Saint Joseph College Institute of Health Sciences Cavite City NURSING CARE PLAN Name of Client: Address: Impression/Diagnosis:

ASSESSMENT Cues/Evidences Nursing Diagnosis Subjective: I have hearing loss. As verbalize by the client Disturbed sensory perception (auditory) related to normal physiological Objective: changes of Disorientati aging as manifested on in time, by: place or Disorient person ation in Reported time, and place or measured person changed in Reported auditory acuity and measured Poor changed concentratio in hearing n acuity Auditory Poor distortions concentra Age: Chief Complaint: Scientific Rationale PLANNING Nursing Objective Within the shift, the client will demonstrate decrease symptoms of sensory overload as manifested by: Identifies sounds correctly Uses assistive aids to maximize deficits Administers ear medications correctly and complies with Gender:

IMPLEMENTATION Nursing Order/Action Scientific Rationale Assessment: Assess for confusion state, disorientation, difficulty and slowing of mental ability, changes in behavior and emotional response Assess auditory acuity, cerumen in ears, responses to noise and effect on hearing, ability to communicate, difficulty in locating and identifying sounds

EVALUATION

Determine type of hearing loss, if head turned to hear , asks for repeat of conversations frequently, inability to follow verbal conversations

Independent interventions:

Cognitive dysfunction behavior change may result from sensory deficits/deprivation caused y physiological, psychological, and emotional factors. Presbycusis is common in elderly, conductive loss results in a false interpretation of the world and creates poor communication, isolation, depression, impaired thought process as interactions are not heard Elderly with conductive loss will hear any loudly spoken words; sensorineural loss experience loss of hearing even when speech is loud enough to

Altered communicat ion patterns Inappropriat e response The client verbalize hearing loss

tion Auditory distortion s Altered communi cation patterns Inappropr iate response The client verbalize hearing loss

medication regimen Early recognition of changes or increases impairment s of sensory perception and participatio n in tests The family will: Make adjustments in the environmen t to prevent accidents and confusion Make adjustments to enhance hearing Cleanse and care the assistive device properly.

Eliminate background noise Face the client, use eye contact and speak loudly enough to be heard, speak slowly and clearly with pitch, use short sentences and gestures, maintain position even with client allow view of lips, use touch to hold attention Allow time for answers, rephrase message using different words if confused, puzzled or gives inappropriate response

be heard Noise interferes with hearing Enhances communication if hearing impaired and promotes caring and warmth

May need time to sort out and identify sounds or may not understand certain frequency sounds

Instructions to the client and family: Applying, removing hearing device weekly and cleaning ear and device and troubleshoot according to manufacturers instruction pamphlet Environmental modification to enhance hearing as appropriate

Prevents cerumen production and enhances hearing

Inform that time is needed to adapt to assistive devices/aids Reinforce information about aging changes that affect sensory and cognitive perception

Safety precautions prevent injury in presence of sensory impairment Established patterns take time to change Promotes understanding of deficit and motivates to implement measures that improve function

 Dependent action: Application of ear medications; stress importance of drug therapy compliance Administer softening agent to ear and irrigate with bulb syringe or low pulsating water pick Collaborative: Promote use of assistive devices i.e. hearing aid Suggest yearly hearing testing Provide telephone amplifier on receiver and bell tone, flashing light on phone, loud speakers for TV, radio, tape, and CD players

Promotes auditory acuity

Softens cerumen buildup and emulsifies it for easier removal to facilitate hearing Provides correction of deficit Provides for adjustments in corrective devices Promotes auditory perception and acuity