Risk for Disturbed Sensory Perception,

Nursing diagnosis: Risk for Disturbed Sensory Perception

Risk factors may include
Endogenous chemical alteration: glucose and insulin and electrolyte imbalance

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Neurological Status
Maintain usual level of mentation.
Recognize and compensate for existing sensory impairments.

Nursing intervention with rationale:
1. Monitor vital signs and mental status.
Rationale: Provides a baseline from which to compare abnormal findings, for instance, fever may affect mentation.

2. Address client by name; reorient as needed to place, person, time, and situation. Give short explanations, speaking slowly and enunciating clearly.
Rationale: Decreases confusion and helps maintain contact with reality.

3. Schedule nursing time to provide for uninterrupted rest periods.
Rationale: Promotes restful sleep, reduces fatigue, and may improve cognition.

4. Keep client’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able.
Rationale: Helps keep client in touch with reality and maintain orientation to the environment.

5. Protect client from injury—avoid or limit use of restraints as able, place bed in low position—when cognition is impaired. Pad bed rails if client is prone to seizures.
Rationale: Disoriented client is prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions reduce risk of physical injury.

6. Evaluate visual acuity, as indicated.
Rationale: Retinal edema or detachment, hemorrhage, presence of cataracts, or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy or supportive care.

7. Investigate reports of hyperesthesia, pain, or sensory loss in the feet and legs. Look for ulcers, reddened areas, pressure points, and loss of pedal pulses.
Rationale: Peripheral neuropathies may result in severe discomfort and absent or distorted tactile sensation, potentiating risk of dermal injury and impaired balance. Note: Mononeuropathy affects a single nerve (most often femoral or cranial), causing sudden pain and loss of motor and sensory function along affected nerve path.

8. Provide bed cradle. Keep hands and feet warm, avoiding exposure to cool drafts, hot water, or heating pad.
Rationale: Reduces discomfort and potential for dermal injury. Note: Sudden development of cold hands and feet may reflect hypoglycemia, suggesting need to evaluate serum glucose level.

9. Assist with ambulation or position changes.
Rationale: Promotes client safety, especially when sense of balance is affected.

10. Monitor laboratory values, such as blood glucose, serum osmolality, Hgb/Hct, and BUN/Cr.
Rationale: Imbalances can impair mentation. Note: If fluid is replaced too quickly, water intoxication can occur—sodium concentration falls, water enters brain cells, and confusion, disorientation, or coma may develop.