Disturbed sensory perception is a nursing diagnosis that refers to a change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
This condition can significantly impact a patient’s ability to interact with their environment and perform daily activities safely.
Causes (Related to)
Disturbed sensory perception can result from various conditions that affect the nervous system or sensory organs. Common causes include:
- Neurological disorders (multiple sclerosis, Parkinson’s disease, stroke)
- Head injuries or trauma
- Aging processes
- Sensory organ deficits (glaucoma, cataracts, hearing loss)
- Biochemical imbalances (electrolyte imbalances, hypoglycemia)
- Psychological disorders (schizophrenia, severe depression)
- Substance abuse or withdrawal
- Sleep deprivation
- Environmental factors (excessive noise, poor lighting)
- Medication side effects
Signs and Symptoms (As evidenced by)
Disturbed sensory perception can manifest in various ways, depending on the affected sensory modality and the underlying cause. Here are some common signs and symptoms:
Subjective: (Patient reports)
- Changes in sensory acuity (blurred vision, ringing in ears)
- Hallucinations (visual, auditory, tactile, olfactory, or gustatory)
- Altered perception of stimuli
- Disorientation
- Difficulty concentrating
Objective: (Nurse assesses)
- Altered communication patterns
- Changes in problem-solving abilities
- Impaired ability to perform tasks requiring sensory input
- Exaggerated or diminished emotional responses
- Changes in usual behavior patterns
- Disorientation to time, place, or person
- Poor coordination or balance
- Altered reflexes
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for disturbed sensory perception:
- The patient will demonstrate improved sensory perception within their limitations
- The patient will verbalize understanding of their sensory deficits and compensatory techniques
- The patient will maintain safety despite sensory alterations
- The patient will show an improved ability to interpret environmental stimuli accurately
- The patient will engage in activities of daily living with minimal assistance
- The patient will demonstrate effective coping strategies for managing sensory alterations
- The patient will report reduced frequency or intensity of hallucinations (if applicable)
Nursing Assessment
The first step in managing disturbed sensory perception is a thorough nursing assessment. The following steps should be taken:
- Conduct a comprehensive neurological assessment
Evaluate the patient’s level of consciousness, orientation, and cognitive function. This helps identify the extent of sensory perception disturbances. - Assess all sensory modalities.
Evaluate vision, hearing, touch, taste, and smell. Note any deficits or alterations in sensory perception. - Review the patient’s medical history.
Identify any pre-existing conditions or recent changes that could contribute to sensory disturbances. - Perform a medication review.
Check for medications that could potentially cause sensory alterations as side effects. - Assess the patient’s safety.
Given their sensory alterations, evaluate the patient’s ability to navigate their environment safely. - Conduct a psychological assessment.
Look for signs of anxiety, depression, or other psychological factors that may be contributing to or resulting from sensory disturbances. - Evaluate the patient’s coping mechanisms.
Assess how the patient is dealing with their sensory alterations and what strategies they’re using. - Perform environmental assessment
Evaluate the patient’s surroundings for factors that might exacerbate sensory disturbances (e.g., poor lighting, excessive noise). - Assess the impact on daily living.
Determine how sensory alterations are affecting the patient’s ability to perform activities of daily living. - Document baseline findings
Record all assessment findings to establish a baseline for comparison in future evaluations.
Nursing Interventions
Nursing interventions for disturbed sensory perception focus on promoting safety, enhancing sensory function, and helping the patient cope with sensory alterations. Here are some key interventions:
- Ensure a safe environment
Remove potential hazards and implement safety measures to prevent accidents related to sensory deficits. - Provide sensory aids
Offer glasses, hearing aids, or other assistive devices as appropriate to enhance sensory function. - Implement orientation strategies
Clocks, calendars, and familiar objects help orient the patient to time and place. - Manage environmental stimuli
Control noise levels, lighting, and other environmental factors to optimize sensory input. - Encourage sensory stimulation
Engage the patient in activities stimulating various senses, such as music therapy or aromatherapy. - Teach compensatory techniques
Help the patient develop strategies to compensate for sensory deficits, such as using touch to navigate or relying more on unaffected senses. - Promote adequate rest and sleep.
Ensure the patient gets sufficient rest to prevent fatigue-related exacerbation of sensory disturbances. - Administer medications as prescribed.
Give medications that may help manage underlying conditions contributing to sensory disturbances. - Provide emotional support
Offer reassurance and emotional support to help the patient cope with sensory alterations. - Educate the patient and family.
Provide information about the condition, its management, and available resources. - Collaborate with other healthcare professionals.
Work with occupational therapists, physical therapists, and other specialists to provide comprehensive care. - Monitor for changes
Regularly assess for improvements or deterioration in sensory perception and adjust care accordingly.
Nursing Care Plans
Here are five nursing care plans for disturbed sensory perception:
Disturbed Sensory Perception Care Plan #1
Nursing Diagnosis Statement:
Disturbed sensory perception (visual) related to macular degeneration as evidenced by reported blurred central vision and difficulty recognizing faces.
Related factors/causes:
- Age-related macular degeneration
- Progressive loss of central vision
Nursing Interventions and Rationales:
- Assess the patient’s visual acuity using appropriate tests.
Rationale: Establishes a baseline and helps monitor the progression of visual changes. - Teach the patient to use visual aids such as magnifying glasses or large-print materials.
Rationale: Enhances the patient’s ability to perform tasks requiring visual acuity. - Implement environmental modifications (improved lighting, contrasting colors for objects).
Rationale: Enhances visual cues and improves safety in the environment. - Educate the patient about the importance of regular ophthalmology check-ups.
Rationale: Ensures timely detection of changes and appropriate medical management. - Teach the patient techniques for maximizing peripheral vision.
Rationale: Helps compensate for the loss of central vision.
Desired Outcomes:
- The patient will demonstrate safe navigation of their environment within 24 hours.
- The patient will verbalize understanding of visual deficit and compensatory techniques within 48 hours.
- The patient will engage in activities of daily living using visual aids with minimal assistance within one week.
Disturbed Sensory Perception Care Plan #2
Nursing Diagnosis Statement:
Disturbed sensory perception (auditory) related to presbycusis as evidenced by difficulty hearing high-pitched sounds and understanding speech in noisy environments.
Related factors/causes:
- Age-related hearing loss
- Damage to hair cells in the inner ear
Nursing Interventions and Rationales:
- Conduct a hearing assessment using a whisper test or audiometry.
Rationale: Provides objective data about the extent of hearing loss. - Teach the patient and family effective communication strategies (e.g., facing the patient when speaking, speaking clearly).
Rationale: Improves communication and reduces frustration. - Assist the patient in obtaining and using hearing aids if prescribed.
Rationale: Amplifies sound and improves auditory perception. - Educate the patient about protecting residual hearing (avoiding loud noises).
Rationale: Prevents further damage to hearing. - Implement environmental modifications (reducing background noise, using visual cues).
Rationale: Enhances the patient’s ability to perceive and interpret auditory stimuli.
Desired Outcomes:
- The patient will demonstrate improved communication abilities within 48 hours.
- The patient will correctly use hearing aids (if prescribed) within one week.
- The patient will report increased satisfaction with auditory perception in various environments within two weeks.
Care Plan for Disturbed Sensory Perception #3
Nursing Diagnosis Statement:
Disturbed sensory perception (tactile) related to peripheral neuropathy secondary to diabetes mellitus as evidenced by numbness and tingling in extremities.
Related factors/causes:
- Diabetes-induced nerve damage
- Impaired circulation to peripheral nerves
Nursing Interventions and Rationales:
- Assess the patient’s sensation using monofilament testing.
Rationale: Provides objective data about the extent of sensory loss. - Teach the patient to perform daily foot inspections.
Rationale: Helps detect early signs of injury or infection that may go unnoticed due to sensory loss. - Educate the patient about proper foot care and the importance of well-fitting shoes.
Rationale: Prevents injuries and complications related to sensory loss. - Implement a regular exercise program focusing on balance and proprioception.
Rationale: Improves circulation and may help maintain or improve sensory function. - Teach the patient to use visual cues to compensate for lack of tactile sensation.
Rationale: Enhances safety and function in daily activities.
Desired Outcomes:
- The patient will demonstrate proper foot inspection technique within 24 hours.
- The patient will verbalize understanding of the importance of foot care within 48 hours.
- The patient will report no new injuries related to sensory loss within one week.
Care Plan for Disturbed Sensory Perception #4
Nursing Diagnosis Statement:
Disturbed sensory perception (gustatory and olfactory) related to chemotherapy treatment as evidenced by reports of altered taste and smell sensations.
Related factors/causes:
- Chemotherapy-induced damage to taste buds and olfactory receptors
- Dry mouth (xerostomia) secondary to chemotherapy
Nursing Interventions and Rationales:
- Assess the patient’s ability to taste and smell using standardized tests.
Rationale: Establishes a baseline for monitoring changes in sensory perception. - Provide oral care before meals and as needed.
Rationale: Helps maintain oral hygiene and may improve taste perception. - Suggest using herbs, spices, and marinades to enhance food flavors.
Rationale: It may improve food palatability and encourage adequate nutritional intake. - Educate the patient about food safety practices.
Rationale: Compensates for the inability to detect spoiled foods through smell or taste. - Encourage the patient to maintain adequate hydration.
Rationale: Helps combat dry mouth and may improve taste perception.
Desired Outcomes:
- The patient will report improved satisfaction with meals within one week.
- The patient will maintain adequate nutritional intake as evidenced by stable weight within two weeks.
- The patient will demonstrate proper food safety practices within 48 hours.
Disturbed Sensory Perception Care Plan #5
Nursing Diagnosis Statement:
Disturbed sensory perception (kinesthetic) related to multiple sclerosis as evidenced by impaired balance and coordination.
Related factors/causes:
- Demyelination of nerves affecting proprioception
- Muscle weakness and spasticity
Nursing Interventions and Rationales:
- Assess the patient’s balance and coordination using standardized tests (Berg Balance Scale).
Rationale: Provides objective data about the extent of kinesthetic impairment. - Implement a fall prevention program.
Rationale: Reduces the risk of injury due to impaired balance and coordination. - Teach the patient to use assistive devices (cane, walker) properly.
Rationale: Enhances stability and safety during mobility. - Collaborate with physical therapy to develop an exercise program focusing on balance and coordination.
Rationale: Helps maintain or improve kinesthetic function. - Educate the patient about environmental modifications to enhance safety (removing throw rugs and installing grab bars).
Rationale: Creates a safer environment accommodating kinesthetic deficits.
Desired Outcomes:
- The patient will demonstrate the safe use of assistive devices within 24 hours.
- The patient will report no falls within one week.
- The patient will show improved balance and coordination scores on standardized tests within two weeks.
References
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