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Nursing Diagnosis: Sensory Perception, risk for disturbed (specify)
Risk factors may include
- Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance
Desired Outcomes
- Maintain usual level of mentation.
- Recognize and compensate for existing sensory impairments.
6 Diabetes Mellitus Nursing Care Plan (NCP)
- Risk for Infection — Diabetes Mellitus Nursing Care Plan (NCP)
- Risk for Disturbed Sensory Perception — Diabetes Mellitus Nursing Care Plan
- Powerlessness — Diabetes Mellitus Nursing Care Plan
- Imbalanced Nutrition Less Than Body Requirements — Diabetes Mellitus Nursing Care Plan (NCP)
- Deficient Fluid Volume — Diabetes Nursing Care Plan (NCP)
- Fatigue — Diabetes Mellitus Nursing Care Plan (NCP)
Risk for Disturbed Sensory Perception — Diabetes Mellitus Nursing Care Plan (NCP)
| Nursing Interventions | Rationale |
| Monitor vital signs and mental status. | Provides a baseline from which to compare abnormal findings, e.g., fever may affect mentation. |
| Address patient by name; reorient as needed to place, person, and time. Give short explanations, speaking slowly and enunciating clearly. | Decreases confusion and helps maintain contact with reality. |
| Schedule nursing time to provide for uninterrupted rest periods. | Promotes restful sleep, reduces fatigue, and may improve cognition. |
| Keep patient’s routine as consistent as possible. Encourage participation in activities of daily living (ADLs) as able. | Helps keep patient in touch with reality and maintain orientation to the environment. |
| Protect patient from injury (avoid/limit use of restraints as able) when level of consciousness is impaired. Place bed in low position. Pad bed rails and provide soft airway if patient is prone to seizures. | Disoriented patient is prone to injury, especially at night, and precautions need to be taken as indicated. Seizure precautions need to be taken as appropriate to prevent physical injury, aspiration. |
| Evaluate visual acuity as indicated. | Retinal edema/detachment, hemorrhage, presence of cataracts or temporary paralysis of extraocular muscles may impair vision, requiring corrective therapy and/or supportive care. |
| Investigate reports of hyperesthesia, pain, or sensory loss in the feet/legs. Look for ulcers, reddened areas, pressure points, loss of pedal pulses. | Peripheral neuropathies may result in severe discomfort, lack of/distortion of tactile sensation, potentiating risk of dermal injury and impaired balance. |
| Provide bed cradle. Keep hands/feet warm, avoiding exposure to cool drafts/hot water or use of heating pad. | Reduces discomfort and potential for dermal injury. |
| Assist with ambulation/position changes. | Promotes patient safety, especially when sense of balance is affected. |
| Monitor laboratory values, e.g., blood glucose, serum osmolality, Hb/Hct, BUN/Cr. | Imbalances can impair mentation. Note: If fluid is replaced too quickly, excess water may enter brain cells and cause alteration in the level of consciousness (water intoxication). |
| Carry out prescribed regimen for correcting DKA as indicated. | Alteration in thought processes/potential for seizure activity is usually alleviated once hyperosmolar state is corrected. |
