koz74686_ch38.

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998 UNIT IX / Promoting Psychosocial Health

CONCEPT MAP Sensory-Perception Disturbance

• Lived independently in own home for 15 years • Disoriented to place & time
• Recent removal of cataracts • Restless
JH • Experiencing more difficulty hearing • Withdrawn
89 y.o. female assess • Children concerned about her safety and lack • Stated "I'm afraid of all these strange
widow of socialization and urged her to enter creatures in this orphanage"
a nursing home • VS: WNL
• Confused • CXR, CBC, U/A: negative

generate nursing diagnosis

Disturbed Sensory-Perception (sensory overload) r/t change in environment and hearing loss

outcome outcome

Outcome met: Hearing Compensation

Cognitive
• Able to identify her Behavior aeb often
Orientation
nurse by name demonstrated:
aeb not Outcome met:
• Aware that Christmas • Positions self to
compromised: • Wears hearing
is 3 weeks away Evaluation advantage hearing Evaluation
• Identifies aid during
• Anxious to go shopping • Reminds others to
others, current the day
with the group use techniques
place, correct
• Wears hearing aid that advantage hearing
season
during the day • Eliminates background
noise
• Uses hearing aid
nursing intervention
nursing intervention

Reality Orientation Communication Enhancement: Hearing Deficit

activity activity
activity
activity
activity activity
Provide consistent Speak slowly
physical environment activity and distinctly
Use simple words,
and daily routine short sentences
activity
activity activity
Provide or
Provide access adequate Listen
to familiar objects rest and sleep attentively

Use calm Provide

unhurried a low-stimulus Facilitate use of Obtain attention
approach environment hearing aid through touch