A nurse is establishing a plan of care for an older adult client who requires bilateral eye patches and strict bed rest following complex ophthalmic surgery. The client reports feeling highly anxious and "disconnected from reality." Which interventions should the nurse include in the plan of care to address the client's sensory and perceptual alterations? Select all that apply.
- State the nurse's name and the purpose of the interaction immediately upon entering the client's room.Answer
- Explain the source of unfamiliar environmental noises to the client as they occur.Answer
- CReassure the client by stating, "There is no need to worry; your anxiety will resolve as soon as the patches are removed."
- DDirect the unlicensed assistive personnel (UAP) to perform the initial assessment of the client's orientation status.
- EEducate family members that sudden confusion is a normal and expected part of the aging process.
- Provide varying tactile stimulation by offering a warm washcloth or encouraging the use of a stress ball.Answer
Answer
The correct interventions involve orienting the client through verbal identification, explaining environmental stimuli, and providing meaningful tactile stimulation.
Clients with bilateral eye patches are at high risk for sensory deprivation and anxiety due to the sudden loss of visual input. The correct interventions focus on compensating for this loss by providing meaningful stimulation through other senses. Stating the nurse's name and explaining the source of environmental noises helps orient the client, reduces fear of the unknown, and provides necessary auditory context. Offering tactile stimulation provides alternative sensory input to prevent deprivation and maintain the client's connection to their environment.
Step-by-Step Solution
Key Concept
Sensory Deprivation Management and Therapeutic Communication