Possibly evidenced by
Disorientation to time, place, person
Change in behavior pattern and usual response to stimuli; exaggerated emotional responses
Poor concentration, altered thought processes, bizarre thinking
Reported or measured change in sensory acuity: hypoparesthesia, altered sense of taste or smell
Inability to tell position of body parts (proprioception)
Inability to recognize or attach meaning to objects (visual agnosia)
Altered communication patterns
Desired Outcomes/Evaluation Criteria—Client Will
Regain and maintain usual LOC and perceptual functioning.
Acknowledge changes in ability and presence of residual involvement.
Demonstrate behaviors to compensate for or overcome deficits.
Nursing intervention with rationale:
1. Review pathology of individual condition.
Rationale: Awareness of type and area of involvement aids in assessing for and anticipating specific deficits and planning care.
2. Observe behavioral responses such as hostility, crying, inappropriate affect, agitation, and hallucination by using Los Ranchos Scale, as appropriate.
Rationale: Individual responses are variable, but commonalities, such as emotional lability, lowered frustration threshold, apathy, and impulsiveness, may complicate care. Eight-level Los
Ranchos Scale aids in documenting progress during initial weeks following insult.
3. Eliminate extraneous noise and stimuli as necessary.
Rationale: Reduces anxiety and exaggerated emotional responses and confusion associated with sensory overload.
4. Speak in calm, quiet voice, using short sentences. Maintain eye contact.
Rationale: Client may have limited attention span or problems with comprehension. These measures can help client attend to communication.
5. Ascertain and validate client’s perceptions. Reorient client frequently to environment, staff, and procedures.
Rationale: Assists client to identify inconsistencies in reception and integration of stimuli and may reduce perceptual distortion of reality.
6. Evaluate for visual deficits. Note loss of visual field, changes in depth perception (horizontal or vertical planes), and presence of diplopia.
Rationale: Presence of visual disorders can negatively affect client’s ability to perceive environment and relearn motor skills and increases risk of accident and injury.
7. Approach client from visually intact side. Leave light on; position objects to take advantage of intact visual fields. Patch affected eye or encourage wearing of prism glasses
Rationale: Provides for recognition of the presence of persons or objects; may help with depth perception problems; and prevents client from being startled. Patching may decrease the
sensory confusion of double vision, and prism glasses may enhance vision across midline, decreasing neglect of affected side.
8. Assess sensory awareness, such as differentiation of hot and cold, dull or sharp, position of body parts, and muscle and joint sense.
Rationale: Diminished sensory awareness and impairment of kinesthetic sense negatively affects balance and positioning (proprioception) and appropriateness of movement, which interferes
with ambulation, increasing risk of trauma.
9. Stimulate sense of touch—give client objects to touch and grasp. Have client practice touching walls or other boundaries.
Rationale: Aids in retraining sensory pathways to integrate reception and interpretation of stimuli. Helps client orient self spatially and strengthens use of affected side.
10. Protect from temperature extremes; assess environment for hazards. Recommend testing warm water with unaffected hand.
Rationale: Promotes client safety, reducing risk of injury.