Aplikasi Merah Putih

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Nursing Diagnosis: Disturbed Sensory perception (specify: visual, auditory, kinesthetic, gustatory, tactile, olfactory) Application of NANDA, NOC, NIC


Betty J. Ackley

NANDA Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Defining Characteristics: Poor concentration; auditory distortions; change in usual response to stimuli; restlessness; reported or measured change in sensory acuity; irritability; disoriented in time, in place, or with people; change in problem-solving abilities; change in behavior pattern; altered communication patterns; hallucinations; visual distortions

Related Factors: Altered sensory perception; excessive environmental stimuli; psychological stress; altered sensory reception, transmission, and/or integration/insufficient environmental stimuli; biochemical imbalances for sensory distortion (e.g., illusions, hallucinations); electrolyte imbalance; biochemical imbalance

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
Visual
·         Body Image
·         Cognitive Orientation
·         Sensory Function: Vision
·         Vision Compensation Behavior
Auditory
·         Cognitive Orientation
·         Communication: Receptive Ability
·         Distorted Thought Control
·         Hearing Compensation Behavior

Client Outcomes

·         Demonstrates understanding by a verbal, written, or signed response
·         Demonstrates relaxed body movements and facial expressions
·         Explains plan to modify lifestyle to accommodate visual or hearing impairment
·         Remains free of physical harm resulting from decreased balance or a loss of vision, hearing, or tactile sensation
·         Maintains contact with appropriate community resources

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
·         Communication Enhancement: Hearing Deficit
·         Cognitive Stimulation
·         Environmental Management

Nursing Interventions and Rationales

Visual—loss of vision
·         Identify name and purpose when entering client's room. Identification when entering the room helps the client feel secure and decreases social isolation.
·         Orient to time, place, person, and surroundings. Provide a radio or talking books. These actions help client remain oriented and provide sensory stimulation.
·         Keep doors completely open or closed. Keep furniture out of path to bathroom, and do not rearrange furniture. These steps help maintain a safe environment for the client (Beaver, Mann, 1995).
·         Feed client at mealtimes if blindness is temporary.
·         Keep side rails up using half or three-quarter rails, and maintain bed in a low position. Explain this precaution to client.
·         Converse with and touch client frequently during care if frequent touch is within client's cultural norm. Appropriate touch can decrease social isolation.
·         Walk client by having client grasp nurse's elbow and walk partly behind nurse. Walk a frightened or confused client by having client put both hands on nurse's shoulders; nurse backs up in desired direction while holding client around the waist. These methods help the client feel secure and ensure safety.
·         Keep call light button within client's reach, and check location of call light button before leaving the room.
·         For blind client, consider referring to a clinic for use of a blind mobility aid device that utilizes ultrasound. These devices can be helpful to the blind client to increase acuity to the environment and movement of objects in the environment (Bitjoka, Pourcelot, 1999).
·         Ensure access to eyeglasses or magnifying devices as needed.
·         Pay attention to client's emotional needs. Encourage expression of feelings and expect grieving behavior. Blind people grieve the loss of vision and experience a loss of identity and control over their lives (Vader, 1992).
·         Refer to optometrist, ophthalmologist, or specialist in vision loss for vision care if needed. Treatment of diabetic retinopathy can greatly reduce the incidence of blindness (Winslow, 1994). Many clients with eye disorders need frequent medical care to maintain vision.
Auditory-hearing loss
·         Keep background noise to a minimum. Turn off television and radio when communicating with client. Background noise significantly interferes with hearing in the hearing-impaired client (Jupiter, Spiver, 1997).
·         Stand or sit directly in front of client when communicating. Make sure adequate light is on nurse's face, avoid chewing gum or covering mouth or face with hands while speaking, establish eye contact, and use nonverbal gestures. These measures make it easier to read lips and see nonverbal communication, which is a large component of all communication (Jupiter, Spiver, 1997).
·         Speak distinctly in lower voice tones if possible. Do not over-enunciate or shout at client. In many kinds of hearing loss, clients lose the ability to hear higher-pitched tones but can still hear lower-pitched tones. Over-enunciating makes it difficult to read lips. Shouting makes the words less clear and may be painful (Jupiter, Spiver, 1997).
·         If necessary, provide a communication board or personnel who know sign language. Alternative forms of communication help decrease social isolation.
·         Try inserting the earpieces of the stethoscope into the client's ears, and talking into diaphragm. Stethoscopes magnify sound and can help some clients hear better.
·         Refer to appropriate resources such as a speech and hearing clinic; audiologist; or ear, nose, and throat physician. Refer children early for help. Hearing loss can be treated with medical or surgical interventions or use of a hearing aid. Research demonstrates the positive effects of early diagnosis and intervention on the social and cognitive development of hearing impaired children (Meadow-Orland et al, 1997).
·         Encourage client to wear hearing aid, but understand if he or she chooses to leave hearing aid out. Hearing aids amplify all noise, and loud noises in the environment can be amplified to an unbearable volume (Committee on Disabilities, 1997).
·         Observe emotional needs and encourage expression of feelings. Hearing impairments may cause frustration, anger, fear, and self-imposed isolation (Taylor, 1993)
For Disturbed Sensory perception: kinesthetic and tactile, see care plan for Risk for Injury. For Disturbed Sensory perception: olfactory and gustatory, see care plan for Imbalanced Nutrition: less than body requirements.
Geriatric
·         Keep environment quiet, soothing, and familiar. Use consistent caregivers. These measures are comforting to the elderly and help decrease confusion.
·         Avoid providing extremely hot or cold foods or using hot bath water if client has decreased sensation in mouth, hands, or feet.
·         If client has a sensory deprivation, encourage family to provide sensory stimulation with music, voices, photographs, touch, and familiar smells.
·         If client has a hearing or vision loss, work with client to ensure contact with others and to strengthen the social network. Severe loneliness can accompany hearing or vision loss in the elderly as a result of self-imposed isolation (Christian, Dluhy, O'Neill, 1989; Foxall et al, 1992).

Home Care Interventions

·         The listed interventions are applicable in the home care setting.

Client/Family Teaching

Low vision
·         Teach client how to use a lighted magnification device to increase the ability to read text or see details.
·         Teach client to put a yellow or green transparency over text to make the text more visible. An alternative method is to highlight the text with a green or yellow highlighter.
·         Put red or yellow identifiers on important items that need to be seen, such as a red strip at the edge of steps, red behind a light switch, or a red dot on a stove or washing machine to indicate how far to turn knob. Color cues can improve the legibility of the environment and increase the ability to target objects quickly (Cooper, 1999).
·         Use a watch or clock that verbally tells time and a phone with large numbers and emergency numbers programmed in.
·         Teach blind client how to feed self; associate food on plate with hours on a clock so that client can identify location of food.
·         Use low-vision aids including magnifying devices, a closed-circuit television that magnifies print, a special lens for close and distant vision, and guides for writing checks and envelopes.
·         Increase lighting in the home, and decrease glare where light reflects on shiny surfaces. Use motion lights that come on automatically when a person enters the room. Use non-glare wax on the floor. Visual acuity can be improved by taking steps to overcome age-related changes to vision (Smith, 1998). Illumination can increase mobility in clients with age-related macular degeneration (Kuyk, Elliott, 1999).
·         Refer to low-vision clinics and rehabilitation centers. Clients with vision loss should be referred to clinics early, before vision is gone, for help dealing with the loss (Brown, 1998).
Hearing loss
·         Suggest installation of devices such as ring signalers for the telephone and doorbell, sensors that detect an infant's cry, alarm clocks that vibrate the bed, and closed caption decoders for television sets. Other helpful devices include telephone amplifiers, speaker phones, pocket talker personal listening system, and FM and infrared amplification systems that connect directly to a TV or audio output jack. Also available is a telecommunication device—a typewriter keyboard with an alphanumeric display that allows the hearing impaired person to send typed messages over the telephone line, and software and modems are available that allow a home computer to be used in this fashion. Use of a hearing ear dogs—dogs specially trained to alert their owners to specific sound—may also be helpful. These devices and the dogs can be helpful to increase communication and safety for the hearing impaired client (Committee on Disability, 1997; Jupiter, Spiver, 1997).
·         Teach family how to provide appropriate stimuli in the home environment to prevent disturbed sensory perception.
·         Refer to hearing clinics.

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