Nursing Week 12 - Self Concept And Sexuality

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Self-Concept

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the collection of ideas, feelings, and beliefs one has about oneself

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Self-Esteem

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the value one has for oneself; self-confidence

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Personal Identity (Self Identity)

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the conscious sense of individuality and uniqueness that is continually evolving throughout life.

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Body Image

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how a person perceives the size, appearance, and functioning of his or her body and its parts

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Role performance

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what a person does in a particular role in relation to the behaviors expected of that role

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Four components of self-concept are:

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personal identity, body image, role performance, and self-esteem

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Key Factors that influence a person's self-concept

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Stage of development, family and culture, stressors, resources, history of success and failure, and illness.

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Stressors that affect components of Self-Concept

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Resources: internal and external, History of Success and Failure, and Illness

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Identity Stressors

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Change in physical appearance, Declining physical,mental, or sensory abilities, Inability to achieve goals, Relationship concerns, Sexuality concerns, Unrealistic ideal self

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Body Image Stressors

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Loss of body parts, Loss of body functions, Disfigurement, Unrealistic body ideal

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Behaviors associated with low self-esteem

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Avoids eye contact, Stoops in posture and moves slowly, Is poorly groomed and has an unkempt appearance, Is hesitant or halting in speech, Is overly critical of self, May be overly critical of others, Is unable to accept positive remarks about self, Apologizes frequently, Verbalizes feelings of hopelessness, helplessness, and powerlessness.

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Disturbed Body Image

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Confusion in mental picture of one's physical self

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Disturbed Body Image - Related Factors

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Biophysical; cognitive; cultural; developmental changes; illness; illness treatment; injury; perceptual; psychosocial; spiritual; surgery; trauma

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Situational low self-esteem

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Development of a negative perception of self-worth in response to a current situation (specify)

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Situational low self-esteem - Related Factors

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Behavior inconsistent with values; developmental changes; disturbed body image; failures; functional impairment; lack of recognition; loss rejections; social role changes

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Risk for situational low Self-esteem

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At risk for developing negative perception of self-worth in response to a current situation (specify)

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Risk for situational low Self-esteem - Risk Factors

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Behavior inconsistent with values; decreased control over environment; developmental changes; disturbed body image; failures; functional impairment; history of abandonment; history of abuse; history of learned helplessness; history of neglect; lack of recognition; loss; physical illness; rejections; social role changes; unrealistic self-expectations

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Disturbed Body image - Defining Characteristics - General

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Behaviors of acknowledgment of one's body; behaviors of avoidance on one's body; behaviors of monitoring one's body; nonverbal response to actual change in body (e.g., appearance, structure, or function); nonverbal response to perceived change in body (e.g., appearance, structure, or function); verbalization of feelings that reflect an altered view of one's body (e.g. appearance, structure, function); verbalization of perceptions that reflect an altered view of one's body appearance

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Disturbed Body image - Defining Characteristics - Objective

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Actual change in function; actual change in structure; behaviors of acknowledging one's body; behaviors of monitoring one's body; change in ability to estimate spatial relationship of body to environment; change in social involvement; extension of body boundary to incorporate environmental objects; intentional hiding of body part; intentional overexposure of body part; missing body part; not looking at body part; not touching body part; trauma to nonfunctioning part; unintentional hiding of body part; unintentional overexposing of body part

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Disturbed Body image - Defining Characteristics - Subjective

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Depersonalization of loss by impersonal pronouns; depersonalization of part by impersonal pronouns; emphasis of remaining strengths; fear of reaction by others; fear of rejection by others; focus on past appearance; focus on past function; focus on past strength; heightened achievement; negative feelings about body (e.g., feeling of helplessness, hopelessness, or powerlessness); personalization of loss; personalization of part by name; preoccupation with change; preoccupation with loss; refusal to verify actual change; verbalization of change in lifestyle

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Situational low Self-esteem - Defining Characteristics

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Evaluation of self as unable to deal with situations or events; expressions of helplessness; expressions of uselessness; indecisive behavior; nonassertive behavior; self-negating verbalizations; verbally reports current situational challenge to self-worth

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Risk for situational low self esteem - Interventions and Rationales

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Identify environmental and/or developmental factors that increase risk for low self-esteem, especially in children/adolescents, to make needed referrals. EBN: Self-esteem enhancement programs can improve self-esteem in school-age children.
• Assess the client's previous experiences with health care and coping with illness to determine the level of education and support needed. EBN: Experienced clients report needing a different level of support than inexperienced clients.
• Assess for low and negative affect (expression of feelings). EBN: Self-esteem is more closely associated with affect than self-acceptance is.
• Encourage client to maintain highest level of community functioning. EBN: Community volunteerism supports improved self-esteem.
• Treat the client with respect and as an equal to maintain positive self-esteem. EBN: Clients with higher self-esteem need to be confirmed as being equal with care providers.
• Help the client to identify the resources and social support network available at this time. EBN: Greater resourcefulness positively affects feelings of self-worth.
• Assess for unhealthy coping mechanisms, such as substance abuse. More than 50% of people with mental illness also have substance abuse, and low self-esteem increases the risk further.
• Encourage the client to find a self-help or therapy group that focuses on self-esteem enhancement. EBN: Group therapy provides a safe place for feeling exploration, validation, positive role models, and gaining knowledge.
• Teach the client mindfulness techniques to cope with strong emotional responses and to prevent decreases in self-esteem. EBN: Mindfulness strategies increase resolution of internal conflict and promote relaxation.
• Encourage the client to create a sense of competence through short-term goal setting and goal achievement. EB: Sense of competence is related to global self-esteem.
- Assess the client for symptoms of depression and anxiety. Refer to specialist as needed. Prompt and effective treatment can prevent exacerbation of symptoms or safety risks.
• Teach client a systematic problem-solving process. Crisis provides an opportunity for effective change in coping skills.

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Situational low self-esteem - Interventions and Rationales

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- Assess the client for signs and symptoms of depression and potential for suicide and/or violence.
If present, immediately notify the appropriate personnel of symptoms.
• Actively listen to, demonstrate respect for, and accept client. EBN: Encounters between client and caregivers affect the client's emotional status and well being.
• Assist in the identification of problems and situational factors that contribute to problems, offering options for resolution. EBN: Clients often expect professionals to recommend remedies to problems and need encouragement to participate in selecting treatment options.
• Mutually identify strengths, resources, and previously effective coping strategies. EBN: Knowledgeable clients make better decisions regarding their health care.
• Have client list strengths. EBN: Clients were found to use a variety of self-care strategies, medication management techniques, and emotional supports to alleviate symptoms of chronic heart failure (CHF).
• Accept client's own pace in working through grief or crisis situations. Maladjustment to loss or change can have detrimental effects on the entire concept of self (Drench, 1994).
• Accept the client's own defenses in dealing with the crisis. Decision-making behaviors adapt and change with time and experience
.• Assess for unhealthy coping mechanisms, such as substance abuse. More than 50% of clients with mental illness also have substance abuse, and low self-esteem increases the risk further.
• Provide information about support groups of people who have common experiences or interests. EB: Social support and healthy interpersonal relationships foster improved mental and physical health.
• Teach the client mindfulness techniques to cope more effectively with strong emotional responses. EBN: Development of mindfulness strategies increased resolution of internal conflicts.
• Support problem-solving strategies but discourage decision making when in crisis. EBN: Uncertainty is a significant negative predictor of resourcefulness.
• Assess the client's environmental and everyday stressors, including evidence of abusive relationships. EBN: High everyday stressors and a history of abuse in relationships are associated with low self-esteem and depressionr.
• Encourage objective appraisal of self and life events and challenge negative or perfectionist expectations of self. EB: Positive life events improve self-esteem and positive affect.
• Provide psychoeducation to client and family. EBN: Knowledge provides empowerment, which will increase self-esteem.
• Validate confusion when feeling ill but looking well. EBN: Validation of emotions is related to a client's experience of caring.
• Acknowledge the presence of societal stigma. Teach management tools. EBN: Stigma was reported as a major influence on whether depressed and/or suicidal clients sought treatment.
• Validate the effect of negative past experiences on self-esteem and work on corrective measures. People with low self-esteem have a need to be affirmed regarding their value.

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Disturbed Body Image - Interventions and Rationales

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• Incorporate psychosocial questions related to body image as part of nursing assessment to identify clients at risk for body image disturbance (e.g., body builders, cancer survivors, clients with eating disorders, burns, skin disorders, polycystic ovary disease, or those with stomas/ostomies/ colostomies or other disfiguring conditions). EB: Assessment of psychosocial issues can help to identify clients at risk for body image concerns as a result of a disfiguring condition.
• If client is at risk for body image disturbance, consider using a tool such as the Body Image Quality of Life Inventory (BIQLI), which quantifies both the positive and negative effects of body image on one's psychosocial quality of life. EB: A favorable body image quality of life "was related to higher self-esteem, optimism, and social support in both sexes and less eating disturbance among women. EBN: Using a body image scale can help nurses to identify possible body image disturbances and to plan individual nursing interventions.
- Assess for body dysmorphic disorder (BDD) and refer to psychiatry or other appropriate provider. BDD is characterized by a preoccupation with an imagined defect in appearance that causes significant distress or impairment in social, occupational, or other areas of functioning. EB: Clients ivtto BDD often seek medical treatment in dermatology or other areas to correct the imagined defect and thus may be seen by many healthcare providers. Phillips & Diaz (1997) found that approximately 20% of clients receiving psychiatric treatment for BDD had cosmetic surgery.
- Assess for the possibility of muscle dysmorphia (pathological preoccupation with muscularity and leanness; occurs more often in males than in females) and make appropriate referrals. EB: This condition is often seen among body builders or those in sports that emphasize size and bulk (e.g., wrestling) and will likely continue to increase with the societal focus on body image. Fluoxetine alone or in combination with CBT may be an effective treatment.
- Assess client and family response to surgery that results in a change in body and offer support. EBN: A qualitative study by Notter and Burnard (2006) revealed that although many clients and family members received education before surgery, most felt the reality of it differed significantly from their expectations.
- If nursing assessment reveals body image concerns related to a disfiguring condition, assist client in voicing his/her concerns and if appropriate, coaching the client in how to respond to questions from others in social situations. If within the nurse's level of expertise, may assist client in graded practice in social situations (e.g., going to hairdresser, swimming pool). EB: Many clients with disfiguring conditions are concerned about and may avoid exposing the disfigurement to others' gaze and displays of ignorance and negative comments by others
- Refer clients with body image disturbance for CBT and/or social skills training if indicated. EB: CBT and social skills training help clients learn new mental scripts for interacting with others, challenge negative thoughts and replacing these with new thoughts, and applying new behaviors and thoughts in social situations.
- Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle. However, allow client to share emotions when they are ready, rather than rushing them. EB: The influence of emotion-focused coping (venting emotions and mental disengagement) on distress following disfiguring injury was associated with less body image disturbance.
- Encourage the client to discuss interpersonal and social conflicts that may arise. EB: Changes in physical appearance and function associated with disease processes (and sometimes treatment) need to be integrated into the interaction that occurs between clients and lay caregivers.
- Explore opportunities to assist the client to develop a realistic perception of his or her body image. EB: Actual body size may not be consistent with the client's perceived body size. Inaccurate perception by the client can be unhealthy.
- Help client describe self-ideal, and identify self-criticisms, to foster acceptance of self. EB: The perception of self-image involves knowing the self and what is important and valued. Disability causes individuals to live as changed human beings regardless of whether they are willing to do so.
- Encourage clients to verbalize treatment preferences and play a role in treatment decisions. EB: Women who received the treatment they preferred for stage 1 or 2 breast cancer had better body image (and mental health) than women who did not. Good communication between physicians and women improved outcomes.
- Encourage the clients to write a narrative description of their changes. EB: One's experience of coping or adjustment to a disability is represented as narratives about himself or herself. Each person with traumatic brain injury (TBI) reconstructed certain self narratives when coping with their changed self-images and daily lives.
- Take cues from clients regarding readiness to look at wound (may ask if client has seen wound yet) and utilize client's questions or comments as way to teach about wound care and healing. EB: Clients with disfiguring conditions, in this case burns, respond in a variety of ways, and the severity of the disfigurement does not always predict impact on body image. Tailoring interventions to individual clients and reading their nonverbal cues likely contributes to clients' ability to heal emotionally from impact of wound on body image.
- Encourage the client to continue same personal care routine that was followed before the change in body image. It is preferable that this care be completed in the bathroom and not in bed. EBN: This routine gives the client privacy and also prevents the client from settling into an "invalid" role. Women who resume familiar routines and habits heal better and suffer less depression than those who settle into the role of client.

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Sexuality

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is an individually expressed and highly personal phenomenon whose meaning evolves from life experiences. Physiologic, psychosocial, and cultural factors influence a person's sexuality and lead to the wide range of attitudes and behaviors seen in humans.

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PLISSIT

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P - Permission giving
LI - Limited information
SS - Specific suggestions
ITI - ntensive therapy

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Sexual health

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the integration of the somatic, emotional, intellectual, and social aspects of sexuality, in ways that are positively enriching and that enhance personality, communication, and love

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Sexual Development - Characteristics - Infancy - Birth to 18 months

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Given gender assignment of male or female. Differentiates self from others gradually. External genitals are sensitive to touch.
Male infants have penile erections; females, vaginal lubrication.

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Sexual Development - Characteristics - Toddler - 1-3 years

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Continues to develop gender identity. Able to identify own gender.

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Sexual Development - Characteristics - Preschooler - 4-5 years

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Becomes increasingly aware of self. Explores own and playmates' body parts. Learns correct names for body parts. Learns to control feelings and behavior. Focuses love on parent of the other sex.

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Sexual Development - Characteristics - School Age - 6-12 years

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Has strong identification with parent of same gender.
Tends to have friends of the same gender.
Has increasing awareness of self.
Increased modesty, desire for privacy.
Continues self-stimulating behavior.
Learns the role and concepts of own gender as part of the total self-concept.
At about 8 or 9 years becomes concerned about specific sex behaviors and often approaches parents with explicit concerns about sexuality and reproduction.

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Sexual Development - Characteristics - Adolescence - 12-18 years

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Primary and secondary sex characteristics develop. Menarche usually takes place.
Develops relationships with interested partners.
Masturbation is common.
May participate in sexual activity.
May experiment with homosexual relationships. Are at risk for pregnancy and sexually transmitted diseases.

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Sexual Development - Characteristics - Young Adulthood - 18-40 years

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Sexual activity is common.
Establishes own lifestyle and values. Homosexual identity usually established by mid-20s. Many couples share financial obligations and household tasks.

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Sexual Development - Characteristics - Middle Adulthood - 40-65 years

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Men and women experience decreased hormone production.
The menopause occurs in women, usually anywhere between 40 and 55 years.
The climacteric occurs gradually in men.
Quality rather than the number of sexual experiences becomes important.
Individuals establish independent moral and ethical standards.

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Sexual Development - Characteristics - Late Adulthood- 65 years and over

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Interest in sexual activity often continues. Sexual activity may be less frequent.
Women's vaginal secretions diminish, and breasts atrophy.
Men produce fewer sperm and need more time to achieve an erection and to ejaculate.

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Sexual Self-concept

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One's sexual self-concept (how one values oneself as a sex¬ ual being) determines with whom one will have sex, the gender and kinds of people a person is attracted to, and the values about when, where, with whom, and how one expresses sexuality. A positive sexual self-concept enables people to form intimate relationships throughout life. A negative sexual self-concept may impede the formation of relationships.

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Sexual Body image

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a central part of the sense of self, is constantly changing. Pregnancy, aging, trauma, disease, and therapies can alter an individual's appearance and function, which can affect body image. How a person feels about his or her body is related to one's sexuality. People who feel good about their bodies are likely to be comfortable with and enjoy sexual activity. People who have a poor body image may respond negatively to sexual arousal. A major influence on body image for women is the media focus on physical attractiveness and large breasts. Likewise, many men worry about penis size. The myth that "larger is better," particularly if it is erect and has staying power, is pervasive in North America. A person's body image can suffer when unable to achieve these expectations.

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Characteristics of Sexual Health

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- Knowledge about sexuality and sexual behavior
- Ability to express one's full sexual potential, excluding all forms of sexual coercion, exploitation, and abuse
- Ability to make autonomous decisions about one's sexual life within a context of personal and social ethics
- Experience of sexual pleasure as a source of physical, psychologic, cognitive, and spiritual well-being
- Capability to express sexuality through communication, touch, emotional expression, and love
- Right to make free and responsible reproductive choices
- Ability to access sexual health care for the prevention and treatment of all sexual concerns, problems, and disorders

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Factors Influencing Sexuality

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family, culture, religion, personal expectations and ethics.

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Sexual Health History Questions

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Are you currently sexually active? With men, women, or both? With one or more than one partner?
Describe the positive and negative aspects of your sexual functioning.
Do you have difficulty with sexual desire? Arousal? Orgasm?
Satisfaction?
Do you experience any pain with sexual interaction?
If there are problems, how have they influenced how you feel about yourself? How have they affected your partner? How have they affected the relationship?
Do you expect your sexual functioning to be altered because of your illness?
What are your partner's concerns about your future sexual functioning?
Do you have any other sexual questions or concerns that I have not addressed?

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Nursing Diagnosis - Ineffective Sexuality Patterns - Definition

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Expressions of concern regarding own sexuality

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Nursing Diagnosis - Ineffective Sexuality Patterns - Defining Characteristics

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Alteration in relationship with significant other; alterations in achieving perceived sex role; conflicts involving values; reported changes in sexual activities; reported changes in sexual behaviors; reported difficulties in sexual activities; reported difficulties in sexual behaviors; reported limitations in sexual activities; reported limitations in sexual behaviors

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Nursing Diagnosis - Ineffective Sexuality Patterns - Related Factors (r/t)

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Absent role model; conflicts with sexual orientation or variant preferences; fear of acquiring a sexually transmitted disease; fear of pregnancy; impaired relationship with a significant other; ineffective role model; knowledge/skill deficit about alternative responses to health-related transitions, altered body function or structure, illness, or medical treatment; lack of privacy; lack of significant other

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Nurses promote sexual health by

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Focusing largely on teaching, clients need to be taught about normal sexual function, the effects of medications on sexual function, preventing sexually transmitted diseases, and performing breast and testicular self-examinations.

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Inappropriate client sexual behavior

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- Exposing themselves.
- Asking the nurse to provide intimate physical care, such as bathing genital areas, when they are capable of doing this themselves.
- Touching or grabbing the nurse's genitals or buttocks.
- Making blatant sexual statements to the nurse.
- Offering the nurse sex.
- Whistling; making comments about the nurse's attractiveness or desirability.
- Making sexual comments to another client in the same room or to visitors about the "sexy" nurse or what they would like to do sexually with the nurse.

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Nursing Strategies to deal with inappropriate client sexual behavior

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- Communicate that the behavior is not acceptable by saying, for example, "I really do not like the things you are saying," or "I see you are not dressed. I will be back in 10 minutes and will help you with breakfast when you get your clothes on."
- Tell the client how the behavior makes you feel: "When you act like that toward me, I am very uncomfortable. It embarrasses me and makes it hard for me to give you the kind of nursing care you need."
- Identify the behavior you expect: "Please call me by my name, not 'honey,'" or "I expect you to keep yourself covered when I am in the room. If you are feeling hot or something is uncomfortable, let me know, and I will try to make you more comfortable."
- Set firm limits: Take the client's hand and move it away, use direct eye contact, and say, "Don't do that!"
- Try to refocus clients from the inappropriate behavior to their real concerns and fears; offer to discuss sexuality concerns: "All morning you have been making very personal sexual comments about yourself. Sometimes people talk like that when they are concerned about the sexual part of their life and how their illness will affect them. Are there things that you have questions about or would like to talk about?"
- Report the incident to your nursing instructor, charge nurse, or clinical nurse specialist. Discuss the incident, your feelings, and possible interventions.
- Assign a nurse who will confront the behavior and relate to the client in a consistent manner.
- Clarify the consequences of continued inappropriate behavior (avoidance, withdrawal of services, no chance to help resolve underlying concerns of client).

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Aphasia

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Any defects in or loss of the power to express oneself by speech, writing, or signs, or to comprehend spoken or written language due to disease or injury of the cerebral cortex

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Alzheimer's disease

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disease that involves progressive dementia, memory loss, and inability to care for self

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Confusion

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is a change in mental status in which a person is not able to think with his or her usual level of clarity. Frequently, confusion leads to the loss of ability to recognize people and or places, or tell time and the date. Feelings of disorientation are common in confusion, and decision-making ability is impaired.

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Delirium

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also called acute confusion; abrupt onset of confusion and a reversible cause

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Delusion

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A false personal belief that is not subject to reason or contradictory evidence and is not explained by a person's usual cultural and religious concepts (so that, for example, it is not an article of faith). A delusion may be firmly maintained in the face of incontrovertible evidence that it is false.

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Dementia

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a global impairment of cognitive function that usually is progressive and may be permanent; interferes with normal social and occupational activities

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disorientation

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a state of mental confusion characterized by inadequate or incorrect perceptions of place, time, or identity. Disorientation may occur in organic mental disorders, in drug and alcohol intoxication, and, less commonly, after severe stress

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emotional status

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the state of a person's emotions

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Hallucinations

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false or distorted sensory experiences that appear to be real perceptions. These sensory impressions are generated by the mind rather than by any external stimuli, and may be seen, heard, felt, and even smelled or tasted.

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Level of consciousness

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Level of consciousness (LOC) is a measurement of a person's arousability and responsiveness to stimuli from the environment.

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Mental status

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Mental status (the patient's level of awareness and interaction with the environment) may be assessed by conversing with the patient and establishing their awareness of person, place, and time. The person will also be observed for clear speech and making sense while talking. This is usually done by the patient's physician just by being in the room with the patient during normal interactions.

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Presbycusis

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loss of hearing related to aging

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Presbyopia

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loss of elasticity of the lens and thus loss of ability to see close objects as a result of the aging process

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Sensory deficit

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partial or complete impairment of any sensory organ

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Sensory deprivation

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insufficient sensory stimulation for a person to function

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Sensory overload

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an overabundance of sensory stimulation

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Sensory perception

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the organization and translation of stimuli into meaningful information

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Sensory reception

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process of receiving environmental stimuli

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sundown syndrome

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A state of disorientation and agitation that occurs at night in institutionalized people who are oriented during the day. It is a temporary state of confusion that cycles with the sun.

• Provide a calm, quiet environment late in the day
• Treatments and activities should be done early in the day
• Do not restrain
• Encourage exercise and activity early in the day
• Promote urinary and bowel elimination
• Do not try to reason with the person
• Do not ask the person to tell you what is bothering him or her
• Provide adequate lighting
• Assess underlying physiologic causes (delirium)

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Sensory deprivation - Cause

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a decrease in or lack of meaningful stimuli.

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Sensory deprivation - Signs

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- Excessive yawning, drowsiness, sleeping
- Decreased attention span, difficulty concentrating, decreased ' problem solving
- Impaired memory
- Periodic disorientation, general confusion, or nocturnal confusion
- Preoccupation with somatic complaints, such as palpitations
Hallucinations or delusions
- Crying, annoyance over small matters, depression
- Apathy, emotional lability

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Sensory overload - Causes

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- Increased quantity or quality of internal stimuli, such as pain, dyspnea, anxiety
- Increased quantity or quality of external stimuli, such as a noisy health care setting, intrusive diagnostic studies, contacts with many strangers
- Inability to disregard stimuli selectively, perhaps as a result of nervous system disturbances or medications that stimulate the arousal mechanism

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Sensory overload - Signs

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- Complaints of fatigue, sleeplessness
- Irritability, anxiety, restlessness - Periodic or general disorientation - Reduced problem-solving ability and task performance
- Increased muscle tension
- Scattered attention and racing thoughts

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Clients at risk for sensory disturbances

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- Risk for Injury related to sensory-perception disturbance (specify). For example,
a. Visual impairment (e.g., decreased depth perception)
b. Reduced tactile sensation secondary to neurologic or circulatory alterations
c. Decreased sense of smell
d. Hearing impairment
e. Decreased kinesthetic sense
- Impaired Home Maintenance related to sensory-perception disturbance (declining visual abilities)
- Risk for Impaired Skin Integrity related to sensory-perception disturbance (altered tactile sensation)
- Impaired Verbal Communication related to sensory-perception disturbance (specify). For example, a. Altered level of consciousness
b. Hearing impairment
c. Sensory overload
d. Sensory deprivation
- Self Care Deficit: Bathing/Hygiene related to sensoryperception disturbance (specify). For example,
a. Visual impairment
b. Diminished kinesthetic sense
c. Inability to perceive body part or spatial relationship
- Social Isolation related to sensory-perception disturbance (specify). For example,
a. Impaired vision
b. Impaired hearing

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Factors affect the amount and quality of sensory stimulation,

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a person's developmental stage, culture, level of stress, medications and illness, and lifestyle.

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Nursing History - Collection of sensory/perceptual, function and cognition data

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VISUAL
- How would you rate your vision (excellent, good, fair, or poor)?
- Do you wear eyeglasses or contact lenses?
- Describe any recent changes in your vision.
- Do you have any difficulty seeing near or far objects?
- Do you have any difficulty seeing at night? Have you ever experienced blurred vision, double vision, spots moving in front of your eyes, blind spots, light sensitivity, flashing lights, or halos around objects?
- When did you last visit an eye doctor?
AUDITORY
- How would you rate your hearing (excellent, good, fair, or poor)?
- Do you wear a hearing aid?
- Describe any recent changes in your hearing.
- Can you locate the direction of sounds and distinguish various voices?
- Do you experience any dizziness or vertigo? Do you experience any ringing, buzzing, humming, crackling noises, or fullness in the ears?
GUSTATORY
- Have you experienced any changes in taste (e.g., difficulty in differentiating sweet, sour, salty, and bitter tastes)?
- Do you enjoy the taste of foods as you did previously?
OLFACTORY
- Have you experienced any changes in smell?
- Do things (foods, flowers, perfumes, and so on) smell the same as previously?
- Can you distinguish foods by their odors and tell when something is burning?
- Have you experienced any changes in appetite? (Changes in appetite may be related to an impaired sense of smell.)
TACTILE
- Are you experiencing any pain or discomfort?
- Have you experienced any decrease in your ability to perceive heat, cold, or pain in your limbs?
- Do you have any numbness or tingling in your extremities?
KINESTHETIC
- Have you noticed any difficulty in perceiving the position of parts of your body?

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Sensory Deprivation - Nursing Actions

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1. Encourage use of sensory aid (glasses, hearing aid)
2. Maintain meaningful interactions with client - call client by name and touch client
3. Provide meaningful environmental stimuli
4. Increase tactile stimulation (textured objects, backrub, foot care, hair wash)
5. Encourage social interaction
6. Encourage mental stimulation and use self-stimulating techniques (signing, etc)
7. Encourage environmental changes

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Sensory Overload - Nursing Actions

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1. Quiet, calm, subdued environment 2. Control client's pain 3. Provide orienting cues 4. Plan care to allow uninterrupted periods of rest and sleep (private room if avail)
5. Establish a routine of care
6. Communicate in calm, unhurried manner
7. Provide information and client teaching at appropriate level
8. Reduce noxious odors
9. Allow client to ask questions and ventilate feelings
10. Teach client stress-reducing techniques

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Disturbed Sensory Perception: Auditory - Interventions and Rationale

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- Use touch and eye contact. These gain patient’s attention.
- When speaking, do the following:
- Reduce or minimize environmental noise. Reduce noise so that speaker does not have to compete to be heard.
- Face patient in good light and keep hands away from mouth. This enhances patient’s use of lip-reading, facial expressions, and gesturing.
- Speak close to patient’s "better" ear, as appropriate.
- Avoid shouting or yelling. This prevents humiliation.
- Use simple language and short sentences.
- Speak slowly.
- Use grease boards, computers, or other writing tools. These help communicate with profoundly hearing-impaired individuals.
- For patients with hearing aid(s), ensure that hearing aid(s) is in place, clean and working. Patients with new hearing aid(s) need time to adjust to the sound produced. Encouragement is often needed, especially among elderly patients who may decide that the hearing aid(s) is not worth the effort.
- Provide encouragement to use hearing aid(s).
- Prepare patient for ear surgery. Tympanoplasty (removal of dead tissue, restoration of bones with prostheses) and mastoidectomy (removal of all or portions of the middle ear structures) are common surgical treatments for hearing loss.

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Disturbed Sensory Perception: Visual - Interventions and Rationale

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- Introduce self to patient, and acknowledge visual impairment. This reduces patient’s anxiety.
- Orient patient to environment. Orientation reduces fear related to unfamiliar environment.

Do not make unnecessary changes in environment. This ensures safety and maintains what the patient has arranged.
- Provide adequate lighting. The use of natural or halogen lighting is preferred to improve vision for patients with diminished vision.
- Place meal tray, tissues, water, and call light within patient’s range of vision or reach. These ensure safety and sense of independence.
- Communicate type and degree of impairment to all involved in patient’s care. This enhances continuity of care.
- Recommend use of visual aids when appropriate. Visual aids such as magnifying glass, large-type printed books, and magazines encourage reading.
- Place food on tray and plate in same place each meal and explain arrangement of food on tray and plate, using clockwise sequence.
- Encourage use of sense of touch. Touch encourages patient to become familiar with unfamiliar objects.
- Explain sounds or other unusual stimuli in environment. Explanations reduce fear.
- Encourage use of radios, tapes, and talking books. Diversional activities should be encouraged. Radio and television increase awareness of day and time.
- Remove environmental barriers to ensure safety. If furniture or wastebaskets are moved, notify patient of changes.
- Discourage doors from being left partially open. Fully open or closed doors reduce the risk for injury among the vision-impaired.
- Maintain bed in low position with side rails up, if appropriate. Side rails help remind patient not to get up without help when needed.

Keep bed in locked position. This prevent falls.
- Guide patient when ambulating, if appropriate. Describe where you are walking; identify obstacles.
- Instruct patient to hold both arms of chair before sitting and to feel for the seat on chairs or sofas without arms. These reduce the risk of falls.
- Consult occupational therapy staff for assistive devices and training in their use.
- Supervise patient when smoking. Supervision prevents accidental fires.

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Nursing Diagnosis - Risk for Injury - Definition

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At risk of injury as a result of the interaction of environmental conditions interacting with the individual's adaptive and defensive resources (overlaps with Risk for Falls, Risk for Trauma, Risk for Poisoning, Risk for Suffocation, Risk for Aspiration, and if the client is at risk of bleeding, Ineffective Protection.)

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Nursing Diagnosis - Risk for Injury - Risk Factors

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- External
Biological (e.g., immunization level of community, microorganism); chemical (e.g., poisons, pollutants, drugs, pharmaceutical agents, alcohol, nicotine, preservatives, cosmetics, dyes); human (e.g., nosocomial agents; staffing patterns; cognitive, affective, psychomotor factors); mode of transport; nutritional (e.g., vitamins, food types); physical (e.g., design, structure, and arrangement of community, building, and/or equipment)
- Internal
Abnormal blood profile (leukocytosis/leucopenia, altered clotting factors, thrombocytopenia, sickle cell, thalassemia, decreased hemoglobin); biochemical dysfunction; developmental age (physiological, psychosocial); effector dysfunction; immune-autoimmune dysfunction; integrative dysfunction; malnutrition; physical (e.g., broken skin, altered mobility); psychological (affective orientation); sensory dysfunction; tissue hypoxia

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Nursing Diagnosis - Risk for Injury - Interventions and Rationales

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- Prevent iatrogenic harm to the hospitalized client by following the 2007 National Patient Safety goals:
- Accuracy of Patient Identification
- Use at least two methods (e.g., client's name and medical record number or birth date) to identify the client before administering medications, blood products, treatments, or procedures.
- Prior to beginning any invasive or surgical procedure, have a final verification to confirm the correct client, the correct procedure, and the correct site for the procedure using active communication techniques.
- Effectiveness of Communication among Care Staff
- When taking verbal or telephone orders, the orders should be written down and then read back for verification to the individual giving the order.
- Standardize use of abbreviations, acronyms, symbols, and dose designations that are used in the institution.
- Make sure of timeliness of reporting and taking action of critical test results and values.
- Utilize a standardized approach of "handing off" communications, including opportunities to ask and answer questions.
- Medication Safety
- Standardize and limit the number of drug concentrations utilized by the institution (e.g., concentrations of medications such as morphine in patient controlled analgesia [PCA] pumps).
- Label all medications and medication containers (e.g., syringes, medication cups, or other solutions on or off the surgical field).
- Identify all of the client's current medications upon admission to a healthcare facility, and ensure that all healthcare staff have access to the information.
- Reconcile all medication at discharge, and provide list to the client.
- Improve the effectiveness of alarm systems in the clinical area.
- Reduce the risk of infections by following Centers for Disease Control (CDC) hand hygiene guidelines.
- Evaluate all clients for fall risk and take appropriate actions to prevent falls.
- Prevent pressure ulcer formation.

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Nursing Diagnosis - Acute Confusion - Definition

Back 80

Abrupt onset of reversible disturbances of consciousness attention, cognition, and perception that develop over a short period of time

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Nursing Diagnosis - Acute Confusion - Defining Characteristics

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Fluctuation in cognition; level of consciousness; psychomotor activity; hallucinations; increased agitation; increased restlessness; lack of motivation to follow through with goal-directed behavior; lack of motivation to follow through with purposeful behavior; lack of motivation to initiate goaldirected behavior; lack of motivation to initiate purposeful behavior; misperceptions

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Nursing Diagnosis - Acute Confusion - Risk Factors

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Alcohol abuse; delirium; dementia; drug abuse; fluctuation in sleep-wake cycle; over 60 years of age; polypharmacy

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Nursing Diagnosis - Acute Confusion - Interventions and Rationales

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• Assess the client's behavior and cognition systematically and continually throughout the day and night, as appropriate. EB: Rapid onset and fluctuating course are hallmarks of delirium. The Confusion Assessment Method (CAM) is sensitive, specific, reliable, and easy to use. Another tool to consider is the Mini-Mental State Examination. It is necessary to pay attention to behavioral changes because recent research has shown that there may be a prodromal phase of delirium in which sudden disorientation and urgent calls for attention may precede the onset of delirium.
• Perform an accurate mental status examination that includes the following:
- Overall appearance, manner, and attitude
- Behavior characteristics and level of psychomotor behavior
- Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by the client)
- Insight and judgment
- Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process, and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking)
- Level of attention New onset of delirium in adults warrants a thorough examination to determine cause and treatment. EB: Early intervention in the case of delirium may decrease the severity and length of the delirious episode. Clients discharged from the hospital with delirium had a high rate of institutionalization and mortality over a 1-year follow-up.
- Assess for and report possible physiological alterations (e.g., sepsis, hypoglyeemia, hypoxia, hypotension, infection, changes in temperature, fluid and electrolyte imbalance, use of medications with known cognitive and psychotropic side effects). Early attention to these risk factors may prevent delirium or shorten the length of the delirium episode.
Treat the underlying causes of delirium in collaboration with the healthcare team: Establish/ maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, normal body temperature, normal oxygenation (if the client experiences low oxygen saturation, deliver supplemental oxygen), normal blood glucose levels, normal blood pressure. EB: Dehydration is a significant risk factor for delirium and should be addressed aggressively.
- Communicate client status, cognition, and behavioral manifestations to all necessary providers.
- Monitor for any trends occurring in these manifestations of delirium.
EB: Recognize that the client's fluctuating cognition and behavior are the hallmark of delirium and are not to be construed as client preference for certain caregivers. EB: Careful monitoring is needed to identify the potential etiologic factors for delirium.
- Laboratory results should be closely monitored and physiological support given as appropriate. EBN: Once acute confusion has been identified, it is vital to recognize and treat the associated underlying causes.
Establish or maintain elimination patterns. EBN and EB: Disruption in elimination may be a cause of confusion. Urinary retention or a urinary tract infection resulting in urosepsis, as well as constipation, may lead to delirium.
- Plan care that allows for an appropriate sleep-wake cycle. EB: Disruptions in usual sleep and activity patterns should be minimized because those clients with nocturnal exacerbations experience more complications from delirium.
- Conduct a medication review. Medication use is one of the most important modifiable factors that can cause or worsen delirium, especially the use of antichohnergics, benzodiazepmes, and hypnotics.
- Modulate sensory exposure and establish a calm environment. EBN: Extraneous lights and noise can give rise to agitation, especially if misperceived. Sensory overload or sensory deprivation can result in increased confusion. EB: Clients with a hyperactive form of delirium often have increased irritability and startle responses and may be acutely sensitive to light and sound.
- Provide reality orientation, including identifying self by name at each contact with the client; calling the client by their preferred name; using orientation techniques; providing familiar objects from home such as an afghan; providing clocks, calendars; and gently correcting misperceptions. EBN: Use of reality orientation can help improve cognition in dementia clients.
- Avoid use of validation therapy with the confused client, other than to validate the feelings the client may be expressing. EB: A Cochrane review demonstrated that there is no evidence that validation therapy is helpful for clients with cognitive impairment.
Use appropriate communication techniques for clients at risk for confusion including communicating clearly and providing simple explanations as needed. Provide supportive nursing care including meeting of basic needs such as feeding, toileting, and hydration. EBN: Delirious clients are unable to care for themselves due to their confusion. Their care and safety needs must be anticipated by the nurse.
Identify, evaluate, and treat pain quickly (see care plans for Acute Pain or Chronic Pain). EB and EBN: Untreated pain is a potential cause of delirium (Inouye, 2000; Milisen et al, 2001. Facilitate appropriate sensory input by having clients use aids (e.g., glasses, hearing aids) as needed. Sensory impairment contributes to misinterpretation of the environment and significantly con¬ tributes to delirium (Inouye, 2006)' Recognize that delirium is frequently treated with an antipsychotic medication. Watch for side effects of the medications. EB: B$ aware of paradoxical effects and side effects such as extrapyramidal symptoms, agitation, sedation, and arrhythmias, because these may exacerbate the delirium.

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Nursing Diagnosis - Chronic Confusion - Definition

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Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior

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Nursing Diagnosis - Chronic Confusion - Defining Characteristics

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Altered interpretation; altered personality; altered response to stimuli; clinical evidence of organic impairment; impaired long-term memory; impaired short-term memory; impaired socialization; long-standing cognitive impairment; no change in level of consciousness; progressive cognitive impairment

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Nursing Diagnosis - Chronic Confusion - Risk Factors

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Alzheimer's disease; cerebral vascular attack; head injury; Korsakoff's psychosis; multi-infarct dementia

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Nursing Diagnosis - Chronic Confusion - Interventions and Rationales

Back 87

- Determine the client's cognitive level using a screening tool such as the Mini-Mental State
Exam (MMSE). The Mini-Cog is also a useful screening tool to be
used in a busy setting. EB: Use of a standard evaluation tool such as the MMSE can help determine the client's abilities and assist in planning appropriate nursing interventions.
- Gather information about the client's predementia cognitive functioning. EBN and EB: Individuals with a history of cognitive dysfunction are at higher risk for acute confusion (i.e., sundowner's syndrome) during acute illness.
- Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior. EB: Up to 95% of individuals with dementia have some neuropsychiatric problems, with the most common being depression.
- Determine client's normal routines and attempt to maintain them. EB: Activities that are designed to be consistent with past routines were effective at providing engagement and interest and enhancing quality of life.
- Begin each interaction with the client by identifying yourself and calling the client by name. Approach the client with a caring, loving, and accepting attitude, and speak calmly and slowly. EBN and EB: Dementia causes a loss of the ability to learn new things and remember people and places (episodic memory)—thus clients will need reassurance and frequent reminding of the identity of caregivers.
- Use a calm approach in interactions and use reminiscence therapy and validation (validating what the clients say is real instead of correcting them). EB: Emotion-centered care, including validation therapy, reminiscence, and emotional support can help reduce anxiety and improve client satisfaction.
- Provide scheduled activities that are matched to the client's abilities and personality. EBN: Activities that are individualized to the client's abilities and personality can reduce agitation and improve quality of life.
- Provide periods of rest along with periods of activities. EB: Balancing times of rest during nonarousal states and times of stimulation during arousal states can decrease agitation in those with dementia.
- Give one simple direction at a time and repeat it as necessary. Use verbal and physical prompts, and model the desired action if needed and possible. EB: There are a variety of communication problems in dementia, but with time and prompting people with dementia can make their needs known.
- Break down self-care tasks into simple steps (e.g., instead of saying, "Take a shower," say to the client, "Please follow me. Sit down on the bed. Take off your shoes. Now take off your socks."). EB: Verbal prompts, assistance with steps of a process, and cueing activities in sequential order can help those with dementia be more independent in activities of daily living.
- Engage the client in communication by individualizing the nurse's interactions to maximize client interaction and response. EBN and EB: Individualized communication strategies that involve the client's interest have been shown to improve communication abilities in those with dementia above the level that would be expected from their cognitive abilities.
- For anxious clients who are having problems relaxing enough to eat, try having them listen to music during meals. EB: Clients who listen to music have been shown to have less agitation and consumed more foods.
- Assess the cause of and consequences of wandering before attempting to control the wandering. EBN: Wandering may be an adaptive response and not need an intervention. Other related problems, such as elopement or falls should be assessed.
- For individuals who have wandering behavior, individualize interventions such as those that provide a safe environment with physical barriers to exits, safe walking paths, and a daily schedule of activities. EBN: Although studies are inconclusive, modifying the environment and providing daily activities have been shown to decrease some types of wandering.
- Use symbols rather than words to identify areas such as the bathroom or kitchen. Utilize environmental cues such as clocks and a sign with mealtimes to decrease common mealtime questions and thus decrease agitation around mealtimes. EBN: The results of a study in which a large clock and a sign with large lettering that identified mealtimes were hung in the dining area suggest cues can reduce repetitive questions commonly exhibited by individuals with dementia.
- Set up scheduled quiet periods in a recliner or room. Use afghans and environmental cues to define rest periods. EB: Sleep disorders are very common in those with dementia, and a lack of sleep has been shown to be related to poorer memory. One study showed that naps in older people can improve sleep amounts without decreasing nighttime sleep and improve cognitive andpsychomotor performance.
- Provide structured social and physical activities that are individualized for the client. EB: Social activities and exercise have been shown to improve sleep quality, which is often impaired in individuals with dementia.
- Provide quiet activities such as listening to music of the client's preference or introduce other cues that promote relaxation in the afternoon or early evening. EB and EBN: Calming activities such as listening to preferred music can reduce agitation.
- Provide simple activities for the client, such as folding washcloths and sorting or stacking activities or other hobbies the individual enjoyed prior to the onset of dementia. EBN and EB: Activities such as folding washcloths, cooking, and gardening involve implicit memory and are thus something that the older adult can become engaged in, which can provide distraction and a sense of accomplishment.
- Use cues, such as picture boards denoting day, time, and location, to help client with orientation. EBN and EB: Reality orientation, used not when clients are agitated, but as overall reminders of orientation, can help some clients remain more oriented.
- Use reminiscence and life review therapeutic interventions; ask questions about the client's work, children, or time spent in military service. Ask questions such as, "What was really important to you as you look back?" to engage the client in storytelling. EB: Reminiscence and life review can help an older person reframe and accept life events and provide social engagement.
- If the client becomes increasingly confused and agitated, perform the following steps:
- Assess the client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation. An acute change in behavior is a medical emergency and should be evaluated. A change in behavior may be due to physical causes, which should be ruled out before behavioral interventions are initiated.
- Assess for psychological causes, including changes in the environment, caregiver, and routine; demands to perform beyond capacity; or multiple competing stimuli, including discomfort. EBN: Agitated behaviors can be an expression of a need that is not being met.
- In clients with agitated behaviors, rather than confronting the client, provide diversional be¬ haviors such as singing, games, and the provision of textured items to handle. EBN: Diversional activities that are individualized can be effective at reducing agitated behaviors.
- Decrease stimuli in the environment (e.g., turn off the television, take the client to a quiet place). Institute activities associated with pleasant emotions, such as playing soft music the client likes, looking through a photo album, providing favorite food, or using simulated presence therapy. EB and EBN: Decreasing stimuli can decrease agitation.
- If clients with dementia become more agitated, assess for pain. EB and EBN: A change in behav¬ for may indicate pain, and pain is often undertreated in those with dementia. Treating pain can improve social interaction, engagement, and decrease agitation.
- Avoid using restraints if at all possible. EB: Restraints have been shown to cause decline in cognition, socialization, and depression in nursing home residents.
- Use PRN or low-dose regular dosing of psycho tropic or antianxiety drugs only as a last resort. They can be effective in managing symptoms of psychosis and aggressive behavior, but have undesirable side effects. Start with the lowest possible dose. EB and EBN: Psychotropic medication use is variable in those with dementia and has many side effects, including sleep disturbances and medication interactions. Effective nursing interventions can reduce psychotropic medication usage.
- Avoid the use of anticholinergic medications such as Benadryl. Anticholinergic medications have a high side effect profile that includes disorientation, urinary retention, and excessive drowsiness. The anticholinergic side effects outweigh the antihistaminic effects.
- For predictable difficult times, such as during bathing and grooming, try the following:
- Massage the client's hands lovingly or use therapeutic touch to relax the client. EBN: Hand massage and therapeutic touch have been shown to induce relaxation that may allow care activities to take place without difficulty.
- When bathing a client with dementia, minimize the client's discomfort by using the Bag Bath (if available). Bathtime is an opportunity to emphasize person-centered nursing. EBN: Bathing is known to be stressful for clients with dementia as evidenced by the frequently seen agitation that occurs during this activity. The Bag Bath decreases discomfort during bathing, and the person-centered approach maintains self-esteem and a sense of control for the client.
- Approach the client in a client-centered framework as this offers a sense of control and promotes self-esteem.
- Involve family in care of the client. EBN: Involving family in care of clients with dementia improved cognitive abilities.
- For care of early dementia clients with primarily symptoms of memory loss, see the care plan for Impaired Memory.
- For care of clients with self-care deficits, see the appropriate care plan (Feeding Self-care deficit; Dressing/grooming Self-care deficit; and Toileting Self-care deficit).

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Reality Orientation

Back 88

1. Use reality information such as time, date and place during conversation.
2. Refer to clocks, calendars, and other reality props when necessary.
3. Do not reinforce or support misconceptions.
4. Call the client by name. Remember to introduce yourself.
5. Redirect client back to reality-oriented endeavors if client rambles.
6. Encourage independence and provide client with choices (even if limited).
7. Make sure client has any necessary sensory or mobility aids.
8. Reward even the small changes in behavior that indicate progress.
9. Repeat information as necessary. V^rs • l/^O
10. Give directions/explanations in short sentences and in concrete terms.
11. Maintain consistency in routine and care providers as able.
12. Provide visual cues (family photos and possessions in room, written schedule, name outside room).

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Strategies to Manage - Agitation

Back 89

- Approach in a calm, quiet manner
- Ensure congruency between caregiver verbal and nonverbal behavior
- Determine cause of behavior and remove cause (if hungry - provide food)
- Individualized music therapy
- Maintain consistency in caregivers and routine
- Provide for client's and others' safety

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Strategies to Manage - Hallucinations

Back 90

- Do not argue with person
- Identify yourself and let the person know you are a nurse and want to help
- Reassure person, tell them you will provide protection
- Acknowledge that the person is experiencing something that you are not experiencing
- Do not challenge the hallucination as unreal
- Do not leave client alone while hallucination is being experienced or ' immediately afterward
- Avoid sedatives or hypnotics

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Strategies to Manage - Sundowning

Back 91

- Provide a calm, quiet environment late in the day
- Treatments and activities should be done early in the day
- Do not restrain
- Encourage exercise and activity early in the day
- Promote urinary and bowel elimination
- Do not try to reason with the person
- Do not ask the person to tell you what is bothering him or her
- Provide adequate lighting
- Assess underlying physiologic causes (delirium)

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Strategies to Manage - Verbal/Physical Abuse

Back 92

- Avoid confrontation with client, allow to dissipate energy by performing repetitive tasks
- De-escalation, decrease by degrees anxiety and aggressive behavior
- Calmly state the violence will not be tolerated
- Set limits, identify the rules/standards of acceptable behavior and define consequences of violating limits
- Speak slowly, clearly, behave politely and listen uncritically
- Approach in a non-threatening manner, relaxed posture, hands and arms at side, use direct eye contact
- Maintain same physical level as client
- Allow plenty of space between yourself and client
- Reinforce positive behavior
- Provide for others' safety
- Alert security, police ("show of force")

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Strategies to Manage - Wandering

Back 93

- Doors and windows securely locked
- Door alarms turned on
- ID bracelet in place
- Provide adequate exercise
- Do not restrain
- Do not argue with the person who wants to leave
- Go with the person who insists on going outside, guide the person inside after a few minutes
- Let the person wander in enclosed areas
- Assess any underlying cause (pain, toileting)