Question

DISTURBED SENSORY PERCEPTION AUDITORY

Nursing care plan:

Assessment, diagnosis, planning,intervention, Evaluation

Answer 1

DISTURBED SENSORY PERCEPTION AUDITORY

ASSESSMENT

SUBJECTIVE DATA:

" I can neither hear nor understand what you are speaking , nurse" as verbalized by the patient.

OBJECTIVE DATA:

Irritability inthe right eardue to thefluid.

Impairedcommunication.

NURSING DIAGNOSIS:

Disturbed auditory sensory perception related to ear discomfort secondary to surgical procedure done.

PLANNING

After 2 hours of nursing intervention,the patient will be able to:

verbalize understanding about the health teaching done.

demonstrate some non-verbal gestures.

Interpret verbal and non verbal messages.

demonstrate understanding by a verbal, written, or signed response

demonstrates relaxed body movements and facial expressions

explains plan to modify lifestyle to accommodate visual or hearing impairment

remains free of physical harm resulting from decreased balance or a loss of   

hearing sensation

maintains contact with appropriate community resources

INTERVENTIONS

1.Instruct thepatient inusing safe techniques for cleaning ears.

RATIONALE: Thin wash cloths and fingersare best for cleaning the ears. Cotton-tipped applicators should be avoided to prevent injury to the eardrum.

2. Teach some non-verbal gestures.

RATIONALE:Teaching of non-verbal gestures will help the patient understand the words others will utter.

3.Instruct patient to have a routine examination by an audiologist.

RATIONALE:Examinations will be the best source to check for the status of the auditory senses.

4.Keep background noise to a minimum. Turn off television and radio when communicating with client.

RATIONALE : Background noise significantly interferes with hearing in the hearing-impaired client.

5. Stand or sit directly in front of client when communicating. Make sure adequate light is on nurse's face, avoid chewing gum or covering mouth or face with hands while speaking, establish eye contact, and use nonverbal gestures.

RATIONALE: These measures make it easier to read lips and see nonverbal communication, which is a large component of all communication .

6. Speak distinctly in lower voice tones if possible. Do not over-enunciate or shout at client.

RATIONALE: In many kinds of hearing loss, clients lose the ability to hear higher-pitched tones but can still hear lower-pitched tones. Over-enunciating makes it difficult to read lips. Shouting makes the words less clear and may be painful.

7. If necessary, provide a communication board or personnel who know sign language.

RATIONALE: Alternative forms of communication help decrease social isolation.

6. Try inserting the earpieces of the stethoscope into the client's ears, and talking into diaphragm.

RATIONALE: Stethoscopes magnify sound and can help some clients hear better.

7. Refer to appropriate resources such as a speech and hearing clinic; audiologist; or ear, nose, and throat physician.

RATIONALE: Hearing loss can be treated with medical or surgical interventions or use of a hearing aid.

8.Encourage client to wear hearing aid, but understand if he or she chooses to leave hearing aid out.

RATIONALE:Hearing aids amplify all noise, and loud noises in the environment can be amplified to an unbearable volume.

9. Observe emotional needs and encourage expression of feelings.

RATIONALE: Hearing impairments may cause frustration, anger, fear, and self-imposed isolation

10. Patient and family teaching:

Suggest installation of devices such as telephone amplifiers, speaker phones,

pocket talker personal listening system, and FM and infrared amplification systems that connect directly to a TV or audio output jack.

Use of a hearing ear dogs specially trained to alert their owners to specific sound—may also be helpful.

Teach family how to provide appropriate stimuli in the home environment to prevent disturbed sensory perception.

Refer to hearing clinics.

EVALUATION

Patient is able to understand health teaching and answers appropriately to the questions asked.

Patient has relaxed body movements and facial expressions.