Disturbed Sensory Perception

RLE 002 Cebu Normal University College of Nursing Cebu City Mission-Vision: “Care Using Knowledge and Compassion”

Theory-based (Betty Neuman)

NURSING CARE PLAN Assessment Diagnosis

3 points 3 points

Goals Theoretical Basis

2 points 2 points

Name of Student: Rabor, Johann Margarette F Client’s Initials: Age: Gender: Civil Status: Religion: Allergies: Diet: Date of Admission: Diagnosis/Impression: NURSING DIAGNOSIS Assessment Subjective:

Objective:

Diagnosis Disturbed sensory perception r/t Altered sensory reception

4 points 1 point

Bibliography 15 points

Stressor Classification: (Please check) ___/___ Physiological (body structure and functions) ______ Psychological (mental processes and emotion ______ Socio-cultural (relationships, social expectations) ______ Spiritual (influence of spiritual beliefs) NURSING GOALS Mutual Planning (Goal attainable within the shift) After 8 hours of nursing intervention the pt. will be able to: Short Term >Regain/maintain usual level of consciousness and perceptual functioning Long Term >Acknowledge changes in ability and presence of

Cebu Normal University SDF-CON-NF-7002-034-00

Interventions Evaluation

NURSING OUTCOME Interventions (with Rationale & Source) PRIMARY INTERVENTIONS Promotive: I. Establish and maintain communication with the patient. R. even an unresponsive patient may be able to hear S. (Doenges, Moorhouse, & Murr. 2011) I. Protect from temperature extremes; assess environment for hazards. R. Promotes patient safety, reducing risk of injury. S. (Doenges, Moorhouse, & Murr. 2011) I. Observe behavioral responses: crying, inappropriate affect, agitation, hostility, agitation, hallucination. R. Individual responses are variable, but commonalities such as emotional lability, lowered frustration threshold, apathy, and

Actual Evaluation

Theoretical basis: Cerebrovascular accident, also known as stroke, cerebral infarction, brain attack, is any functional or structural abnormality of the brain caused by pathological condition of the cerebral vessels of the entire cerebrovascular system. It is the sudden impairment of cerebral circulation in one or more of the blood vessels supplying the brain. One of the signs and symptoms of stroke is hemiparesis. Hemiparesis is weakness on one side of the body. You can still move the affected side of your body, but with reduced muscular strength. Treatment is focused on improving feeling and motor skills, allowing you to better manage your daily living. S: http://www.stroke.org/wecan-help/survivors/strokerecovery/post-strokeconditions/physical/hemiparesis

residual involvement. >Demonstrate behaviors to compensate for/overcome deficits.

impulsiveness may complicate care. S. (Doenges, Moorhouse, & Murr. 2011) Preventive: I. Eliminate extraneous noise and stimuli as necessary. R. Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload. S. (Doenges, Moorhouse, & Murr. 2011) SECONDARY INTERVENTIONS Curative I. Speak in calm, comforting, quiet voice, using short sentences. Maintain eyecontact. R. Patient may have limited attention span or problems with comprehension. S. (Doenges, Moorhouse, & Murr. 2011) I. Ascertain patient’s perceptions. Reorient patient frequently to environment, staff, and procedures. R. Assists patient to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality. S. (Doenges, Moorhouse, & Murr. 2011) I. Stimulate sense of touch. Give patient objects to touch, and hold. R. Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. S. (Doenges, Moorhouse, & Murr. 2011) TERTIARY INTERVENTIONS Rehabilitative I. Note inattention to body parts, segments of environment, lack of recognition of familiar objects/persons. R. 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. S. (Doenges, Moorhouse, & Murr. 2011)

Bibliography:  Doenges, M.E., and Moorhouse, M.F. (2011). Nurses pocket guide: nursing diagnoses with interventions (11th ed., Ser. 2011). Philadelphia: F.A. Davis  Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth's Textbook of Medical-Surgical Nursing. Philadelphia: Wolters Kluwer Health / Lippincott Williams & Wilkins.  http://www.stroke.org/we-can-help/survivors/stroke-recovery/post-stroke-conditions/physical/hemiparesis

Cebu Normal University SDF-CON-NF-7002-034-00