Looking for nursing daignosis

  1. Gotta come up with a nursing diagnosis from NANDA that covers the following. This is part of a basic needs assessment that we have to assess and list nsg dx for such things as sleep patterns, sensory, thought process, psychosocial data, activity-exercise, elimination, etc.

    The only one I am having a problem with is the sensory-perceptual. The person is almost blind d/t macular degeneration and in a wheelchair. Needs sit/stand lift and level 4 assistance. Also has hrg deficit but refuses hearing aids. very sensitive to touh and pain.

    I just can't come up with a nursing dx that would fit here iexclusively. Can anyone help me out here? I was thinking sedentary lifestyle but are there others directly related to loss of sensory perceptions?

    Thinking Disturbed Sensory preception related to macular degeneration, loss of hearing, altered communication pattern as evidenced by inability to see and hear well, extreme sensitivity to touch and pain, inability to orient to time.
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    About kukukajoo

    Joined: Dec '05; Posts: 1,375; Likes: 248

    5 Comments

  3. by   Daytonite
    yes, your thinking is correct. the official nanda diagnosis(es) for a visual or hearing loss or impairment is disturbed sensory perception: (specify as visual, auditory, kinesthetic [movement], gustatory [taste], tactile, olfactory. the related factors, and these are right out of nursing diagnoses: definitions & classification 2005-2006 published by nanda international, page 173, are:
    • altered sensory perception
    • excessive environmental stimuli
    • psychological stress
    • altered sensory reception, transmission, and/or integration
    • insufficient environmental stimuli
    • biochemical imbalances for sensory distortion (e.g., illusions, hallucinations)
    • electrolyte imbalance
    • biochemical imbalance
    you can't use macular degeneration as a "related to" factor as it is a medical diagnosis. however, if you break that down into it's symptoms (central vision loss, wavy vertical lines in the middle of the visual field, middle of the visual field appears fuzzy, smudged or empty to the patient, and/or loss of color vision) http://www.fpnotebook.com/eye93.htm, you can use the symptoms as "defining characteristics", or aeb part of your diagnostic statement. loss of hearing and the inability to hear and see well would be symptoms of altered sensory reception. extreme sensitivity to touch and pain would also be altered sensory reception or altered sensory integration.

    with the inability to orient to time i might be inclined to look at other nursing diagnoses because of the cause of this disorientation. i would look at:
    • acute confusion
    • chronic confusion
    • impaired memory
    • disturbed thought processes
    you would be helped greatly if you have a nursing diagnosis book to help you out since these list the related factors and defining characteristics that are an integral part of each nursing diagnosis. at least one of the related factors of a nursing diagnosis must be present in order to apply that particular diagnosis to someone. here are two web pages from an online care plan constructor site for the nursing diagnosis disturbed sensory perception for you to look at.
    1. http://www1.us.elsevierhealth.com/me...ex.cfm?plan=46 - disturbed sensory perception: visual
    2. http://www1.us.elsevierhealth.com/me...ex.cfm?plan=45 - disturbed sensory perception: auditory
    hope that gives you the kick-start you need to complete your assignment.
  4. by   kukukajoo
    Thank you so much! I do have the nsg dx handbook but just are not familiar enough with them all yet. I think I need to keep it by my bed for nighttime reading or something!

    One instructor lets us use med. dx and the other won't from what I hear.

    Thank you so much for the ideas! I am almost done (finally!) it's only taken me almost 2 days!
  5. by   Daytonite
    it gets better! the whole point to doing these in school is to learn what each diagnosis is about. and, now you know a little more about nursing diagnoses and sensory deficits!

    i don't normally go against anything an instructor would tell anyone, at least publicly, however, when it comes to making heads or tails of a subject such as nursing process and written care planning, i feel that any supplemental books that are going to help you are worth having in your home arsenal, i mean, library! nursing diagnosis handbook: a guide to planning care, 7th edition, by betty j. ackley and gail b. ladwig has an extensive index at it's beginning that cross-references you to potential nursing diagnoses by medical diagnosis, medical and diagnostic procedures, symptoms and problems. some of this extensive index, but not all of it, is listed on their online care plan constructor site at this link:
    http://www1.us.elsevierhealth.com/ev...e/constructor/
    i did check it earlier looking for the nursing diagnosis of disturbed sensory perception. however, it, unfortunately, is one of the nursing diagnoses that was not included on their care plan constructor site. there was good information on it in the book itself though. i have heard that there is another care plan or nursing diagnosis book out there that has a similar indexing, but i do not recall which one it is, so i have not seen what it looks like. this indexing, i think, is very helpful when you are new at choosing nursing diagnoses. it helps send you to potential nursing diagnoses you could be using.
  6. by   kukukajoo
    That's the book I have thankfully! It has a companion as well that I ordered too!

    yeah my instructors say we don't need any other books than the required. But I have to confess- I have a TON of books so far! The more I learn the better for me is the way I look at it!

    Thanks so much for helping me- you saved me HOURS (even though I probably spent 12 on this assignment already!), and that I appreciate so very much! I also registered for the site that comes with it and the builder is great but does not list all of the dx. I am reviewing my work now and pray I got it all and did not forget something! I hear the first one is always a challenge and this only has to have diagnosis not care plan and interventions!!

    Take care!
  7. by   Daytonite
    No time is ever wasted, kiddo, if you learned something from it. Think of all the students who have yet to advance to the point you are now at. Take the time and opportunity to teach this to your fellow students. It will help consolidate these techniques of the nursing process in your own mind.

    As for the constructor site for the Ackley and Ladwig book, I've done a mock care plan on it and printed it out. The print out is only a bare bones plan and I don't think it meets the requirements of what a student needs to turn in for a grade. However, it's helpful.

    As long as your AEB symptoms support the R/T cause of each of your nursing diagnoses you should be OK with them. Be careful to avoid using medical diagnoses. The trick is to break down a medical diagnosis into it's component symptoms. Those symptoms are fair game for us nurses to use as well as the docs in formulating our nursing diagnoses. Use your Ackley and Ladwig diagnosis book to do some critical thinking about what related factors for a diagnosis fit as the cause of one or more of those symptoms. You'll have it nailed. Later you'll be including symptoms that are the signs and symptoms YOU discovered when you did your nursing assessment of the patient. It all adds a little more depth to the care plan.

    Best wishes. Sounds like you're probably on your way to some good care plan writing! (Just what everyone wants to be known for! )

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