Angelite Nurses: 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:________________
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Patient/Significant other signature

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RN signature

Angelite Nurses