Disturbed Sensory Perception NCLEX Review Care Plans
5 Nursing Care Plans on Disturbed Sensory Perception
Disturbed Sensory Perception is a NANDA nursing diagnosis that pertains to an alteration in the response to stimuli, which can be either a weaker or a stronger response to them.
The client may also have an impaired or distorted response to incoming stimuli, such as in the case of schizophrenia or other psychiatric disorders. This may involve one or more of the 6 human senses, which include visual, gustatory, auditory, olfactory, tactile, and kinesthetic.
Defining Characteristics of Disturbed Sensory Perception
The defining characteristics of Disturbed Sensory Perception may involve:
Nursing Stat Facts
- changes in the behavioral patterns of the patient
- alterations in mental acuity and sensory sharpness
- problems in critical thinking and/or decision making
- poor concentration
- lack of orientation and attention to people, time, place, and stimuli
- poor communication
Related Factors of Disturbed Sensory Perception
There are many risk factors that can be related to alterations in how a person perceives sensory cues. These may include:
- Environment – disturbance of sensory perception may be related to a particular time, place, or people around the patient (e.g., night blindness, noisy and disruptive places, staying in a hospital, or crowded places)
- Biochemical causes
- Electrolyte imbalances
- Congenital disorders (e.g., born blind or deaf)
- Chronic disorders (e.g., diabetes mellitus and dementia)
- Treatment (e.g., chemotherapy or radiotherapy)
Nursing Care Plans on Disturbed Sensory Perception
Nursing Care Plan 1
Nursing Diagnosis: Disturbed Sensory Perception (Visual) related to damaged retina as evidenced by verbal complaint of vision problems such as blurry or distorted vision and inability to see properly at night, as well as inability to drive at dusk or see in dim places
Desired Outcome: The patient will regain optimal vision while being able to cope with and accept permanent vision changes.
|Assess the vision ability of the patient using an eye chart, and I.V. fluorescein angiography.||To establish a baseline assessment of retinitis in terms of vision capacity.|
|Encourage the patient to have regular checkups with an ophthalmologist at least once a year.||To monitor worsening of vision loss and treat accordingly.|
|Encourage the patient to promote sufficient lighting at home.||The patient may not be able to perform activities of daily living as normal if he/she cannot see properly. Sufficient lighting also reduces the risk for injury.|
|Administer medications as prescribed.||Anti-angiogenic drugs stop the body from forming new blood vessels in the eye and the leaking of fluids in the retina.|
|Encourage the patient to use low vision aides. Advise to wear sunglasses when out and about.||Lenses or devices that enlarge images are helpful in addressing difficulties such as visual distortions. Sunglasses can help protect the eyes from the danger of ultraviolet rays.|
|Advise to use low vision magnifiers.||Low vision magnifiers make object appear bigger and brighter, which can help the patient see better and remain active and independent.|
|Advise to include fish that are high in omega-3 fatty acid, such as salmon, sardines and tuna. Encourage the patient to add foods containing vitamins C, E, beta-carotene, zinc, and copper in his/her diet in accordance to daily recommended intake.||Current research shows benefits if foods containing omega-3 fatty acids, lutein, vitamins C, E, beta-carotene, zinc, and copper are introduced to the patient’s diet.|
|Discourage the patient to drive at dusk or night time.||To ensure patient’s safety.|
Nursing Care Plan 2
Nursing Diagnosis: Disturbed Sensory Perception (Auditory) related to damage in the inner ear secondary to Meniere’s disease as evidenced by recurrent vertigo, tinnitus or ringing in the ears, verbal complaint of hearing and communication problems
Desired Outcome: The patient will be able to cope with the auditory loss as evidenced by improved communication and quality of life.
|Assess the hearing ability of the patient. Older children can be asked questions if there is muffling or absence of sounds in one ear.||To establish a baseline assessment in terms of hearing capacity.|
|Inform the patient and family that while there is no current cure for the hearing loss, there are effective interventions to reduce vertigo and help the client cope with communication problems.||To reduce anxiety of the patient and carer.|
|Encourage the use of a hearing aid.||Meniere’s disease usually involves only one ear. Using a hearing aid on the affected ear can help the patient cope with hearing problems.|
|Educate the patient and family regarding positive pressure therapy.||Positive pressure therapy involves the application of pressure in the middle ear. This helps reduce the fluid buildup in the affected ear.|
|Inform the carer or family to speak slowly and clearer to the patient. Encourage them to face the patient while speaking.||To promote good communication between the patient and the carer.|
|Encourage the patient to inform his/her carer or family if there is any worsening of symptoms, such as ear pain, discharge, or worsening of hearing ability.||To monitor if the hearing loss is worsening and if there is a need for further investigation and change of hearing aid.|
|Administer medications for vertigo and nausea.||Meniere’s disease may cause moderate to severe episodes of vertigo, which can also trigger nausea and vomiting.|
Nursing Care Plan 3
Chemotherapy-induced Peripheral Neuropathy
Nursing Diagnosis: Disturbed Sensory Perception (Tactile) related to peripheral neuropathy secondary to ongoing chemotherapy as evidenced by tingling sensations on the fingertips and toes, numbness of the fingers at times, dropping objects when holding them, occasional pain on the fingertips, inability to drive due to occasional loss of feeling the feet on the pedals
Desired Outcome: The patient will verbalize being able to cope with peripheral neuropathy and retain optimal quality of life while chemotherapy is ongoing.
|Use the hospital’s approved chemotherapy assessment grading system to assess the patient’s peripheral neuropathy prior to the start of each chemotherapy session.||It is important to check any worsening or improvement of peripheral neuropathy prior to giving any chemotherapy drugs as it can determine the appropriate course of action whether to continue the treatment at the current dose/s, hold or postpone the treatment, change the doses, or stop/change the chemotherapy regimen altogether. Assessment using approved grading systems such as CTCAE also helps the nurse determine the level of care that the patient requires, such as referral to occupational therapy/physiotherapy (OT/PT) service or pain specialist.|
|Consider referral to the OT/PT team.||Occupational therapists and physiotherapists can help the patient gain optimal quality of life by means of creating tailored action plans for improving functionality, as well as providing assistive devices to maintain balance and prevent the occurrence of falls.|
|Educate the patient and family regarding the importance of maintaining safety and preventing any injuries. Advise that it is best for the patient to have someone with him/her at all times.||Patients with chemotherapy-induced peripheral neuropathy are at high risk for falls and injuries such as burns. For safety purposes, the patient will need someone to assist him/her in doing activities of daily living, such as bathing, cooking, and mobilizing.|
|Advise the patient to pay special attention to foot and hand care.||Many chemotherapy drugs can cause damage to the peripheral nerves of the hands and feet.|
|Inform the patient and caregiver that chemotherapy-induced neuropathy may be reversible if proper actions to manage it are done in a timely manner.||Mild peripheral neuropathy due to chemotherapy is usually reversible after a few months following its completion. Dose adjustments or treatment changes can help reverse peripheral neuropathy as well.|
|Consider referral to psychology service.||Chemotherapy-induced peripheral neuropathy can be a constant reminder of cancer and treatment, which can result to anxiety, depression, and ineffective coping. A psychologist can guide the patient to process feelings of helplessness and hopelessness.|
Nursing Care Plan 4
Nursing Diagnosis: Disturbed Sensory Perception related to cerebral edema and increased intracranial pressure secondary to meningitis as evidenced by lack of orientation to time, person, and place and decreased level of consciousness
Desired Outcome: The child will regain normal sensorium, orientation, and level of consciousness.
|Use the pediatric Glasgow coma scale to assess the level of consciousness of the patient.||GCS is a universal method of assessing the level of consciousness, which includes the measurement of the person’s sensory, verbal, and motor cues. Assessment of the child’s level of consciousness can help determine the extent of damage due to meningitis.|
|Maintain an environment that is free from unnecessary noise and ensure that the lights are dim.||To reduce the amount of stimuli thereby preventing possible episodes of convulsion which are common in pediatric patients with meningitis.|
|Place the patient on seizure precautions. Commence seizure chart.||To effectively monitor the client for the occurrence of seizures which can facilitate early recognition and management. This helps prevent any complication such as brain damage.|
|Ensure that the patient’s caregiver (parent or guardian) is always present.||To promote patient safety and provide support in performing activities of daily living.|
|Administer prescribed medications, which may include antibiotics, osmotic diuretics and anticonvulsants.||Bacterial meningitis can be treated with antibiotics. Osmotic diuretics may be given to reduce intracranial pressure. Anticonvulsants are usually prescribed in meningitis patients as a prophylactic treatment for convulsions and seizures.|
Nursing Care Plan 5
Nursing Diagnosis: Risk for Disturbed Sensory Perception
Desired Outcome: The patient will recognize any changes in sensory and tactile perception and effectively cope with them.
|Assess vital signs and perform an initial head-to-toe assessment, particularly checking visual acuity, presence of tingling or numbness in the extremities, and response to pain stimuli.||Retinopathy and peripheral neuropathy are some of the complications of diabetes.|
|Educate the patient for the need to monitor and report any visual disturbances or other sensory changes.||To facilitate early detection and management of disturbed sensory perception.|
|Create a daily routine for the patient, as consistent as possible.||To maintain patient safety.|
|Monitor blood sugar levels regularly.||Uncontrolled levels of blood glucose may lead to serious complications such as neuropathy and retinopathy.|
|Encourage the patient to use visual aids.||Lenses or devices that enlarge images are helpful in addressing difficulties such as visual distortions.|
|Encourage the patient to add foods containing vitamins C, E, beta-carotene, zinc, and copper in his/her diet in accordance to daily recommended intake.||A study by AREDS shows some benefits if foods containing vitamins C, E, beta-carotene, zinc, and copper are introduced to the patient’s diet.|
|Encourage the patient to inform the ophthalmologist if there is any worsening of symptoms.||To know if there is a need for further investigation and treatment.|
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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