADLs) that focus on something outside the self that is concrete reality.
and reality oriented. .
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NURSING CARE PLAN Sensory-Perception Disturbance continued

NURSING INTERVENTIONS*/SELECTED ACTIVITIES RATIONALE

Communication Enhancement: Hearing Deficit [4974]

■ Facilitate use of hearing aids, as appropriate. Hearing can be enhanced if the volume is appropriate and the
hearing aid is consistently used.
■ Listen attentively. Effective listening is essential in a nurse–client relationship.
Poor listening skills can undermine trust and block therapeutic
communication.

■ Use simple words and short sentences, as appropriate. Using simple terms and short sentences facilitates understanding
and minimizes anxiety.

■ Obtain Mrs. Hagstrom’s attention through touch. Gaining the attention of a client with a hearing impairment is an
essential first step toward effective communication. However, the
client’s personal space should be respected and permission to
touch should be obtained.

EVALUATION
Outcomes met. Mrs. Hagstrom identifies her primary nurse by sight and name on the third day. She is aware that Christmas is 3 weeks
away 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 each
client.

CRITICAL THINKING CHECKPOINT

Mrs. Dodd is a 51-year-old client who is being cared for in the critical
care 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 with
respirations, and is receiving various pain and other medications.
1. Identify factors that place Mrs. Dodd at risk for the development
of 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.