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Risk for Disturbed Sensory Perception — Diabetes Mellitus

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 Risk for Disturbed Sensory Perception — Diabetes Mellitus Nursing Care Plan

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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.
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.