NURSING DIAGNOSIS: Sensory/Perceptual alterations

1. 2.

visual related to ischemia of portions of the visual pathways in the occipital lobe and the
parieto-occipitotemporal interpretative (association) area;

kinesthetic related to visual deficits and ischemia of portions of the parietal lobe
(primarily of the nondominant hemisphere) and the cerebellum.

Desired Outcome

The client will experience a reduction in and/or demonstrate beginning adaptation to sensory/perceptual alterations as evidenced by: 1. communication of same 2. increased participation in activities.
Nursing Actions and Selected Purposes/Rationales

1. Assess for signs and symptoms of: A. visual impairments such as homonymous hemianopsia and/or diplopia (e.g. lack of response to visual stimuli on side of hemiplegia, reports of double vision, decreased participation in activities) B. kinesthetic impairment (e.g. difficulty maintaining balance, determining body position, buttoning clothing, or locating mouth when trying to feed self; decreased participation in activities). 2. Implement measures to improve cerebral tissue perfusion (see Diagnosis 1, action b) in order to reduce cerebral ischemia. 3. Implement measures to assist client to adapt to changes in visual and/or kinesthetic functioning: A. provide an eyepatch or opaque lens for client to wear if diplopia is present B. if client is experiencing homonymous hemianopsia: I. perform actions to decrease the risk of startling client (e.g. approach client from unaffected side whenever possible, verbally acknowledge client before touching him/her if approaching on affected side) II. perform actions to ensure client receives visual stimuli (e.g. position client's bed and chair so that window or door to hall rather than blank wall is within visual field, instruct visitors to sit or stand on client's unaffected side) III. after condition has stabilized, place some items (e.g. television, clock, calendar, pictures) on affected side to promote environmental scanning

C. if client is experiencing kinesthetic impairments, place him/her in front of a full-length mirror during activities when possible after condition has stabilized (viewing his/her reflection may help the client to identify body position and vertical and horizontal planes) D. perform actions to facilitate performance of self-care activities (see Diagnosis 7, actions b.3 and 4) E. consult physical and occupational therapists about additional ways to facilitate client's adaptation to sensory/perceptual impairments F. inform significant others and health care personnel of approaches being used to increase client's awareness of affected side; encourage their use of these techniques. 4. Consult appropriate health care provider (e.g. physical therapist, occupational therapist, physician) if sensory/perceptual alterations worsen or client is unable to adapt to the ones he/she is experiencing.