Nursing Diagnosis: Application to Clinical Practice
11th Edition

Disturbed Sensory Perception
DEFINITION
Disturbed Sensory Perception: State in which a person/group experiences or is at risk of experiencing a negative change in the amount, pattern, or interpretation of incoming stimuli
DEFINING CHARACTERISTICS
Major (Must Be Present)
Inaccurate interpretation of environmental stimuli and/or negative change in amount or pattern of incoming stimuli
Minor (May Be Present)
  • Disoriented in time or place
  • Altered ability to solve problems
  • Restlessness
  • Fear
  • Apathy
  • Disoriented about people
  • Altered behavior or communication pattern
  • Reports auditory or visual hallucinations
  • Anxiety
  • Irritability
RELATED FACTORS
Many factors can contribute to disturbed sensory perception. Some common factors are below.
Pathophysiologic (Sensory Organ Alterations)
Related to misinterpretations secondary to:
Sensory organ alterations
  • Visual, gustatory, auditory, olfactory, and tactile deficits
Neurologic alterations
  • Cerebrovascular accident (CVA)
  • Tumors
  • Neuropathies
  • Meningitis
  • Encephalitis
Metabolic alterations
  • Fluid and electrolyte imbalance
  • Alkalosis
  • Acidosis
  • Renal failure
Impaired oxygen transport
  • Cerebral
  • Anemia
  • Cardiac
  • Respiratory
Related to mobility restrictions secondary to:
  • Paraplegia
  • Quadriplegia
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Treatment-Related
Related to chemical changes secondary to:
Medications (eg, sedatives, tranquilizers, steroids, anticonvulsants, antihistamines, cardiac glycosides, anticholinergics)
Surgery (eg, glaucoma, cataract, detached retina)
Related to physical isolation (eg, reverse isolation, communicable disease, prison)
Related to immobility
Related to mobility restrictions (eg, bed rest, traction, casts, Stryker frame, CircOlectric bed)
Situational (Personal, Environmental)
Related to
  • Pain
  • Stress
  • Sleep interpretations
Related to environmental barriers
  • Noise
  • Constant changes
  • Lights
  • Excess activity
  • Lack of privacy
  • Frequent demands
Related to monotonous environment
Related to loss of socialization
Related to loss of control
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Focus Assessment Criteria
Subjective Data
Assess for Defining Characteristics
History of symptoms
The person reports
  • Difficulty concentrating
  • Anxiety
  • Fatigue or irritability
  • Unusual sensations
Onset and description
  • Precipitated by?
  • Relieved by?
  • Frequency?
Assess for Related Factors
  • Recent surgery
  • Sensory organ deficit
  • Substance abuse (drugs, alcohol)
  • Recent hospitalization
  • Change in biorhythm pattern
  • Social isolation
  • Neurologic impairment
  • Mobility restrictions
  • Medications
  • Environmental (noise, lights)
Objective Data
Assess for Related Factors
Subjective and Objective Data
Assess Risk Level
Refer to Table II.22.
TABLE II.22 Assessing the Degree of Suicidal Risk
Because all people in certain environments are at risk for disturbed sensory perception, the tool shown in Table II.23 identifies which people are at high risk. The higher the score, the higher the risk (Wilson, 1993).
TABLE II.23 Drugs That Impair Sexuality
Drug Effect on Sexuality
Alcohol In small amounts, may increase libido and decrease sexual inhibitions
In large amounts, impairs neural reflexes involved in erection and ejaculation
Chronic use causes impotence and sterility in men; decreased desire and orgasmic dysfunction in women
Amyl nitrate Peripheral vasodilator reputed to cause intensified orgasms when inhaled at time of orgasm
May cause loss of erection, hypotension, and syncope
Antidepressants Peripheral blockage of nervous innervation to sex organs
Significant percentage of impotence and ejaculatory dysfunction in men
Decreased libido in both genders
Antihistamines Block parasympathetic innervation of sex organs
Sedative effect may decrease desire
Decrease in vaginal lubrication
Antihypertensives Libido may be decreased in both genders
Some cause impotence and ejaculatory problems in up to 50% of men
See specific class of medications.
Antispasmodics Inhibit parasympathetic innervation of sex organs
May cause impotence
Chemotherapeutics Combination therapy may cause azoospermia or oligospermia in men and temporary or permanent menopause in women; fertility may be temporarily or permanently altered; libido may be decreased and body image altered.
Cocaine Short-term use is reported to enhance sexual experience.
Chronic use causes loss of desire and sexual dysfunction in both sexes.
Hormones Estrogen suppresses sexual function in men.
Testosterone may increase libido in both sexes but causes virilization in women.
Chronic use of anabolic steroids causes testicular atrophy, decreased testosterone and decreased sperm production; may cause permanent sterility.
Marijuana May decrease sexual inhibitions
Chronic use may cause decreased libido and impotence.
Narcotics Chronic use causes decreased libido in both sexes.
Testosterone levels and amount of semen decreased
Erectile and ejaculatory dysfunction common
Oral contraceptives Remove fear of pregnancy
May cause decreased libido
Sedatives/tranquilizers Initially and in low doses may enhance sexual pleasure due to relaxation and decrease of inhibitions
Long-term use decreases libido and may cause orgasmic dysfunction and impotence.
Diuretics May cause erectile, ejaculatory, and libido problems, especially at higher doses
Anxiolytics Altered libido in both genders; erectile problems and delayed ejaculation in men
Sildenafil citrate (Viagra) Enhances erectile ability in men with impaired potency
For more information on Focus Assessment Criteria, visit http://connection.lww.com.
Goal
The person will demonstrate decreased symptoms of sensory overload, as evidenced by (specify).
Indicators
  • Identify and eliminate the potential risk factors, if possible.
  • Describe the rationale for the treatment modalities.
General Interventions
Identify High-Risk Individuals
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Reduce or Eliminate Causative and Contributing Factors, When Possible
Excessive Noise or Light
Cover nonessential blinking lights at bedside with tape.
Dim lights at night.
Encourage use of blindfolds.
Decrease noise output.
  • Shut off nonessential alarms.
  • Encourage use of earplugs.
  • If possible, limit the use of flasher and similar equipment during sleep hours.
  • Turn off unnecessary equipment.
  • Position person away from direct source of noise, if possible.
  • Curtail nonessential personnel conversation.
  • Avoid loud noises.
  • Discourage television after 10 PM.
Share with person the source of the noise.
Discuss the use of a radio with earplugs to provide soft, relaxing music.
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Share with personnel the need to reduce noise and provide clients with uninterrupted sleep of at least 2 to 4 h duration.
Discuss the advantages of turning hearing aid off during high noise times.
Unfamiliar Environment
Attempt to reduce fears and concerns by explaining equipment, its purpose, and noises.
Encourage person to share his or her perceptions of noises.
Enlist the aid of an interpreter to explain the environment to person who does not speak English.
Promote Reorientation
Orient Client to All Three Spheres (Person, Place, Time)
Address person by name.
Introduce yourself frequently.
Identify the place.
Identify the time.
  • “Good morning, Mr. Jones. I am Mary Smith. I will be your nurse today.”
  • “Where are you, Mr. Jones? You are in the hospital.”
  • “Today is May sixth and it is eight-thirty in the morning.”
Explain All Activities
Offer simple explanations of each task.
Provide subjective and objective descriptions of sensations that will be experienced.
Allow person to handle equipment related to the task.
Allow client to participate in task, such as washing his or her face.
Acknowledge when you leave and when you will return.
Promote Movement
Encourage client to remain out of bed as much as possible (eat meals in chair).
Teach client to perform isometric and isotonic exercises when in bed.
Encourage client to change position frequently, even if it is just lifting one side off a surface by rolling slightly.
To encourage walking, choose a destination to reach or give the walk a purpose (walking to the lounge for breakfast).
Use Measures to Prevent Injury
Keep siderails in place and bed in lowest position.
Place call bell in convenient location.
Refer to Risk for Injury for additional interventions.
Assist Client to Differentiate Reality From Fantasy
Refer to Disturbed Thought Processes. for additional interventions.
Rationales
  • Promoting regular and varied sensory stimulation can help prevent alterations from prolonged sensory deprivation.
  • “Care givers should be aware that their actions and activity patterns may add to the environmental chaos or become a positive contribution to the therapeutic milieu” (Drury & Akins, 1991, p. 379).
  • Immobility or confinement reduces the quality and quantity of sensory input.
  • Explaining what sensory stimuli the person will experience before the experience reduces distress, tension, and confusion.
  • Wearing hearing aids in an excessively noisy environment (eg, clinic, intensive care unit) also can cause sensory overload.