Open Resources for Nursing (Open RN) Show This section outlines the steps of the nursing process when providing care for individuals with altered sensory function in any setting. AssessmentWhen assessing a patient for sensory impairments, it is important to first establish a therapeutic relationship. Individuals may be hesitant to discuss sensory problems. By establishing a good rapport, patients are more likely to share their sensory concerns and effects on functioning. The health history should include questions regarding current status of sensory function, as well as risk for development of sensory impairment. For example, medications that can be ototoxic should be considered a risk factor for hearing impairment. Additionally, opioids and sedatives depress the central nervous system and can impair stimuli perception and reaction. Techniques to identify deficits in vision, hearing, smell, taste, and sensation are used during the physical exam. Read additional information about assessment techniques using the following hyperlinks. Read about common disorders of the eyes and ears in the “Eye and Ear Assessment” chapter of the Open RN Nursing Skills textbook. Read more about assessing sensory functioning in the “Neurological Assessment” chapter of the Open RN Nursing Skills textbook. There are several factors to consider when assessing a patient’s sensory functioning, such as age, their perception of the impairment, and the impact of the sensory impairment on their daily functioning. Age is an important consideration because many sensory functions can be affected by the aging process. However, it should not be assumed that all sensory problems are a normal part of the aging process. It is important to assess the patient’s perception of sensory impairment and its impact on their functioning, as well for any changes in recent behavior, mental status, emotional status, or cognitive function changes. For example, individuals experiencing hearing loss may be more irritable or anxious and avoid social gatherings due to their hearing impairment. If a patient is experiencing confusion, it is important to evaluate underlying factors that can cause confusion. The environment is also an important consideration when assessing an individual’s sensory functioning. It is important to understand the patient’s daily activities and their ability to perform them; their work and living environment; their use of protective equipment, such as ear protection when working with loud equipment; and their adherence with routine screenings, such as vision and hearing exams. Individuals with sensory impairments are at increased risk for falls and injury, so it is important to encourage basic safety features in the environment, including adequate lighting, availability of handrails and grab bars, hazard-free walkways, and appropriate settings on water heater controls. When sensory impairments are identified, they should be documented in the patient’s chart and communicated to collaborative team members working with the individual. For example, when an individual has a hearing impairment, it is important to consider their alternative communication needs. They may use lipreading and require face-to-face views when communicating. The use of assistive devices for sensory functioning, such as glasses and hearing aids, should also be documented and communicated. It is important to ensure proper functioning of the devices for optimal patient outcomes. In fact, a hospitalized older adult is at greater risk for developing delirium when their typical glasses and hearing aids (i.e., their “eyes and ears”) are not available, causing sensory deprivation. See Table 7.3a for a comparison of expected versus unexpected findings on assessment, including those that require notification of the health care provider. Table 7.3a Expected Versus Unexpected Findings
DiagnosesCommonly used NANDA-I nursing diagnoses for patients experiencing alterations in sensory function include the following:[1]
A common NANDA diagnosis related to sensory alterations is Risk for Injury, which is defined as, “Susceptible to physical damage due to environmental conditions interacting with the individual’s adaptive and defensive resources, which may compromise health.” “Alteration in sensation” is an associated condition for this nursing diagnosis. For risk diagnoses, there are no related factors (etiological factors) because you are identifying a vulnerability in a patient for a potential problem that is not yet present. Additionally, the nurse cannot resolve sensory alteration, so it should not be listed as a related factor to which interventions are directed. Instead, the phrase “as evidenced by” is used to refer to the evidence of risk that exists. Therefore, a sample NANDA-I diagnosis in current PES format would be as follows: “Risk for Injury as evidenced by alteration in vision.” OutcomesAn overall goal for a patient at risk for injury related to alteration in sensation is as follows:
An example of a “SMART” expected outcome for a patient with impaired vision is as follows:
Planning InterventionsThere are many nursing interventions that can be implemented for individuals with impaired sensory function. To assist patients to communicate effectively and to promote their quality of life, it is important for the nurse to customize appropriate interventions based on their individual needs. As always, refer to an evidence-based nursing care planning resource when customizing interventions for specific patients. See Table 7.3b for basic nursing interventions to implement for a variety of sensory alterations.[2] Table 7.3b Nursing Interventions to Address Sensory Alterations[3]
Standards of CareNational Patient Safety Goals established by The Joint Commission include prevention of falls. Appropriately assessing the risk of falls for patients with sensory impairments and implementing effective nursing interventions to prevent falls help to meet this standard of care.[4] EvaluationEvaluate a patient’s progress toward the expected outcomes established. Include safety, functioning, ability to communicate, and satisfaction with quality of life when evaluating the effectiveness of interventions. Determine if changes in the plan of care are needed to better meet the needs of the individual. Which step of the nursing process in which the nurse used sense of sight?Observation. Observation is an assessment tool that depends on the use of the five senses (sight, touch, hearing, smell, and taste) to learn information about the client. This information relates to characteristics of the client's appearance, functioning, primary relationships, and environment.
What are the 5 stages of nursing process?The common thread uniting different types of nurses who work in varied areas is the nursing process—the essential core of practice for the registered nurse to deliver holistic, patient-focused care. Assessment. ... . Diagnosis. ... . Outcomes / Planning. ... . Implementation. ... . Evaluation.. What is the 4 step nursing process?These are assessment, diagnosis, planning, implementation, and evaluation.
What is the 6th step in the nursing process?The six phases of the nursing process are
1- assessment, 2- diagnosis, 3-out come identification, 4- planning, 5- implementation, 6- and evaluation.
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