Alteration in Sensory Perceptual

Alteration
in Sensory Perceptual

(_)Actual (_)
Potential

Related
To:
[Check
those that apply]
(_)
Amputation
(_) Bedrest
(_) Cast

(_) Hearing
(_) Immobility
(_) Impaired oxygen transport
(_) Medications
(_) Metabolic alterations
(_) Neurological alterations

(_) Pain

(_)
Paraplegia
(_) Physical isolation
(_) Social isolation
(_) Stress
(_) Traction

(_) Visual
(_) Other:_____________________________
____________________________________
____________________________________

 

As
evidenced by:
[Check
those that apply]
Major:

(
Must be
present
)
(_)
Inaccurate interpretation of environmental stimuli.
(_) Negative change in amount or pattern of incoming
stimuli.
Minor:

(
May be
present
)
(_)
Disoriented about person, place, or time.
(_) Altered problem solving ability.
(_) Altered behavior or communication pattern.
(_) Sleep pattern disturbances.
(_) Restlessness.
(_) Reports auditory or visual hallucinations.

(_) Fear.
(_) Anxiety.
(_) Apathy.

 

Date &
Sign.
Plan and Outcome
[Check
those that apply]
Target

Date:

Nursing Interventions
[Check
those that apply]
Date
Achieved:
  The
patient will:

(_)
Demonstrate optimal contact with reality.

(_) Demonstrate an
increase in self care activities.

(_) Experience
decreased symptoms of sensory overload.

(_) Other:

  (_)
Assess ability of patient to accurately interpret sensory
stimuli.

(_)
Monitor electrolytes, adequacy of BP.

(_) Organize nursing
care to provide uninterrupted sleep at night.

(_) Reduce unessential
stimuli, if possible. Orient to person, place, and time
with every nurse/patient contact.

(_) Encourage
interaction with familiar persons.

(_) Explain all
nursing care.

(_)
Other:________________
________________________
________________________
________________________

 

 

__________________________
Patient/Significant other signature

 

__________________________

RN signature