Disturbed Sensory Perception | Nursing Care Plan for Spinal Cord Injury

Nursing diagnosis: Disturbed Sensory Perception May be related to Destruction of sensory tracts with altered sensory reception, transmission, and integration, Reduced environmental stimuli, Psychological stress—narrowed perceptual fields caused by anxiety

Possibly evidenced by
Measured change in sensory acuity, including position of body parts or proprioception
Change in usual response to stimuli
Motor incoordination
Anxiety, disorientation, bizarre thinking; exaggerated emotional responses

Desired Outcomes/Evaluation Criteria—Client Will
Neurological Status: Spinal Sensory/Motor Function
Recognize sensory impairments.
Knowledge: Personal Safety
Identify behaviors to compensate for deficits.
Verbalize awareness of sensory needs and potential for deprivation or overload.

Nursing intervention with rationale
1. Assess and document sensory function or deficit, such as by means of touch, pinprick, or heat and cold, progressing from area of deficit to neurologically intact area.
Rationale: Changes may not occur during acute phase, but as spinal shock resolves, dermatome charts or anatomic landmarks should document changes, such as, “2 inches above nipple line.”

2. Protect from bodily harm, such as falls, burns, and positioning of arm or objects.
Rationale: The client may not sense pain or be aware of body position.

3. Assist client to recognize and compensate for alterations in sensation.
Rationale: Increased attention to alterations in sensation may help reduce anxiety of the unknown and prevent injury.

4. Explain procedures before and during care while identifying the involved body part.
Rationale: These measures enhance client perception of “whole” body.

5. Provide tactile stimulation by touching the client in intact sensory areas, such as shoulders, face, and head.
Rationale: Touching conveys caring and fulfills normal physiological and psychological needs.

6. Position client to see surroundings and activities. Provide prism glasses when prone on turning frame. Talk to client frequently.
Rationale: These nursing actions provide sensory input, which may be severely limited, especially when client is in prone position.

7. Provide diversional activities, including television, radio, music, and liberal visitation. Use clocks, calendars, pictures, bulletin boards, and so on. Encourage SO and family to discuss general and personal news.
Rationale: The activities aid in maintaining reality orientation and provide some sense of normality in daily passage of time.

8. Provide uninterrupted sleep and rest periods.
Rationale: Adequate sleep and rest reduce sensory overload, enhance orientation and coping abilities, and aid in reestablishing natural sleep patterns.

9. Note presence of exaggerated emotional responses and altered thought processes, including disorientation and bizarre thinking.
Rationale: Exaggerated emotional responses and altered thought processes indicate damage to sensory tracts affecting reception or interpretation of stimuli, or psychological stress, requiring further assessment and intervention.