4.4 Diagnosis
Open Resources for Nursing (Open RN)
Diagnosis is the second step of the nursing process (and the second Standard of Practice by the American Nurses Association). This standard is defined as, “The registered nurse analyzes assessment data to determine actual or potential diagnoses, problems, and issues.” The RN “prioritizes diagnoses, problems, and issues based on mutually established goals to meet the needs of the health care consumer across the health–illness continuum and the care continuum.” Diagnoses, problems, strengths, and issues are documented in a manner that facilitates the development of expected outcomes and a collaborative plan.[1] See Figure 4.7a for an illustration of how the Diagnosis phase of the nursing process corresponds to the NCSBN Clinical Judgment Measurement Model (NCJMM).[2]
Analyzing Assessment Data
After collection of assessment data, the RN analyzes the data to form generalizations and create and prioritize hypotheses for nursing diagnoses. Steps for analyzing assessment data include performing data analysis, clustering information, identifying hypotheses for potential nursing diagnosis, performing additional in-depth assessment as needed, and establishing nursing diagnosis statements. The nursing diagnoses are then prioritized and the nursing care plan is developed based on them.[3] Analyzing assessment data is completed by an RN and falls outside of the scope of practice of the LPN/VN. However, LPN/VNs must understand data analysis so that new, concerning data is promptly reported to the RN for follow-up.
Performing Data Analysis
After nurses collect assessment data from a client, they use their nursing knowledge to analyze that data to determine if it is “expected” or “unexpected” or “normal” or “abnormal” for that client according to their age, development, and baseline status. From there, nurses determine what data is “clinically relevant” as they prioritize their nursing care.[4]
Example of Analyzing Cues
In Scenario C in the “Assessment” section of this chapter, the nurse analyzes the vital signs data and determines the blood pressure, heart rate, and respiratory rate are elevated, and the oxygen saturation is decreased for this client. These findings are considered “relevant cues” because they are abnormal compared to this client’s baseline and may indicate a new health problem or complication is occurring.
Clustering Information/Seeing Patterns/Making Hypotheses
After analyzing the data and determining relevant cues, the nurse begins clustering data into similar domains or patterns. Evidence-based assessment frameworks, such as Gordon’s Functional Health Patterns, assist nurses in clustering data based on patterns of human responses. See the box below for an outline of Gordon’s Functional Health Patterns.[5] Concepts related to many of these patterns will be discussed in chapters later in this book.
Gordon’s Functional Health Patterns[6]
Health Perception-Health Management: A client’s perception of their health and well-being and how it is managed
Nutritional-Metabolic: Food and fluid consumption relative to metabolic need
Elimination: Excretory function, including bowel, bladder, and skin
Activity-Exercise: Exercise and daily activities
Sleep-Rest: Sleep, rest, and daily activities
Cognitive-Perceptual: Perception and cognition
Self-perception and Self-concept: Self-concept and perception of self-worth, self-competency, body image, and mood state
Role-Relationship: Role engagements and relationships
Sexuality-Reproductive: Reproduction and satisfaction or dissatisfaction with sexuality
Coping-Stress Tolerance: Coping and effectiveness in terms of stress tolerance
Value-Belief: Values, beliefs (including spiritual beliefs), and goals that guide choices and decisions
Example of Using Gordon’s Health Patterns to Cluster Data
Refer to Scenario C in the “Assessment” section of this chapter. The nurse clusters the following relevant cues: elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, shortness of breath, medical history of heart failure, and currently prescribed a diuretic medication into a pattern of fluid balance, which can be classified under Gordon’s Nutritional-Metabolic Functional Health Pattern. Based on the related data in this cluster, the nurse makes a hypothesis that the client has excess fluid volume present.
Identifying Nursing Diagnoses
After the nurse has analyzed and clustered the data from the client assessment, the next step is to begin to answer the question, “What are my client’s human responses to their health condition(s) (i.e., their nursing diagnoses)?” A nursing diagnosis is defined as, “A clinical judgment concerning a human response to health conditions/life processes, or susceptibility to that response, by an individual, caregiver, family, group, or community.”[7] Nursing diagnoses are customized to each client and drive the development of the nursing care plan. The nurse should refer to a care planning resource and review the definitions and defining characteristics of the hypothesized nursing diagnoses to determine if additional in-depth assessment is needed before selecting the most accurate nursing diagnosis. Formulation of nursing diagnoses is completed by an RN and is outside the scope of practice of LPN/VNs.
Nursing diagnoses are developed by nurses, for use by nurses. For example, NANDA International (NANDA-I) is a global professional nursing organization that develops nursing terminology that names actual or potential human responses to health problems and life processes based on research findings. Currently, there are over 220 NANDA-I nursing diagnoses developed by nurses around the world. This list is continuously updated, with new nursing diagnoses added and old nursing diagnoses retired that no longer have supporting evidence.[8] A list of commonly used NANDA-I diagnoses is listed in Appendix A. For a full list of NANDA-I nursing diagnoses, refer to a current nursing care plan reference.
NANDA-I nursing diagnoses are grouped into 13 domains that assist the nurse in selecting diagnoses based on the patterns of clustered data. These domains are similar to Gordon’s Functional Health Patterns and include health promotion, nutrition, elimination and exchange, activity/rest, perception/cognition, self-perception, role relationship, sexuality, coping/stress tolerance, life principles, safety/protection, comfort, and growth/development.
NANDA Diagnoses and the NCLEX
Knowledge regarding specific NANDA-I nursing diagnoses is not assessed on the NCLEX. However, analyzing cues, clustering data, forming appropriate hypotheses, and prioritizing hypotheses are components of clinical judgment assessed on the NCLEX and used in nursing practice. Read more about the Next Generation NCLEX in the “Scope of Practice” chapter.
Nursing Diagnoses vs. Medical Diagnoses
You may be asking yourself, “How are nursing diagnoses different from medical diagnoses?” Medical diagnoses focus on diseases or other medical problems that have been identified by the physician, physician’s assistant, or advanced nurse practitioner. Nursing diagnoses focus on the human response to health conditions and life processes and are made independently by RNs. Clients with the same medical diagnosis will often respond differently to that diagnosis and thus have different nursing diagnoses. For example, two clients have the same medical diagnosis of heart failure. However, one client may be interested in learning more information about the condition and the medications used to treat it, whereas another client may be experiencing anxiety when thinking about the effects this medical diagnosis will have on their family. The nurse must consider these different responses when creating the nursing care plan. Nursing diagnoses consider the client’s and family’s needs, attitudes, strengths, challenges, and resources as a customized nursing care plan is created to provide holistic and individualized care for each client.
Example of a Medical Diagnosis
A medical diagnosis identified for Ms. J. in Scenario C in the “Assessment” section is heart failure. This cannot be used as a nursing diagnosis because it is outside the nurse’s scope of practice to make a medical diagnosis, but it is considered as an “associated condition” when creating hypotheses for nursing diagnoses. Associated conditions are medical diagnoses, injuries, procedures, medical devices, or pharmacological agents that are not independently modifiable by the nurse, but support accuracy in nursing diagnosis. The nursing diagnosis in Scenario C will relate to the client’s responses to her medical diagnosis of heart failure, such as “Excess Fluid Volume.”
Additional Definitions Used in NANDA-I Nursing Diagnoses
The following definitions are used in association with NANDA-I nursing diagnoses.
Patient
The NANDA-I definition of a “patient” includes the following:[9]
- Individual: a single human being distinct from others (i.e., a person).
- Caregiver: a family member or helper who regularly looks after a child or a sick, elderly, or disabled person.
- Family: two or more people having continuous or sustained relationships, perceiving reciprocal obligations, sensing common meaning, and sharing certain obligations toward others; related by blood and/or choice.
- Group: a number of people with shared characteristics
- Community: a group of people living in the same locale under the same governance, such as neighborhoods and cities.
Age
The age of the person who is the subject of the diagnosis is defined by the following terms:[10]
- Fetus: an unborn human more than eight weeks after conception, until birth.
- Neonate: a person less than 28 days of age.
- Infant: a person greater than 28 days and less than 1 year of age.
- Child: a person less than or equal to 19 years of age, unless national law defines a person to be an adult at an earlier age
- Adolescent: a person aged 10 to 19 years.
- Adult: a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.
- Older adult: a person 65-84 years of age.
- Aged adult: Person 85 years or older.
Time
The duration of the diagnosis is defined by the following terms:[11]
- Acute: lasting less than three months.
- Chronic: lasting greater than three months.
- Intermittent: stopping or starting again at intervals.
- Continuous: uninterrupted, going on without stop.
Two terms used to assist in creating nursing diagnosis statements are at-risk populations and associated conditions:[12]
- At-risk populations are groups of people who share a sociodemographic characteristics, health/family history, stages of growth/development, exposure to certain events/experiences that cause each member to be susceptible to a particular human response. These characteristics are not modifiable by independent nursing interventions.
- Associated conditions are medical diagnoses, diagnostic/surgical procedures, medical/surgical devices, or pharmaceutical preparations. These conditions are not modifiable by independent nursing interventions.
Types of Nursing Diagnoses
There are four types of NANDA-I nursing diagnoses:[13]
- Problem-Focused
- Health Promotion
- Risk
- Syndrome
A problem-focused nursing diagnosis is a clinical judgment concerning an undesirable human response to health conditions/life processes that is recognized in an individual, caregiver, family, group, or community.[14]
To make an accurate problem-focused diagnosis, related factors and defining characteristics must be present. Related factors (also called etiology) are antecedent factors shown to have a partnered relationship with the human response. These factors must be modifiable by independent nursing interventions, and whenever possible, interventions should be aimed at these etiological factors Problem-focused and syndromes must have related factors; health promotion diagnoses may have related factors if they help clarify the diagnosis.[15]
Defining characteristics are observable cues or inferences that cluster as manifestations of a problem-focused diagnosis, health promotion diagnosis, or syndrome. Defining characteristics refer to things a nurse can see, hear, touch, or smell.[16]
A health promotion nursing diagnosis is a clinical judgment concerning motivation and desire to increase well-being and to actualize human health potential that is recognized in an individual, caregiver, family, group, or community. These responses are expressed by the client’s readiness to enhance specific health behaviors. In individuals who are unable to express their own readiness to enhance health behaviors, the nurse may determine a condition for health promotion exists and act on the client’s behalf. To make a health promotion nursing diagnosis, defining characteristics must be present.[17]
A risk nursing diagnosis is a clinical judgment concerning the susceptibility for developing an undesirable human response to health conditions/life processes that is recognized in an individual, caregiver, family, group, or community. To make a risk nursing diagnosis, risk factors must be present that contribute to increased susceptibility.[18] A risk nursing diagnosis is different from the problem-focused diagnosis in that the problem has not yet actually occurred. However, problem diagnoses should not be automatically viewed as more important than risk diagnoses because sometimes a risk diagnosis can have the highest priority for a client.
A syndrome nursing diagnosis is a clinical judgment concerning a specific cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To make a syndrome nursing diagnosis, defining characteristics must include two or more nursing diagnosis and related factors.[19]
Establishing Nursing Diagnosis Statements
NANDA-I recommends creating statements for nursing diagnosis that include the nursing diagnosis and related factors as exhibited by defining characteristics. The accuracy of the nursing diagnosis is validated when a nurse is able to clearly link the defining characteristics, related factors, and/or risk factors found during the client’s assessment.[20]
To create a nursing diagnosis statement, the RN analyzes the client’s subjective and objective data and clusters the data into patterns. Based on these patterns, the RN generates hypotheses for nursing diagnoses based on how the patterns meet defining characteristics of a nursing diagnosis. Recall that “defining characteristics” are the signs and symptoms related to a nursing diagnosis. Defining characteristics are included in care planning resources for each nursing diagnosis, along with a definition of that diagnosis, so the nurse can select the most accurate diagnosis.
Example
An RN clusters objective and subjective data such as weight, height, and dietary intake as a pattern related to nutritional status and then compares these signs and symptoms to the defining characteristics for the NANDA nursing diagnosis, “Imbalanced Nutrition: Less Than Body Requirement.”
When creating a nursing diagnosis statement, the nurse also identifies the cause, or etiology, of the problem for that specific client. Recall that the term “related factors” refers to the underlying causes (etiology) of a client’s problem or situation. Related factors should not refer to medical diagnoses, but instead should be causes that the nurse can treat. When possible, the nursing interventions planned for nursing diagnoses should attempt to modify or remove these underlying causes of the nursing diagnosis.
Creating nursing diagnosis statements is also called “using PES format.” The PES mnemonic no longer applies to the current terminology used by NANDA-I, but the components of a nursing diagnosis statement remain the same. A nursing diagnosis statement should contain the problem, related factors, and defining characteristics. These terms fit under the former PES format in this manner:
Problem (P): The problem (i.e., the nursing diagnosis)
Etiology (E): The related factors (i.e., the etiology/cause) of the nursing diagnosis; phrased as “related to” or “R/T”
Signs and Symptoms (S): The defining characteristics manifested by the client (i.e., the signs and symptoms/subjective and objective data/clinical cues) that led to the identification of that nursing diagnosis/hypothesis for the client; phrased with “as manifested by” (AMB) or “as evidenced by” (AEB).
Examples of different types of nursing diagnoses are further explained in the following sections.
Problem-Focused Nursing Diagnosis
A problem-focused nursing diagnosis contains all three components of the PES format:
Problem (P): Client problem (nursing diagnosis)
Etiology (E): Related factors causing the nursing diagnosis
Signs and Symptoms (S): Defining characteristics/cues manifested by that client (i.e., the signs and symptoms demonstrating there is a problem)
Example of a Problem-Focused Nursing Diagnosis
Refer to Scenario C of the “Assessment” section of this chapter. The cluster of data for Ms. J. (elevated blood pressure, elevated respiratory rate, crackles in the lungs, weight gain, worsening edema, and shortness of breath) are defining characteristics for the NANDA-I Nursing Diagnosis Excess Fluid Volume. The NANDA-I definition of Excess Fluid Volume is “surplus retention of fluid.” The related factor (etiology) of the problem is that the client has excessive fluid intake.[21]
The components of a problem-focused nursing diagnosis statement for Ms. J. would be:
Problem (P): Excess Fluid Volume
Etiology (E): Related to excessive fluid intake
Signs and Symptoms (S): As manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, increased weight of 1ten pounds, and the client reports, “My ankles are so swollen.”
A correctly written problem-focused nursing diagnosis statement for Ms. J. would be written as follows:
Excess Fluid Volume related to excessive fluid intake as manifested by bilateral basilar crackles in the lungs, bilateral 2+ pitting edema of the ankles and feet, an increase weight of 1ten pounds, and the client reports, “My ankles are so swollen.”
Health-Promotion Nursing Diagnosis
A health-promotion nursing diagnosis statement contains the problem (P) and the defining characteristics (S). The defining characteristics component of a health-promotion nursing diagnosis statement should begin with the phrase “expresses desire to enhance,” followed by what the client states in relation to improving their health status:[22]
A health-promotion diagnosis statement consists of the following:
Problem (P): Client problem (nursing diagnosis)
Signs and Symptoms (S): The client’s expressed desire to enhance
Example of a Health-Promotion Nursing Diagnosis
Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. demonstrates a readiness to improve her health status when she told the nurse that she would like to “learn more about my health so I can take better care of myself.” This statement is a defining characteristic of the NANDA-I nursing diagnosis Readiness for Enhanced Health Self-Management, which is defined as “a pattern of satisfactory management of symptoms, treatment regimen, physical, psychosocial, and spiritual consequences and lifestyle changes inherent in living with a chronic condition, which can be strengthened.”[23]
The components of a health-promotion nursing diagnosis for Ms. J. would be:
Problem (P): Readiness for Enhanced Health Self-Management
Symptoms (S): Expressed desire to “learn more about my treatment regimen so I can take better care of myself.”
A correctly written health-promotion nursing diagnosis statement for Ms. J. would be written as follows:
Enhanced Readiness for Health Promotion as manifested by expressed desire to “learn more about my treatment regimen so I can take better care of myself.”
Risk Nursing Diagnosis
A risk nursing diagnosis should be supported by evidence of the client’s risk factors for developing that problem. For example, the phrase “as evidenced by” is used to refer to the risk factors for developing that diagnosis.[24]
A risk diagnosis consists of the following:
Problem (P): Client problem (nursing diagnosis)
As Evidenced By: Risk factors for developing the problem
Example of a Risk Nursing Diagnosis
Refer to Scenario C in the “Assessment” section of this chapter. Ms. J. has an increased risk of falling due to weakness and fear of falling that she is experiencing. The NANDA-I definition of Risk for Adult Falls is “an adult susceptible to experiencing an event resulting in coming to rest inadvertently on the ground, floor, other level, which may compromise health.”[25]
The components of a risk nursing diagnosis statement for Ms. J. would be:
Problem (P): Risk for Adult Falls
As Evidenced By: Decreased lower extremity strength and fear of falling
A correctly written risk nursing diagnosis statement for Ms. J. would be written as follows:
Risk for Adult Falls as evidenced by decreased lower extremity strength and fear of falling.
Syndrome Nursing Diagnosis
A syndrome nursing diagnosis statement is a cluster of nursing diagnoses that occur together and are best addressed together and through similar interventions. To create a syndrome diagnosis, two or more nursing diagnoses must be used as defining characteristics (S) that create a syndrome. Related factors may be used if they add clarity to the definition but are not required.[26]
A syndrome statement consists of these items:
Problem (P): The syndrome
Signs and Symptoms (S): The defining characteristics are two or more similar nursing diagnoses
Example of a Syndrome Nursing Diagnosis
Refer to Scenario C in the “Assessment” section of this chapter. Clustering the data for Ms. J. identifies several similar NANDA-I nursing diagnoses of Decreased Activity Tolerance and Social Isolation nursing diagnoses that can be categorized under a syndrome diagnosis called Frail Elderly Syndrome. This syndrome is defined as a “dynamic state of unstable equilibrium that affects the older individual experiencing deterioration in one or more domains of health (physical, functional, psychological, or social) and leads to increased susceptibility to adverse health effects, in particular disability.”[27]
Example
The components of a syndrome nursing diagnosis for Ms. J. would be:
Problem (P): Risk for Frail Elderly Syndrome
Signs and Symptoms (S): The nursing diagnoses of Activity Intolerance and Social Isolation
Additional related factor: Fear of falling
A correctly written syndrome diagnosis statement for Ms. J. would be written as follows:
Risk for Frail Elderly Syndrome related to activity intolerance, social isolation, and fear of falling
See Table 4.4a for a summary of the types of nursing diagnoses.
Table 4.4a. Types of Nursing Diagnoses
| Diagnosis | What Is It? | Example of Nursing Diagnosis Statement |
|---|---|---|
| Problem-Focused (Actual) | Problem is present at the time of assessment | (PES) Fluid Volume Excess R/T excessive fluid intake AEB bilateral basilar crackles in the lungs, bilateral 2+ pitting edema in the ankles and feet, an increased weight of 10 pounds over 1 week, and the client reports, “My ankles feel swollen.” |
| Health-Promotion | A motivation/desire to increase well-being or a client’s strength | Enhanced Readiness for Health Promotion AEB expressed desire to “learn more about health so I can take better care of myself.” |
| Risk | Problem is likely to develop | Risk for Falls AEB dizziness and decreased lower extremity strength |
| Syndrome | Cluster of nursing diagnoses that occur together and are best addressed together | Risk for Frail Elderly Syndrome R/T activity intolerance, social isolation, and fear of falling |
It can feel overwhelming for nursing students to determine which nursing diagnoses to use for their clients due to the complexity of nursing diagnoses. Rest assured, use of nursing diagnoses becomes easier with practice and exposure to client care plans. Refer to trustworthy sources, such as a nursing diagnosis handbook or reputable care-planning resources to become aware of current NANDA-I nursing diagnoses.
Nursing diagnoses can be viewed to establish familiarity with them on the Nanda Diagnoses website, but be aware this is not an official NANDA nursing diagnosis site. Evidence-based care planning resources should be used when planning client care.
Prioritization
After identifying nursing diagnoses, the next step is prioritizing diagnoses and actions according to the specific needs of the client. Nurses prioritize their actions while providing client care multiple times every day. Prioritization is the skillful process of deciding which actions to complete first for client safety and optimal client outcomes. Through prioritization, the most significant nursing problems, as well as the most important interventions in the nursing care plan, are identified.
Client care situations fall somewhere between routine care and a medical crisis. It is essential that life-threatening concerns and crises are identified immediately and addressed quickly. Depending on the severity of a problem, the steps of the nursing process may be performed in a matter of seconds for life-threatening concerns, such as respiratory arrest or cardiac arrest. Critical situations can occur at any time when providing nursing care for clients, and the steps of the nursing process must be performed rapidly. Nursing students must have a full understanding of how to correctly analyze cues, cluster data, form appropriate hypotheses, and prioritize hypotheses to take appropriate action using clinical judgment. Nurses recognize cues signaling a change in client condition, apply evidence-based practices in a crisis, and communicate effectively with interprofessional team members.
There are several concepts used to prioritize, including Maslow’s Hierarchy of Needs, the “ABCs” (Airway, Breathing and Circulation), and acute, uncompensated conditions. See the infographic in Figure 4.7b[28] on The How To of Prioritization.
Maslow’s Hierarchy of Needs is used to categorize the most urgent client needs. The bottom levels of the pyramid represent the top priority needs of physiological needs intertwined with safety. See Figure 4.8[29] for an image of Maslow’s Hierarchy of Needs. You may be asking yourself, “What about the ABCs – isn’t airway the most important?” The answer to that question is “it depends on the situation and the associated safety considerations.” Consider this scenario – you are driving home after a lovely picnic in the country and come across a fiery car crash. As you approach the car, you see that the passenger is not breathing. Using Maslow’s Hierarchy of Needs to prioritize your actions, you remove the passenger from the car first due to safety even though he is not breathing. After ensuring safety and calling for help, you follow the steps to perform cardiopulmonary resuscitation (CPR) to establish circulation, airway, and breathing until help arrives.
In addition to using Maslow’s Hierarchy of Needs and the ABCs of airway, breathing, and circulation, the nurse also considers if the client’s condition is an acute or chronic problem. Acute, uncompensated conditions require priority interventions over chronic conditions. Additionally, actual problems generally receive priority over potential problems, but risk problems sometimes receive priority depending on the client vulnerability and risk factors.
Example of Prioritization
Refer to Scenario C in the “Assessment” section of this chapter. Four types of nursing diagnoses were identified for Ms. J.: Excess Fluid Volume, Enhanced Readiness for Health Promotion, Risk for Falls, and Risk for Frail Elderly Syndrome. The top priority diagnosis is Excess Fluid Volume because this condition affects the physiological needs of breathing, homeostasis, and excretion. However, the Risk for Falls diagnosis comes in a close second because of safety implications and potential injury that could occur if the client fell.
- American Nurses Association. (2021). Nursing: Scope and standards of practice (4th ed.). American Nurses Association. ↵
- “Diagnosis in the Nursing Process Compared to the NCJMM” by Tami Davis is licensed under CC BY 4.0 ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company. ↵
- Gordon, M. (2008). Assess notes: Nursing assessment and diagnostic reasoning. F.A. Davis Company. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/ ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- NANDA International. (n.d.). Glossary of terms. https://nanda.org/nanda-i-resources/glossary-of-terms/ ↵
- Herdman, T. H., Kamitsuru, S., & Lopes, C. T. (Eds.). (2021). Nursing diagnoses: Definitions and classification 2021-2023, Twelfth Edition. Thieme Publishers New York. ↵
- “The How To of Prioritization” by Valerie Palarski for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
- “Maslow's hierarchy of needs.svg” by J. Finkelstein is licensed under CC BY-SA 3.0 ↵
Apnea: Temporary cessation of breathing. When apnea occurs during sleep, it is often caused by the condition called Obstructive Sleep Apnea (OSA). (Chapter 8.2)
Arterial Blood Gas (ABG): Diagnostic test performed on an arterial sample of blood to determine its pH level, oxygenation status, and carbon dioxide status. (Chapter 8.2)
Barrel chest: An increased anterior-posterior chest diameter, resulting from air trapping in the alveoli, that can occur in chronic respiratory diseases like COPD. (Chapter 8.3)
Bradypnea: Decreased respiratory rate less than the normal range according to the client’s age. (Chapter 8.3)
Cardiac output: The amount of blood the heart pumps in one minute. (Chapter 8.2)
Clubbing: Enlargement of the fingertips that occurs with chronic hypoxia. (Chapter 8.3)
Coughing and deep breathing: A breathing technique where the client is encouraged to take deep, slow breaths and then exhale slowly. After each set of breaths, the client should cough. This technique is repeated 3 to 5 times every hour. (Chapter 8.2)
Cyanosis: Bluish discoloration of the skin and mucous membranes. (Chapter 8.2)
Dyspnea: A subjective feeling of not getting enough air. Depending on severity, dyspnea causes increased levels of anxiety. (Chapter 8.2)
Endotracheal Tube (ET tube): An ET tube is inserted by an advanced practitioner to maintain a secure airway when a client is experiencing respiratory failure or is receiving general anesthesia. For more information, see the “Oxygenation Equipment” section of the "Oxygen Therapy" chapter in Open RN Nursing Skill, 2e. (Chapter 8.2)
Gas exchange: Refers to the exchange of oxygen and carbon dioxide in the alveoli and the pulmonary capillaries; also called respiration. (Chapter 8.2)
HCO3-: Bicarbonate level of arterial blood indicated in an arterial blood gas (ABG) result. Normal range is 22-26. (Chapter 8.2)
Huffing technique: A technique helpful for clients who have difficulty coughing. Teach the client to inhale with a medium-sized breath and then make a sound like “ha” to push the air out quickly with the mouth slightly open. (Chapter 8.2)
Hypercapnia: Elevated level of carbon dioxide in the blood. (Chapter 8.2)
Hypoxemia: A specific type of hypoxia that is defined as decreased partial pressure of oxygen in the blood (PaO2) indicated in an arterial blood gas (ABG) result. (Chapter 8.2)
Hypoxia: A reduced level of tissue oxygenation. Hypoxia has many causes, ranging from respiratory and cardiac conditions to anemia. (Chapter 8.2)
Incentive spirometer: A medical device commonly prescribed after surgery to reduce the buildup of fluid in the lungs and to prevent pneumonia. While sitting upright, the client should breathe in slowly and deeply through the tubing with the goal of raising the piston to a specified level. The client should attempt to hold their breath for five seconds, or as long as tolerated, and then rest for a few seconds. This technique should be repeated by the client ten times every hour while awake. (Chapter 8.2)
Orthopnea: Difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position. (Chapter 8.3)
PaCO2: Partial pressure of carbon dioxide level in arterial blood indicated in an ABG result. Normal range is 35-45 mmHg. (Chapter 8.2)
PaO2: Partial pressure of dissolved oxygen in arterial blood indicated in an ABG result. Normal range is 80-100 mmHg. (Chapter 8.2)
Perfusion: The passage of blood through the arteries to an organ or tissue. (Chapter 8.2)
pH level: A measurement of acidity or alkalinity of the blood in an ABG result. The normal range of pH level for arterial blood is 7.35-7.45. A pH level below 7.35 is considered acidic, causing a condition called acidosis, and a pH level above 7.45 is considered alkaline, causing a condition known as alkalosis. (Chapter 8.2)
Pursed-lip breathing: A breathing technique that encourages a person to inhale through the nose and exhale through the mouth at a slow, controlled flow. (Chapter 8.2)
Purulent sputum: Yellow, green, or brown sputum that often indicates a respiratory infection. (Chapter 8.3)
Respiration: Gas exchange occurring at the alveolar level where blood is oxygenated. and carbon dioxide is removed. (Chapter 8.2)
SaO2: Calculated oxygen saturation level in an ABG result. Normal range is 95-100%. (Chapter 8.2)
Saturation of peripheral oxygen (SpO2): Hemoglobin saturation level measured by pulse oximetry. Normal range is 94-98%. (Chapter 8.2)
Sputum: Mucus and other secretions that are coughed up and expelled from the mouth. (Chapter 8.3)
Tachypnea: Elevated respiratory rate above normal range according to the client’s age. (Chapter 8.3)
Tripod position: A position that enhances air exchange when a client sits up and leans over by resting their arms on their legs or on a bedside table; also referred to as a three-point position. (Chapter 8.2)
Ventilation: Mechanical movement of air into and out of the lungs. (Chapter 8.2)
Vibratory Positive Expiratory Pressure (PEP) Therapy: Handheld devices such as flutter valves or Acapella devices used with clients who need assistance in clearing mucus from their airways. (Chapter 8.2)
Adult day care centers: Care that offers people with dementia and other chronic illnesses the opportunity to be social and to participate in activities in a safe environment, while also giving their caregivers the opportunity to work, run errands, or take a much-needed break. (Chapter 6.3)
Ageism: The stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs. (Chapter 6.4)
Alzheimer’s disease: An irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks. (Chapter 6.3)
Cognition: A term used to describe our ability to think. (Chapter 6.1)
Cognitive impairment: Impairment in mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge. (Chapter 6.2)
Delirium: An acute state of cognitive impairment that typically occurs suddenly due to a physiological cause, such as infection, hypoxia, electrolyte imbalances, drug effects, or other acute brain injury. (Chapter 6.2)
Dementia: A chronic condition of impaired cognition, caused by brain disease or injury, marked by personality changes, memory deficits, and impaired reasoning. Dementia can be caused by a group of conditions, such as Alzheimer’s disease, vascular dementia, frontal-temporal dementia, and Lewy body disease. It is gradual, progressive, and irreversible. (Chapter 6.2)
Depression: A brain disorder that can cause a persistent low mood, memory problems, loss of interest in life, and other symptoms that can overlap with dementia. (Chapter 6.2)
Development: Biological changes, as well as social and cognitive changes, that occur continuously throughout our lives. (Chapter 6.2)
Growth: Physical changes that occur during the development of an individual beginning at the time of conception. (Chapter 6.2)
Hospice care: A type of care selected by clients who are terminally ill and whose health care provider has determined they are expected to live six months or less that focuses on providing comfort and dignity at the end of life. It involves care and support services that can be of great benefit to people in the final stages of dementia and to their families. (Chapter 6.3)
Intellectual disability: A diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period prior to the age 18. (Chapter 6.2)
Respite care: Care provided at home (by a volunteer or paid service) or in a care setting, such as adult day centers or residential facilities, that allows the caregiver to take a much-needed break. (Chapter 6.3)
Sundowning: Increased confusion, anxiety, agitation, pacing, or disorientation in clients with dementia that typically begins at dusk and continues throughout the night. (Chapter 6.3)
The following client scenario applies information from this chapter to create an abbreviated nursing care plan and sample documentation note.
Client Scenario
Mr. Smith is an 82-year-old client with a history of chronic obstructive pulmonary disease (COPD). This morning Mr. Smith told the CNA as he was getting ready for breakfast, “I’m feeling weak today and I can't breathe.” The CNA obtained vital signs and reported them to you: respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. View a video simulation of Mr. Smith in the following box.
View a YouTube[1] of Mr. Smith this morning:
Applying the Nursing Process
Assessment: You auscultate Mr. Smith’s breath sounds and find scattered wheezing and rhonchi anteriorly, with diminished breath sounds in the posterior lower lobes. You ask Mr. Smith to rate his shortness of breath now on a scale from 0-10, and he reports it is a “4,” but usually a “2” during activity. While assessing Mr. Smith, you note he is using accessory muscles to breathe and is sitting up in the tripod position. He also has a barrel chest. You quickly check his chart and note the following orders and scheduled medications:
- Tiotropium (Spiriva) inhaler daily
- Fluticasone (Flovent) inhaler daily
- Oxygen via nasal cannula at 1-2 L per minute as needed to maintain O2 saturation greater than 90%
- Albuterol nebulizer as needed for wheezing
Based on this information, you formulate the following nursing care plan:
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea and use of accessory muscles to breathe and client stating, “I’m feeling weak today and I can't breathe.”
Overall Goal: The client will have adequate movement of air into and out of the lungs.
SMART Expected Outcome: Mr. Smith’s reported level of dyspnea will be within his stated desired range of 1-2 within one hour.
Planning and Implementing Nursing Interventions:
| Interventions | Rationale |
|---|---|
| 1. Implement NIC interventions for Respiratory Monitoring NIC (as described in section 8.3). | Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented. |
| 2. Implement NIC Interventions for Anxiety Reduction (as described in section 8.3). | Dyspnea creates feelings of anxiety. Decreasing the client’s anxiety levels will help decrease the feeling of dyspnea. |
| 3. Place client in high Fowler’s or tripod position as needed to reduce feelings of dyspnea. | Positioning will assist in maximum expansion of lungs. |
| 4. Apply oxygen via nasal cannula, starting at 1 L/min and titrate until 90% pulse oximetry reading is obtained per standing order. | Oxygen therapy will reduce the work of breathing. |
5. Administer scheduled and PRN medications:
|
Each medication has a different mechanism of action that will assist Mr. Smith’s dyspnea.
|
| 6. Encourage Mr. Smith to use pursed-lip breathing and Huff coughing. | Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions. |
| 7. Encourage fluids (2000 mL/24 hours) and monitor intake and output. | Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly clients who have increased risk for developing fluid overload. |
| 8. Schedule care activities to allow frequent rest periods. | Resting frequently decreases oxygen demand. |
| 9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. | Ambulation will help to mobilize the secretions so they can be removed. |
Sample Documentation:
Upon awakening, the client reported a dyspnea level of a “4” and stated, “I’m feeling weak today and I can't breathe.” Vital signs were respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. Scattered wheezing and rhonchi present anteriorly, with diminished breath sounds in the posterior lower lobes. Oxygen applied via nasal cannula at 1 L/min; albuterol nebulizer and scheduled medications were administered. Client was placed in tripod position at edge of bed and encouraged to use pursed-lip breathing and Huff coughing. Post albuterol administration, vital signs were respiratory rate 16, pulse 78, and O2 sat 90% on room air. The wheezing and rhonchi in the anterior lungs were diminished. Client reported dyspnea decreased to a “2” but stated, “I feel less short of breath, but I am still tired.” Encouraged client to push fluids and ambulate as tolerated today, along with frequent rest breaks. Will continue to monitor respiratory rate, pulse, lung sounds, and reported level of dyspnea every four hours today.
Evaluation:
After administering medications and applying the oxygen, you reassess Mr. Smith and find the following: respiratory rate 16, pulse 78, and O2 sat 90% with NC at 1 L/min. The wheezing and rhonchi in the anterior lungs have diminished. You ask Mr. Smith how he is feeling. He rates his current level of dyspnea as a “2” and states, “I feel less short of breath, but I am still tired.” The SMART outcome was "met." You encourage Mr. Smith to rest after eating breakfast but encourage a walk in the hallway later that morning. You enter the documentation note in the client record.
The following client scenario applies information from this chapter to create an abbreviated nursing care plan and sample documentation note.
Client Scenario
Mr. Smith is an 82-year-old client with a history of chronic obstructive pulmonary disease (COPD). This morning Mr. Smith told the CNA as he was getting ready for breakfast, “I’m feeling weak today and I can't breathe.” The CNA obtained vital signs and reported them to you: respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. View a video simulation of Mr. Smith in the following box.
View a YouTube[2] of Mr. Smith this morning:
Applying the Nursing Process
Assessment: You auscultate Mr. Smith’s breath sounds and find scattered wheezing and rhonchi anteriorly, with diminished breath sounds in the posterior lower lobes. You ask Mr. Smith to rate his shortness of breath now on a scale from 0-10, and he reports it is a “4,” but usually a “2” during activity. While assessing Mr. Smith, you note he is using accessory muscles to breathe and is sitting up in the tripod position. He also has a barrel chest. You quickly check his chart and note the following orders and scheduled medications:
- Tiotropium (Spiriva) inhaler daily
- Fluticasone (Flovent) inhaler daily
- Oxygen via nasal cannula at 1-2 L per minute as needed to maintain O2 saturation greater than 90%
- Albuterol nebulizer as needed for wheezing
Based on this information, you formulate the following nursing care plan:
Nursing Diagnosis: Ineffective Breathing Pattern related to respiratory muscle fatigue as manifested by tachypnea and use of accessory muscles to breathe and client stating, “I’m feeling weak today and I can't breathe.”
Overall Goal: The client will have adequate movement of air into and out of the lungs.
SMART Expected Outcome: Mr. Smith’s reported level of dyspnea will be within his stated desired range of 1-2 within one hour.
Planning and Implementing Nursing Interventions:
| Interventions | Rationale |
|---|---|
| 1. Implement NIC interventions for Respiratory Monitoring NIC (as described in section 8.3). | Establish a baseline status for today and continue to monitor for improvement or worsening as interventions are implemented. |
| 2. Implement NIC Interventions for Anxiety Reduction (as described in section 8.3). | Dyspnea creates feelings of anxiety. Decreasing the client’s anxiety levels will help decrease the feeling of dyspnea. |
| 3. Place client in high Fowler’s or tripod position as needed to reduce feelings of dyspnea. | Positioning will assist in maximum expansion of lungs. |
| 4. Apply oxygen via nasal cannula, starting at 1 L/min and titrate until 90% pulse oximetry reading is obtained per standing order. | Oxygen therapy will reduce the work of breathing. |
5. Administer scheduled and PRN medications:
|
Each medication has a different mechanism of action that will assist Mr. Smith’s dyspnea.
|
| 6. Encourage Mr. Smith to use pursed-lip breathing and Huff coughing. | Pursed-lip breathing will help keep the airways open longer on expiration so that more air can then be inhaled on inspiration. Huff coughing will help clear secretions. |
| 7. Encourage fluids (2000 mL/24 hours) and monitor intake and output. | Additional fluids will help thin secretions so they can more easily be coughed up. Mr. Smith does not have fluid restrictions, but it is important to monitor intake/output when encouraging fluids, especially in elderly clients who have increased risk for developing fluid overload. |
| 8. Schedule care activities to allow frequent rest periods. | Resting frequently decreases oxygen demand. |
| 9. Encourage ambulation as tolerated, with the CNA, in the hallway, after the O2 saturation is greater than 90%. | Ambulation will help to mobilize the secretions so they can be removed. |
Sample Documentation:
Upon awakening, the client reported a dyspnea level of a “4” and stated, “I’m feeling weak today and I can't breathe.” Vital signs were respiratory rate 24, O2 sat 86%, pulse 88, and temperature 36.8 C. Scattered wheezing and rhonchi present anteriorly, with diminished breath sounds in the posterior lower lobes. Oxygen applied via nasal cannula at 1 L/min; albuterol nebulizer and scheduled medications were administered. Client was placed in tripod position at edge of bed and encouraged to use pursed-lip breathing and Huff coughing. Post albuterol administration, vital signs were respiratory rate 16, pulse 78, and O2 sat 90% on room air. The wheezing and rhonchi in the anterior lungs were diminished. Client reported dyspnea decreased to a “2” but stated, “I feel less short of breath, but I am still tired.” Encouraged client to push fluids and ambulate as tolerated today, along with frequent rest breaks. Will continue to monitor respiratory rate, pulse, lung sounds, and reported level of dyspnea every four hours today.
Evaluation:
After administering medications and applying the oxygen, you reassess Mr. Smith and find the following: respiratory rate 16, pulse 78, and O2 sat 90% with NC at 1 L/min. The wheezing and rhonchi in the anterior lungs have diminished. You ask Mr. Smith how he is feeling. He rates his current level of dyspnea as a “2” and states, “I feel less short of breath, but I am still tired.” The SMART outcome was "met." You encourage Mr. Smith to rest after eating breakfast but encourage a walk in the hallway later that morning. You enter the documentation note in the client record.
Adult day care centers: Care that offers people with dementia and other chronic illnesses the opportunity to be social and to participate in activities in a safe environment, while also giving their caregivers the opportunity to work, run errands, or take a much-needed break. (Chapter 6.3)
Ageism: The stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs. (Chapter 6.4)
Alzheimer’s disease: An irreversible, progressive brain disorder that slowly destroys memory and thinking skills and eventually the ability to carry out the simplest tasks. (Chapter 6.3)
Cognition: A term used to describe our ability to think. (Chapter 6.1)
Cognitive impairment: Impairment in mental processes that drive how an individual understands and acts in the world, affecting the acquisition of information and knowledge. (Chapter 6.2)
Delirium: An acute state of cognitive impairment that typically occurs suddenly due to a physiological cause, such as infection, hypoxia, electrolyte imbalances, drug effects, or other acute brain injury. (Chapter 6.2)
Dementia: A chronic condition of impaired cognition, caused by brain disease or injury, marked by personality changes, memory deficits, and impaired reasoning. Dementia can be caused by a group of conditions, such as Alzheimer’s disease, vascular dementia, frontal-temporal dementia, and Lewy body disease. It is gradual, progressive, and irreversible. (Chapter 6.2)
Depression: A brain disorder that can cause a persistent low mood, memory problems, loss of interest in life, and other symptoms that can overlap with dementia. (Chapter 6.2)
Development: Biological changes, as well as social and cognitive changes, that occur continuously throughout our lives. (Chapter 6.2)
Growth: Physical changes that occur during the development of an individual beginning at the time of conception. (Chapter 6.2)
Hospice care: A type of care selected by clients who are terminally ill and whose health care provider has determined they are expected to live six months or less that focuses on providing comfort and dignity at the end of life. It involves care and support services that can be of great benefit to people in the final stages of dementia and to their families. (Chapter 6.3)
Intellectual disability: A diagnostic term that describes intellectual and adaptive functioning deficits identified during the developmental period prior to the age 18. (Chapter 6.2)
Respite care: Care provided at home (by a volunteer or paid service) or in a care setting, such as adult day centers or residential facilities, that allows the caregiver to take a much-needed break. (Chapter 6.3)
Sundowning: Increased confusion, anxiety, agitation, pacing, or disorientation in clients with dementia that typically begins at dusk and continues throughout the night. (Chapter 6.3)
Learning Objectives
- Identify risk factors for sensory impairments
- Identify cues related to sensory impairments across the life span
- Identify interventions to support diverse clients (individual, family, or group) with sensory impairments
- Contribute to a plan of care for clients with sensory impairments
- Detail support for family/significant others caring for clients with a sensory impairment
- Include community resources available for clients and families with a sensory impairment
- Include adaptations to the environment to maintain safety for the client with a sensory impairment
- Outline evidence-based nursing interventions for specific sensory disorders
Our five basic senses of sight (vision), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory) help us perceive and act in the world around us. See Figure 7.1[3] for an illustration of our five senses.
We may not often consider the importance of our sensory input. As nurses, we especially rely on our senses when providing client care as we gather assessment data. We ask questions and listen to client responses, we listen to their heart and lung sounds, we evaluate the appearance of their skin, we may smell an infectious process when changing a wound dressing, and we feel the sensation of pulses when assessing circulation.
When an individual experiences sensory impairment because of the loss of one or more senses or is affected by the amount of stimuli (too much or too little), their ability to safely function is impacted. Nurses identify clients’ sensory impairments and implement interventions to improve their safety, functioning, and quality of life. The nurse’s goal is to provide support and dignity to individuals and their families by using strategies and resources that will help them to engage with their surroundings and others to the best of their ability.
This chapter will review common sensory impairments and related nursing care.
Learning Objectives
- Identify risk factors for sensory impairments
- Identify cues related to sensory impairments across the life span
- Identify interventions to support diverse clients (individual, family, or group) with sensory impairments
- Contribute to a plan of care for clients with sensory impairments
- Detail support for family/significant others caring for clients with a sensory impairment
- Include community resources available for clients and families with a sensory impairment
- Include adaptations to the environment to maintain safety for the client with a sensory impairment
- Outline evidence-based nursing interventions for specific sensory disorders
Our five basic senses of sight (vision), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory) help us perceive and act in the world around us. See Figure 7.1[4] for an illustration of our five senses.
We may not often consider the importance of our sensory input. As nurses, we especially rely on our senses when providing client care as we gather assessment data. We ask questions and listen to client responses, we listen to their heart and lung sounds, we evaluate the appearance of their skin, we may smell an infectious process when changing a wound dressing, and we feel the sensation of pulses when assessing circulation.
When an individual experiences sensory impairment because of the loss of one or more senses or is affected by the amount of stimuli (too much or too little), their ability to safely function is impacted. Nurses identify clients’ sensory impairments and implement interventions to improve their safety, functioning, and quality of life. The nurse’s goal is to provide support and dignity to individuals and their families by using strategies and resources that will help them to engage with their surroundings and others to the best of their ability.
This chapter will review common sensory impairments and related nursing care.
Interpreting Sensations
Before learning about sensory function, it is important to understand how the nervous system works. An intact nervous system is necessary for information to be delivered from the environment to the brain to trigger responses from the body. For neurons to transmit these messages, they are in the form of an action potential. Sensory receptors perceive a stimulus and then change the sensation to an electrical signal so that it can be transmitted to the brain and then out to the body. For example, a pain receptor perceives pain as your hand touches a hot tray. The signal is transmitted to the brain where it is interpreted, and then signals are quickly sent to the hand to pull away from the hot stimuli.[5]
Our bodies interpret sensations through a process using reception, perception, and reaction. Reception is the first part of the sensory process when a nerve cell or sensory receptor is stimulated by a sensation. Sensory receptors are activated by mechanical, chemical, or temperature stimuli. In addition to our five senses, we also have somatosensation. Somatosensation refers to sensory receptors that respond to stimuli such as pain, pressure, temperature, and vibration. It also includes vestibular sensation, a sense of spatial orientation and balance, and proprioception, the sense of the position of our bones, joints, and muscles. Although these sensory systems are all very different, they share a common purpose. They change a stimulus into an electrical signal that is transmitted in the nervous system.[6]
The sensory receptors for each of our senses work differently from one another. Light receptors, sound receptors, and touch receptors are each activated by different stimuli with specialized receptor specificity. For example, touch receptors are sensitive to pressure but do not have sensitivity to sound or light. Nerve impulses from sensory receptors travel along pathways to the spinal cord or directly to the brain. Some stimuli are also combined in the brain, such as our sense of smell that can affect our sense of taste.[7]
As an individual becomes aware of a stimulus and it is transmitted to the brain, perception occurs. Perception is the interpretation of a sensation. All sensory signals, except olfactory system input, are transmitted to the thalamus and to the appropriate region of the cortex of the brain. The thalamus, which is in the forebrain, acts as a relay station for sensory and motor signals. When a sensory signal leaves the thalamus, it is sent to the specific area of the cortex that processes that sense.[8] However, conditions that affect a person’s consciousness also affect the ability to perceive and interpret stimuli.
Reaction is the response that individuals have to a perception of a received stimulus. The brain determines what sensations are significant because it is impossible to react to all stimuli that are constantly received from our environment. A healthy brain maintains a balance between sensory stimuli received and those reaching awareness. However, sensory overload can occur if the amount of stimuli the brain is receiving is overwhelming to an individual. Sensory deprivation can also occur if there are insufficient sensations from the environment.[9]
Sensory Impairment
Alterations in sensory function include sensory impairment, sensory overload, and sensory deprivation. Sensory impairment includes any type of difficulty that an individual has with one of their five senses. When an individual experiences loss of a sensory function, such as vision, the way they interact with the environment is affected. For example, when an individual gradually loses their vision, their reliance on other senses to receive information from the environment is often enhanced.
Safety is always a nursing consideration for a client with a sensory impairment. Intact senses are required to make decisions about functioning safely within the environment. For example, an individual who has impaired hearing may not be able to hear a smoke alarm and requires visual indicators when the alarm is triggered.
Sensory impairments are very common in older adults. Most older adults develop impaired near vision called presbyopia, resulting in the need for reading glasses. See Figure 7.2[10] for an image of simulated presbyopia.
Deficits in taste and smell are also prevalent in this age group. Additionally, kinesthetic impairment (an altered sense of touch) can occur in adults as young as 55. Kinesthetic impairment can cause difficulty in daily functioning, such as buttoning one’s shirt or performing other fine motor tasks. These sensory losses can greatly impact how older adults live and function.[11]
Vision Impairments
Several types of visual impairments commonly occur in older adults, including macular degeneration, cataracts, glaucoma, diabetic retinopathy, and presbyopia. See Table 7.2 for more information about each of these visual conditions.
Table 7.2 Common Visual Conditions
| Macular Degeneration | Macular degeneration is the leading cause of legal blindness in individuals over 60 years of age. Risk factors include advancing age, a positive family history, hypertension, and smoking. In macular degeneration, there is loss of central vision with classic symptoms such as blurred central vision, distorted vision that causes difficulty driving and reading, and the requirement for brighter lights and magnification for close-up visual activities.[12] |
|---|---|
| Cataracts | Cataracts are the opacity of the lens of the eye that causes clouded, blurred, or dimmed vision. About half of individuals ages 65 to 75 will develop cataracts, with further incidence occurring after age 75. Cataracts can be removed with surgery that replaces the lens with an artificial lens.[13] |
| Glaucoma | Glaucoma is caused by elevated intraocular pressure that leads to progressive damage to the optic nerve, resulting in gradual loss of peripheral vision. It affects about 4% of individuals over age 70.[14] |
| Diabetic Retinopathy | Diabetic retinopathy is the leading cause of blindness in adults diagnosed with type 1 and type 2 diabetes mellitus. Diabetic retinopathy is a complication of diabetes mellitus due to damaged blood vessels in the retina causing vision loss.[15] Clients with diabetes are encouraged to receive annual eye exams so that retinopathy can be discovered and treated early. Treatments, such as laser treatment that can help shrink blood vessels, injections that can reduce swelling, or surgery, can prevent permanent vision loss.[16] |
| Presbyopia | As a person ages, the lens of the eye gradually becomes thicker and loses flexibility. It stops focusing light on the retina correctly, causing impaired near vision and accommodation at all distances. Presbyopia starts in the early to mid-forties and worsens with aging. It can lead to significant visual impairment but does not usually cause blindness.[17] |
Hearing Loss and Ear Problems
Approximately one third of individuals aged 70 and older have hearing loss. Good hearing depends on a series of events that change sound waves in the air into electrical signals. The auditory nerve conducts these electrical signals from the ear to the brain through a series of steps. The structures of the ear, such as the tympanic membrane and cochlea, must be intact and functioning appropriately for conduction of sound to occur. Age-related hearing loss (presbycusis) gradually occurs in most individuals as they age.[18] Typically, low-pitched sounds are easiest to hear, but it often becomes increasingly difficult to hear normal conversation, especially over loud background noise. Hearing aids are commonly used to enhance hearing. See Figure 7.3[19] for an image of common hearing aids used to treat hearing loss.
Hearing loss can be caused by other factors in addition to aging. A build-up of ear wax in the ear canal can cause temporary hearing loss. Sounds that are too loud or long-term exposure to loud noises can cause noise-induced hearing loss. For example, a loud explosion or employment using loud machinery without ear protection can damage the sensory hair cells in the ear. After these hair cells are damaged, the ability to hear is permanently diminished. Tinnitus, a medical term for ringing in the ears, can also occur. Some medications, such as high doses of aspirin or loop diuretics, can cause toxic effects to the sensory cells in the ear and lead to hearing loss or tinnitus.[20],[21] In addition to hearing loss, ear problems can also cause problems with balance, dizziness, and vertigo due to vestibular dysfunction.
Kinesthetic Impairments
Kinesthetic impairments, such as peripheral neuropathy, affect the ability to feel sensations. Symptoms of peripheral neuropathy include sensations of pain, burning, tingling, and numbness in the extremities that decrease a person’s ability to feel touch, pressure, and vibration. Position sense can also be affected and makes it difficult to coordinate complex movements, such as walking, fastening buttons, or maintaining balance when one’s eyes are closed. Peripheral neuropathy is caused by nerve damage that commonly occurs in clients with diabetes mellitus or peripheral vascular disease. It can also be caused by physical injuries, infections, autoimmune diseases, vitamin deficiencies, kidney diseases, liver diseases, and certain medications like chemotherapy medications.[22]
Life Span Considerations
Impaired sensory functioning increases the risk for social isolation in older adults. For example, when individuals are not able to hear well, they may pretend to hear in an attempt to avoid embarrassment when asking for the information to be repeated. They may begin to avoid noisy environments or stop participating socially in conversations around them.
Infants and children are also at risk for vision and hearing impairments related to genetic or prenatal conditions. Early determination of sensory impairments is crucial so that problems can be addressed with accommodations to minimize the impact on a child’s development. For example, a screening hearing test is completed on all newborns before discharge to evaluate for hearing impairments that can affect their speech development.
Sensory Overload and Sensory Deprivation
Stimuli are continually received from a variety of sources in our environment and from within our bodies. When an individual receives too many stimuli or cannot selectively filter out meaningful stimuli, sensory overload can occur. Symptoms of sensory overload include irritability, restlessness, covering ears or eyes to shield them from sensory input, and increased sensitivity to tactile input (i.e., scratchy fabric or sensations of medical equipment).[23] Sensory overload affects an individual’s ability to interpret stimuli from their environment and can lead to confusion and agitation. See Figure 7.4[24] of an image of a client reacting to sensory overload.
The health care environment with its frequent noisy alarms, treatments, staff interruptions, and noisy hallway conversations can cause sensory overload for clients. Additionally, the amount of information provided to a client experiencing a health crisis can contribute to sensory overload, such as teaching about procedural and diagnostic testing. Clients may only be able to process small chunks of information provided at a time and may need this information repeated to ensure they understand their situation and retain the information.
Individuals have different tolerances for the amount of stimuli that will affect them adversely. Tolerance to stimuli is impacted by factors such as pain, stress levels, sleep patterns, physical health, and emotional health. When sensory overload occurs in a hospitalized client, it can lead to delirium and acute confusion. It is important for the nurse to limit unnecessary awakenings and interactions with the health care team members when a client is experiencing sensory overload.
Conversely, symptoms of sensory deprivation may occur when there is a lack of sensations due to sensory impairments or few quality stimuli in the client environment. This may include hearing or vision impairments, brain or spinal injuries resulting in lack of tactile sensations, having few or no visitors, or having transmission-based precautions resulting in decreased staff interaction. Interventions such as opening window curtains, providing a clock and calendar for orientation to the time and the day of the week, encouraging visitors, and spending additional time with the client can help prevent sensory deprivation.
Clients with sensory deprivation may experience excessive tiredness or lethargy, disorientation, depression or apathy. People experiencing sensory deprivation often report perceptual disturbances such as hallucinations. Symptoms of sensory deprivation can mimic delirium, so it is important for a nurse to further investigate new perceptual disturbances.[25]
