Nursing 109

N109: Foundations in Nursing Practice Study Guide

Analysis With the patient, family, and healthcare team, the nurse must analyze the assessment and formulate and prioritize the potential and actual nursing diagnoses pertinent to the individual with a sensory impairment. Each diagnosis should be written in a way that indicates the diagnosis related to some deficiency, as evidenced by some measurable criteria. For example, “Risk for self-care deficit related to loss of vision as evidenced by inability to drive to healthcare appointments.” Possible nursing diagnoses might include: • Disturbed sensory perception (specify which sense is affected) • Risk for impaired verbal communication • Risk for confusion • Risk for compromised human dignity • Risk for injury • Self-care deficit • Risk for social isolation Planning With the patient, family, and healthcare team, the nurse must plan the expected outcomes and interventions to reach those goals pertinent to the individual with a sensory impairment. Assign patient care activities to be implemented by other members of the healthcare team as appropriate. Possibleoutcome interventions associated with the nursing diagnoses might include: • Disturbed sensory perception: (specify which sense is affected) o Goal: The individual will use adaptive devices. o Interventions: Encourage the use of adaptive devices. Increase tactile stimulation and social interaction. Alter the environment to accommodate the impairment. Provide teaching about medications or other treatments that may be used for the impairment. • Risk for impaired verbal communication o Goal: The individual will use assistive devices and techniques (includinglip reading and signing, if appropriate) to communicate with family and the healthcare team. o Interventions: Face the client when speaking and talk in a normal tone of voice but slower than usual. Explain all activities. Lightly touch the impaired person to get her attention. Ensure that all staff members are aware of the individual’s impairment. • Risk for confusion o Goal: The individual will be alert and oriented to person, place, time, and surroundings. o Interventions: Talk in a normal tone of voice but slower than usual. Explain all activities. Lightly touch the person with impairment to get her attention. Orient the individual during each visit. Ensure that the individual is using hearing aids or other assistive devices correctly in order to maximize his senses. • Risk for compromised human dignity o Goal: The individual’s self-esteem will be maintained at a high level.

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