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Disturbed Sensory NANDA Definition: ÷hange After 8 hours of nursing After 8 hrs of nursing
Perception: Auditory in the amount or intervention Patient intervention the patient
related to direct trauma to patterning of incoming achieves optimal was able to achieve
the left ear as manifested stimuli accompanied by a functioning within limits of optimal functioning within
by Head tilting and Ear diminished, exaggerated, hearing impairment as limits of hearing
Pain distorted, or impaired evidenced by ability to impairment
response to such stimuli communicate effectively
   and to engage in
Ôp ÷lient verbalized: Hearing loss is common meaningful activities 
͞ wala talaga among older adults but 
akong marinig sa may also occur as the After 45 minutes of  


kaliwang tenga ko͟ result of congenital nursing intervention, the
exposure to virus; during patient will: Encourage the client not to Avoid further Damage to
Ôp ÷lient verbalized: childhood after frequent lie down on the affected the affected side ÷lient Maintained the
͞masakit din ear infections or trauma; Maintain the affected ear side affected ear from possible
paminsan minsan and during adulthood as from possible trauma High back rest relieves p- trauma
ang ulo ko͟ the result of trauma, Encourage client to sit on pressure from the head. As
infection, or exposure to high back rest well as the nose, eyes,
Ôp ͞÷lient verbalized: occupational and/or ears. º
 

Masakit minsan environmental noise. Some 
  
  
ang tenga ko͟ causes of hearing loss are 
surgically correctable.
Ôp ÷lient verbalized: ͞ Many hearing assistive
meron lumalabas devices and services are Encourage ÷lient not to Prevent Transmission of
sa kaliwang tenga available to help the touch affected side Rnfection from hands to
ko, konting buo hearing-impaired ears as well as relieves
buong dugo ͞ individual. Nursing pressure to the ear.
interventions with the º



hearing impaired are 

   aimed at assisting the
Ôp Head Tilting individual in effective Rnstruct patient or Thin washcloths and
Ôp Rnappropriate communication despite caregiver in safe fingers are best for
response to the loss of normal hearing. techniques for cleaning cleaning ears. ÷otton-
questions ears. tipped applicators should
Ôp Difficulty learning º


 be avoided to prevent
or following 
 inadvertent injury to
directions eardrum
Ôp Ear pain º






Vital Signs
T 36.2 ÷ Rnstruct patient in the ÷lient was able to
P 80 BPM ÷lient will be able to importance of routine Monitor the status of the communicate easily
R 19 ÷PM communicate easily examination by an EENT affected ear
BP 110/70 doctor

Reduce or minimize
environmental noise. Reduce noise so that Maintained the affected
Maintain the affected ear speaker does not have to ear from free from
from free from infection. compete to be heard. infection
º






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Monitor Vital Signs
 Know the client͛s baseline
 data
Administer Ear Drops as
Ordered Prevent Ear Rnfection,
serve as prophylaxis
Assess for drainage from
ear canal. Purulent, foul-smelling
drainage indicates an
infection; serous, mucoid,
or bloody drainage may
indicate effusion of the
middle ear after an upper
respiratory or sinus
infection.º