Alteration in Sensory Perceptual
Alteration in Sensory Perceptual
(_)Actual (_) Potential
| (_)
Amputation (_) Bedrest (_) Cast (_) Hearing (_) Immobility (_) Impaired oxygen transport (_) Medications (_) Metabolic alterations (_) Neurological alterations (_) Pain |
(_)
Paraplegia (_) Physical isolation (_) Social isolation (_) Stress (_) Traction (_) Visual (_) Other:_____________________________ ____________________________________ ____________________________________ |
| 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