Disturbed Sensory Perception (Sensory Overload) related to change in environment, and hearing loss (as evidenced by disorientation to time

and place; restlessness; and altered behavior)

Provide a consistent physical environment and a daily routine. Provide access to familiar objects, when possible. Provide a low-stimulation environment for Mrs. Hagstrom because disorientation may be increased by overstimulation. Provide for adequate rest, sleep, and daytime naps. Use a calm and unhurried approach when interacting with Mrs. Hagstrom. Speak to the client in a slow, distinct manner with appropriate volume. Engage Mrs. Hagstrom in concrete here and now activities (that is, ADLs) that focus on something outside the self that is concrete and reality oriented.

Routine eliminates the element of surprise, overstimulation, and further confusion. Familiarity helps reduce confusion. A disruption in the quality or quantity of incoming stimuli can affect a person s cognitive status. Sensory overload blocks out meaningful stimuli. Reduces overstimulation and fatigue, which may be contributing factors to confusion. Promotes communication that enhances the person s sense of dignity. The client who has difficulty hearing will be better able to lip read and comprehend speech. Assists the individual to differentiate between own thoughts and reality. Hearing can be enhanced if the volume is appropriate and the hearing aid is consistently used. Effective listening is essential in a nurse client relationship. Poor listening skills can undermine trust and block therapeutic communication. Using simple terms and short sentences facilitates understanding and minimizes anxiety. Gaining the attention of a client with a hearing impairment is an essential first step toward effective communication. However, the client s personal space should be respected and permission to touch should be obtained.

Facilitate use of hearing aids, as appropriate. Listen attentively. Use simple words and short sentences, as appropriate. Obtain Mrs. Hagstrom s attention through touc

Nursing Diagnosis: Bathing hygiene Self care deficit NANDA Definition: Impaired ability to perform or complete bathing/hygiene activities for oneself Defining Characteristics: Inability to: wash body or body parts; obtain or get to water source; regulate temperature or flow of bath water; get bath supplies; dry body; get in and out of bathroom Impaired physical mobility-functional level classification: y Completely independent Requires use of equipment or device Requires help from another person for assistance, supervision, or teaching Requires help from another person and equipment or device Dependent does not participate in activity Related Factors: Decreased or lack of motivation; weakness and tiredness; severe anxiety; inability to perceive body part or spatial relationship; perceptual or cognitive impairment; pain; neuromuscular impairment; musculoskeletal impairment; environmental barriers NOC Outcomes (Nursing Outcomes Classification) Suggested NOC Labels Self-Care: Activities of Daily Living (ADLs) Self-Care: Bathing Self-Care: Hygiene Nursing Interventions and Rationales y Assess client's ability to bathe self through direct observation (in usual bathing setting only) and from client/caregiver report, noting specific deficits and their causes. Use of observation of function and report of function provide complementary assessment data for goal and intervention planning . y If in a typical bathing setting for the client, assess via direct observation using physical performance tests for ADLs. Observation of bathing performed in an atypical bathing setting may result in false data for which use of a physical performance test compensates to provide more accurate ability data . y Ask client for input on bathing habits and cultural bathing preferences. Creating opportunities for guiding personal care honors long-standing routines, increases control, prevents learned helplessness, and preserves self-esteem. Cultural preferences are respected. y Develop a bathing care plan based on client's own history of bathing practices that addresses skin needs, self-care needs, client response to bathing and equipment needs. Bathing is a healing rite and should not be routinely scheduled with a task focus. It should be a comforting experience for the client that enhances health.. y Individualize bathing by identifying function of bath , frequency required to achieve function, and best bathing form to meet client preferences, preserve client dignity, make bathing a soothing experience, and reduce client aggression. Individualized bathing produces a more positive bathing experience and preserves client dignity. Client aggression is increased with shower and tub bathing. Towel bathing increases privacy and eliminates need to move client to central bathing area; therefore it is a more soothing experience than either showering or tub bathing. y Request referrals for occupational and physical therapy. Collaboration and correlation of activities with interdisciplinary team members increases the client's mastery of self-care tasks. y Plan activities to prevent fatigue during bathing and seat client with feet supported. Energy conservation increases activity tolerance and promotes self-care. y Provide medication for pain 45 minutes before bathing if needed. Pain relief promotes participation in self-care. y Consider environmental and human factors that may limit bathing ability, such as bending to get into tub, reaching required for bathing items, grasping force needed for faucets, and lifting of self. Adapt environment by placing items within easy reach, lowering faucets, and using a handheld shower. Environmental factors affect task performance. Function can be improved based on engineering principles that adapt environmental factors to the meet the client's capabilities. y Use any necessary adaptive bathing equipment. Adaptive devices extend the client's reach, increase speed and safety, and decrease exertion.

Provide privacy: have only one caregiver providing bathing assistance, encourage a traffic-free bathing area, and post privacy signs. The client perceives less privacy if more than one caregiver participates or if bathing takes place in a central bathing area in a high-traffic location that allows staff to enter freely during care . y Keep client warmly covered. Clients, especially elderly clients, who are prone to hypothermia may experience evaporative cooling during and after bathing, which produces an unpleasant cold sensation . y Allow client to participate as able in bathing. Smile and provide praise for accomplishments in a relaxed manner. The client's expenditure of energy provides the caregiver the opportunity to convey respect for a well-done task, which increases the client's self-esteem. Smiling and being relaxed are associated with a calm, functional client response. y Inspect skin condition during bathing. Observation of skin allows detection of skin problems. y Use or encourage caregiver to use an unhurried, caring touch. The basic human need of touch offers reassurance and comfort. y If client is bathing alone, place assistance call light within reach. A readily available signaling device promotes safety and provides reassurance for the client. Risk for ineffective airway clearance related to aspiration of tube feeding N U R S I N G C A R E OF T H E P A T I E N T W I T H A N A S O G A S T R I C T U B E a. P r ovi de g o o d o r a l h y g i e n e at r e g u l ar a n d f r e q u e n t i n t er va l s. O f f e r w a t e r or m o u t h w a s h to r i n se t h e m o u t h e v e r y h o u r . Assi st t h e pa ti e nt to b r u s h h i s t e e t h at l e a st ever y 4 hours. b. K e e p t h e nostr i l s f r e e of a c c u m u l a t i o n s of dr ied sec r eti on s. c. If perm i ssi bl e, a p p l y l ub r i c a nt s u c h as Vasel i ne to t h e li ps a n d nostr i l s f o r t h e pati ent's c o m f or t . P ati ents may w e a r lipstick. d. E n c o u r a g e t h e p ati en t to s w a l l o w s al i va n a t u r a l l y ; t h e t u b e is a c o n s t a n t s o u r c e of a n n o y a n c e a n d t h e p at i en t may h a v e a t e n d e n c y to e xp ec tor at e e xc e s s i v el y . The p hy s i c i a n may a l l o w c h e w i n g gum or h a r d c a n d y to h e l p m ai n t a i n m o u t h m o i s t ur e a n d to e n c o u r a g e n o r m a l s w a l l o w i n g of s al i v a. Only c o n sc i o u s , r e s p o n si ve , a l e r t pati en ts s h o u l d be g i v e n t h e s e i tem s. C A U T I O N : R e m i n d t h e pa ti e nt to r e m o v e gum or c a n d y b ef or e m o u t h c a r e a n d s l e ep. e. R e p o r t c om p l a i n t s a n d s i g n s of n o s e or t h r o a t irri tation ( e xc e s si v e m u c u s , s o r e t h r o a t , or h o a r s en e s s ) . f. E n c o u r a g e t h e pa ti e nt to c h a n g e posi ti on f r e qu e n t l y , u s i n g c a r e n o t to p u l l on t h e t u b e a n d n o t to l i e on t h e dr ai nag e t u b i n g . g. F o l l o w diet or der s e x a c t l y . If w a t e r or c l ea r f l ui d s a r e a l l o w e d by m o u t h , be s u r e to c h e c k on a m o u n t to be g i v e n at o n e ti m e. K n o w e x a c t l y w h e t h e r or n o t t h e t u b e is to be c l a m p e d when f l ui d s a r e g i v e n a n d at w h a t t i m e i n te r v al in r el ati on to o r a l i n ta ke. F o r e x a m p l e , t h e or d er may be to c l a m p t h e dr ai nag e t u b e f o r 1 h o u r af te r i nt ak e to a l l o w s o m e abs or pti o n y