section name header

Information

  1. TYPES OF SENSORY DISTURBANCE:
    1. Sensory deprivation—amount of stimuli less than required, such as isolation in bed or room, deafness, victim of stroke (brain attack).
    2. Sensory overload—receives more stimuli than can be tolerated (e.g., bright lights, noise, strange machinery, barrage of visitors).
    3. Sensory deficit—impairment in functioning of sensory or perceptual processes (e.g., blindness, changes in tactile perceptions).
  2. ASSESSMENT—based on awareness of behavioral changes:
    1. Sensory deprivation—boredom, daydreaming, increasing sleep, thought slowness, inactivity, thought disorganization, hallucinations.
    2. Sensory overload—same as sensory deprivation, plus restlessness and agitation, confusion.
    3. Sensory deficit—may not be able to distinguish sounds, odors, and tastes or differentiate tactile sensations.
  3. ANALYSIS/NURSING DIAGNOSIS: problems related to sensory disturbance:
    1. Altered thought processes.
    2. Confusion (acute vs. chronic).
    3. Anger, aggression.
    4. Body-image disturbance.
    5. Sleep pattern disturbance.
  4. NURSING CARE PLAN/IMPLEMENTATION:
    1. Management of existing sensory disturbances in:
      1. Acute sensory deprivation:
        1. Increase interaction with staff.
        2. Use TV.
        3. Provide touch.
        4. Help clients choose menus that have aromas, varied tastes, temperatures, colors, textures.
        5. Use light cologne or aftershave lotion, bath powder.
      2. Sensory overload:
        1. Restrict number of visitors and length of stay.
        2. Reduce noise and lights.
        3. Reduce newness by establishing and following routine.
        4. Organize care to provide for extended rest periods with minimal input.
      3. Sensory deficits:
        1. Report observations about hearing, vision.
        2. May imply need for new glasses, medical diagnosis, or therapy.
    2. Health teaching: prevention of sensory disturbance involves education of parents during child's growth and development regarding tactile, auditory, and visual stimulation.
      1. Hold, talk, and play with infant when awake.
      2. Provide bright toys with different designs for children to hold.
      3. Change environment.
      4. Provide music and auditory stimuli.
      5. Give foods with variety of textures, tastes, colors.
  5. EVALUATION/OUTCOME CRITERIA:
    1. Client is oriented to time, place, person.
    2. Little or no evidence of mood or sleep disturbance.