00122 Sensory perception disturbance

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00122 Sensory perception disturbance

Definition of the NANDA label

State in which the individual presents a change in the amount or in the pattern of sensory stimuli that he perceives, accompanied by a modification of the response to said stimuli.

Defining characteristics

• Disorientation in time, space and with respect to other people.
• Change in problem solving skills.
• Changes in behavior patterns.
• Reported or measured change in acoustic sensitivity.
• Agitation.
• Irritability.
• Changes in habitual response to stimuli.
• Alteration of communication patterns.
• Hallucinations.
• Lack of concentration.
• Visual and auditory distortions.
• Changes in communication patterns.
• Changes in usual responses to stimuli.

Related factors

• Alteration of sensory perception.
• Excess and insufficient environmental stimuli.
• Alteration of sensory reception, transmission or integration.
• Psychological stress.
• Biochemical imbalances due to sensory distortion (illusions, hallucinations).
• Electrolyte disorders.

NOC

• AVD personal care.
• Communication: receptive capacity.
• Hearing compensation behavior.
• Control of distorted thinking.
• Balance.
• Neurological status: central motor control.
• Muscle function.
• Sensory function: proprioceptive.
• Initial body position.
• Nutritional status: food and fluid intake
• Sensitive function: taste and smell.
• Neurological state: sensitive function.
• Sensitive function: cutaneous.
• Visual compensation behavior.
• Sensitive function: vision.
• Body image.

NIC

• Promotion of communication: hearing deficit.
• Handling illusory ideas.
• Management of hallucinations.
• Cognitive stimulation.
• Orientation of reality.
• Exercise therapy: balance.
• Neurological monitoring.
• Promotion of body mechanisms.
• Promotion of exercise: extension training.
• Liquid monitoring.
• Management of nausea.
• Nutritional monitoring.
• Nutrition management.
• Environmental management: safety.
• Management of altered peripheral sensitivity.
• Surveillance: security.
• Promotion of communication: visual deficit.
• Environmental management.
• Management of communication.
• Enhancement of self-esteem.
• Enhancement of body image.

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