00123 Unilateral Desatunction

Domain 5: perception/cognition
Class 1: attention
Diagnostic Code 00123
Nanda label: unilateral neglect
Diagnostic focus: unilateral neglect
Approved 1986 • Revised 2006, 2017 • Evidence level 2.1

NANDA Nursing Diagnosis Definition

The Nanda nursing diagnosis « unilateral disattach Attention to the side of the body and its surroundings and excessive attention to the opposite side. The negligence on the left side is more severe than that of the right side.

Definite characteristics

  • Alteration of security behavior on the unattended side
  • Sound lateralization disturbance
  • Failure when dressing the neglected body side
  • Failure when eating foods on the part of the course corresponding to the unattended side
  • Failure when cleaning and fixing the unattended side
  • Failure when moving the eyes in the unattended hemiespace
  • Failure to move the head in the unattended hemiespace
  • Failure when moving the limbs in the unattended hemiespace
  • Failure to move the trunk in the unattended hemiespace
  • Failure to detect people who approach the unattended side
  • Hemianopia
  • DETERIORATION IN THE EXECUTION OF BISECTION TEST OF LINES
  • Performance deterioration in line cancellation tests
  • DETERIORATION IN THE EXECUTION OF OBJECTIVE CANCELLATION TEST
  • Left hemiplegia because of stroke
  • Eye pronounced deviation before stimuli on the unattended side
  • Funned deviation from the trunk before stimuli on the unattended side
  • omission of the drawing on the unattended side
  • Perseveration
  • Representational negligence
  • Replacement of letters to form alternative words when reading
  • Transfer of painful sensation to the unattended side
  • I know the position of the unattended member
  • Unilateral viso -spatial neglect
  • Write only in the vertical half of the page

Related factors

  • To develop

Associated problems

  • Cerebral lesions

Suggestions of use

Unilateral negligence can occur with medical diseases such as brain lesions, aneurysms or brain tumors, as well as stroke. In general, there are other nursing diagnoses associated with the pathophysiology of unilateral negligence, such as those included in the next section.

Suggested alternative diagnostics

  • Anxiety
  • Self -care, deficit of (specify)
  • injury, risk of

NOC Results

  • Attention to the affected side: Personal actions carried out to recognize, protect and integrate in a cognitive way, body parts to the self
  • Self -care: Activities of daily life (AVD): ability to perform physical tasks and more basic personal care activities independently, with or without help devices
  • Body placement: Self-initiated: Ability to change body posture itself, with or without the help of a device
  • Coordinated movement: muscles capacity to work voluntarily to achieve a certain movement

Evaluation objectives and criteria

  • Perform self -care: Activities of daily life (AVD), which is manifested by the following indicators (specify from 1 to 5: severely, substantially, moderately, slightly or not compromised): eat, dress, go to the toilet, Bath, groom yourself, keep hygiene, walk, move in a wheelchair and move
  • Other examples

    The patient will be able to:

    • Change the position of your body (specify: to be lying to sit; to be sitting to bed; to be kneeling to stand, etc.)
    • Recognize the degree of deficit
    • Modify behavior and environment to adjust to deficit
    • Demonstrate a better perception of the environment
    • Do not experience falls or other accidents

    NIC Interventions

    • The following interventions apply to unilateral negligence. Other interventions are likely to be required to treat the patient’s related factors (for example, cerebral edema)
    • Help in self -care: Help another person to carry out activities of daily life
    • Teaching: Individual: Planning, implementation and evaluation of an educational program designed to address the specific needs of a patient
    • Promotion of bodily mechanisms: Facilitation of the application of postures and movements in daily activities to prevent fatigue and lesions or musculoskeletal tensions
    • Unilateral negligence management: safe protection and reintegration of the affected part of the body, while the patient is helped to adapt to the deterioration of their perceptual abilities
    • Management of the environment: manipulation of the patient’s environment to obtain therapeutic benefit, sensory attraction and psychological well -being
    • Exercise therapy: Muscle control: monitoring of activity or exercise protocols to improve or restore controlled body movement

    Nursing Activities

    Valuations

    • Evaluate the nature and magnitude of the deficit
    • (NIC) Unilateral negligence management: monitor abnormal responses to the three main types of stimuli: sensory, visual and auditory.

    Patient and family education

    • Explain and strengthen the nature and magnitude of the deficit to the patient and his family
    • Provide information about community resources
    • (NIC) Unilateral negligence management ’, educate caregivers on causes, mechanisms and the treatment of unilateral negligence

    Collaboration activities

    • (NIC) Unilateral negligence management: consult physical and occupational therapists regarding strategies and the right time to facilitate the reintegration of body parts and ignored functions

    Others

    • Provide visual, olfactory and tactile stimuli
    • (NIC) Unilateral negligence management:
      • Provide realistic feedback on the patient’s perceptual deficit
      • Touch the shoulder not affected to start a conversation
      • Place food and drinks inside the visual field and turn the plate, as required
      • Reorganize the environment to use the right or left visual field, such as placing personal items, television or reading materials on the unseeded side
      • Gradually move the personal effects and activities to the affected side, as the patient demonstrates the ability to compensate for negligence
      • Help the patient to wash and groom the affected side first, as it demonstrates the ability to compensate for negligence
      • Keep the bed rail that corresponds to the affected side, as required
      • Ensure that the affected limbs are placed in an adequate and safe position
      • Include the family in the rehabilitation process to support the patient’s efforts and help with care, as required

    At home

    • Most previous activities can be used or adapted in home care
    • If possible, place the patient’s bed so that it can be incorporated on the unf affected side, especially when lifting at night to go to the bathroom