Putting It All Together

Review how to apply the nursing process for a client with impaired sensation in the following scenario.

Client Scenario

Mr. Mitchell, age 87, is accompanied to the primary care clinic with his daughter Elise. See Figure 7.5^[1] for a simulated image of Mr. Mitchell. Elise tells the nurse that her father has been increasingly withdrawn and she has difficulty getting in contact with him during the week by phone. She is concerned that he is experiencing depression. Mr. Mitchell is alert, well-groomed, and smiling. As the nurse begins the initial assessment interview, it is noted that Mitchell smiles and nods a lot but does not answer direct questions appropriately. Elise has shared that she has not noted problems with her father’s ability to care for himself; he is paying his own bills and orders groceries online for delivery.

When questioned further about his answers, Mr. Mitchell admits that he is unsure what was asked of him. He is embarrassed about this and avoids asking people to repeat themselves. He also explains that his father had a hearing device, and it always “rang loudly” so he has not considered this option.

The nurse performs a whisper test and discovers he is unable to report any of the six words whispered behind him. She notes that Mr. Mitchell is interested in improving his ability to hear and participate in conversations with others.

Applying the Nursing Process

Assessment: The nurse performs a whisper test and discovers he is unable to report any of the six words whispered behind him. He is interested in improving his ability to hear and participate in conversations with others.

Based on the interview and assessment information, the following nursing care plan is created for Mr. Mitchell.

Nursing Diagnosis: Readiness for Enhanced Communication as evidenced by expressed desire to enhance hearing and communication.

Overall Goal: The client will experience enhanced communication with improved hearing.

SMART Expected Outcome: Mr. Mitchell will attend an appointment arranged with an audiologist within two weeks.

Planning and Implementing Nursing Interventions:

The nurse provides education about available hearing devices and encourages the client to attend an appointment with an audiologist. While speaking to the client, she faces him directly and provides good lighting so that he can read her lips. She shuts the door to the exam room to provide a quiet environment and uses short, simple sentences. She does not interpret nodding to indicate understanding. She shares her assessment findings with the provider and requests a referral to an audiologist and then assists the client in making the appointment. She asks the client and his daughter if they have any questions before they leave the clinic.

Sample Documentation:

During the intake interview, the client answered some questions appropriately but at times did not answer questions at all. He appeared to be embarrassed when asking people to repeat their statements. Daughter states, “He is becoming increasingly withdrawn.” Ear canals are clear without cerumen present. Unable to report six out of six words during the whisper test. Provided brief explanation of new technology available for hearing loss while standing directly in front of the client, and he appeared to be able to slightly read lips. Encouraged consultation with an audiologist and notified the provider of assessment findings. Appointment made with the audiologist and communicated place, date, and time to the client and his daughter.

Evaluation:

During the next clinic appointment in two weeks, Mr. Mitchell is wearing a hearing aid device and answers questions appropriately. He reports that he has been attending more social events “now that I can hear better.” The SMART outcome was “met.”