Evaluating - Pearson Education

1 996 UNIT IX / Promoting Psychosocial HealthEvaluatingUsing the measurable desired outcomes developed during theplanning stage as a guide, the nurse collects data needed tojudge whether client goals and outcomes have been of client outcomes and related indicators are shownin the earlier Identifying Nursing Diagnoses, Outcomes, and In-terventions and in the Nursing Care Plan. If outcomes are notachieved, the nurse and client, and support people if appropri-ate, need to explore the reasons before modifying the care CARE PLANS ensory-Perception DisturbanceASSESSMENT DATANURSING DIAGNOSISDESIRED OUTCOMES*Nursing AssessmentJulia Hagstrom is an 80-year-old widow who has recently be-come a resident of an extended care facility. Just prior to her ad-mission she underwent surgery for the removal of cataracts andalso experienced more difficulty with hearing. Her children wereconcerned about her physical safety and lack of socialization andurged her to enter a nursing home.

2 Mrs. Hagstrom had cared forherself independently for 15 years in her own home. Three daysafter admission the nurse finds the client somewhat confusedand disoriented to place, and time. She appears restless andwithdrawn. She states, I m afraid of all of these strange crea-tures in this orphanage. Disturbed Sensory Perception(Sensory Overload)related tochange in environment, andhearing loss (as evidenced bydisorientation to time andplace; restlessness; and alteredbehavior)Cognitive Orientation[0901] as evidenced by notcompromised: Identifies significantother(s) Identifies current place Identifies correct seasonHearing CompensationBehavior [1610] as evidencedby often demonstrated: Positions self to advantagehearing Reminds others to usetechniques that advantagehearing Eliminates backgroundnoise Uses hearing supportive devicesNURSING INTERVENTIONS*/SELECTED ACTIVITIESRATIONALER eality Orientation [4820]Provide a consistent physical environment and a daily access to familiar objects, when a low-stimulation environment for Mrs.

3 Hagstrom becausedisorientation may be increased by for adequate rest, sleep, and daytime a calm and unhurried approach when interacting with Mrs. to the client in a slow, distinct manner with appropriate Mrs. Hagstrom in concrete here and now activities (thatis, ADLs) that focus on something outside the self that is concreteand reality eliminates the element of surprise, overstimulation, andfurther helps reduce disruption in the quality or quantity of incoming stimuli can af-fect a person s cognitive status. Sensory overload blocks outmeaningful overstimulation and fatigue, which may be contributingfactors to communication that enhances the person s sense client who has difficulty hearing will be better able to lip readand comprehend the individual to differentiate between own thoughts ExaminationHeight: 160 cm (5 3 )Weight: kg (122 lb)Temperature: 37 C ( F)Pulse: 72 BPMR espirations: 18/minute Blood Pressure: 128/74 mm HgRinne test: negativeDiagnostic DataChest x-ray, CBC, and urinalysisall 11/8/06 6:16 PM Page 996 CHAPTER 38 / Sensory Perception 997 NURSING CARE PLAN Sensory-Perception DisturbancecontinuedNURSING INTERVENTIONS*/SELECTED ACTIVITIESRATIONALE Hearing can be enhanced if the volume is appropriate and thehearing aid is consistently listening is essential in a nurse client relationship.

4 Poor listening skills can undermine trust and block simple terms and short sentences facilitates understandingand minimizes the attention of a client with a hearing impairment is anessential first step toward effective communication. However, theclient s personal space should be respected and permission totouch should be Enhancement: Hearing Deficit [4974] Facilitate use of hearing aids, as appropriate. Listen attentively. Use simple words and short sentences, as appropriate. Obtain Mrs. Hagstrom s attention through met. Mrs. Hagstrom identifies her primary nurse by sight and name on the third day. She is aware that Christmas is 3 weeksaway and is anxious to go shopping with the group. Her daughter has brought new batteries for her hearing aid, which she wears during the day.*The NOC # for desired outcomes and the NIC # for nursing interventions are listed in brackets following the appropriate outcome or , interventions, and activities selected are only a sample of those suggested by NOC and NIC and should be further individualized for THINKING CHECKPOINTMrs.

5 Dodd is a 51-year-old client who is being cared for in the criticalcare unit following an automobile accident in which she suffered ex-tensive traumatic injuries. Mrs. Dodd is connected to several monitor-ing devices, has an intubation tube and ventilator to assist her withrespirations, and is receiving various pain and other Identify factors that place Mrs. Dodd at risk for the developmentof sensory deprivation or What assessment findings would alert you to Mrs. Dodd s expe-riencing sensory overload as opposed to sensory deprivation?3. How can you intervene to help Mrs. Dodd during this stressful event?4. How might the care of a client in the home setting differ from thecare of a client such as Mrs. Dodd who is receiving care in a crit-ical care unit?See Critical Thinking Possibilities in Appendix A. 11/13/06 4:14 PM Page 997