Nursing diagnosis – UNILATERAL NEGLECT

UNILATERAL  NEGLECT

DEFINITION

Impairment in sensory and motor response, mental representation,

and spatial attention of the body and the corresponding environ-

ment characterized by inattention to one side and overattention to

the opposite side. Left side neglect is more severe and persistent

than right side neglect

DEFINING CHARACTERISTICS

• Consistent inattention to stimuli/positioning on affected side

• Failure to eat food on plate on the affected side

• Inadequate self-care

• Failure to move eyes, head, limbs, or trunk in the affected hemi-

space despite awareness of stimulus in that space

• Marked deviation of the eyes, head, or trunk to the nonaffected

side by stimuli and activities on that side (as if drawn by Magnet)

• Perseveration of visual motor tasks on the nonaffected side

RELATED FACTORS

• Brain injury from tumor, or cerebrovascular, neurological, or trau-

matic causes

• Left hemiplegia from CVA of right hemisphere

• Hemianopsia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Self-care

• Coping

• Sensation/perception

• Neurocognition

• Tissue integrity

EXPECTED OUTCOMES

The patient/family will

• Avoid injury, skin breakdown and contractures on affected body part.

• Recognize the neglected body part.

• Demonstrate exercises for the affected body part.

• Demonstrate measures for maximum functioning and arrange

environment to protect the affected body part.

• Express feelings about altered state of health and neurologic deficits.

• Identify community resources and support groups to help cope

with the effects of illness.

SUGGESTED NOC OUTCOMES

Adaptation to Physical Disability; Body Image; Body Mechanics Per-

formance; Body Positioning: Self-Initiated; Self-Care: ADLs

INTERVENTIONS AND RATIONALES

Determine:  Observe the position of the affected body part frequently

to prevent injury.

Perform:  Place a sling on the affected arm to prevent dangling or injury.

Support affected leg and foot and perform other measures, as

appropriate, to keep patient’s limbs in functional position and avoid

235

contractures. Use a drawsheet to move patient up in bed to avoid

skin abrasions.

Touch and rub the affected limb, and describe the limb in conversa-

tion with patient. This reminds the patient of the neglected body part.

Use safety belts or protective devices to remind patient of limita-

tions and prevent falls. Use devices according to facility policy.

Remove splints and other devices at least every 2 hr. Inspect the

skin for pressure areas. Reapply the splint. Proper use of splints and

other devices prevents deformities and maintains skin integrity.

Perform ROM exercises on the affected side at least once every

shift, unless medically contraindicated, to maintain joint flexibility

and prevent contractures. Establish and follow a regular turning

schedule to maintain skin integrity.

Arrange environment for maximum functioning; for example,

place water, television controls, and the call bell within reach. These

measures enhance orientation and encourage independence.

Assist patient with ADLs or provide supervision, as appropriate,

to protect patient’s affected side.

Inform:  Encourage patient to perform activities that require use of

the affected limb to more easily integrate paretic or paralyzed limb

into body image.

Instruct family and nursing personnel to observe the position of

the affected body part frequently; to remove food or drainage from

the face if unnoticed by patient; and to place the arm or leg in the

proper position as often as necessary. These measures help avoid

injury and maintain dignity.

Attend:  Encourage patient to check the position of the affected body

part with each repositioning or transfer to reestablish awareness of

the body part.

Encourage patient and family members to express their feelings

regarding patient’s condition and level of functioning to release ten-

sion and enhance coping.

Manage:  Request consultations with occupational and physical ther-

apists about adaptive equipment and exercise programs to promote

use of the affected limb.

Refer patient and family members to appropriate support groups

and other community resources to assist in adjusting to patient’s

altered state of health.

SUGGESTED NIC INTERVENTIONS

Body Image Enhancement; Exercise Therapy: Joint Mobility; Mutual

Goal-Setting; Self-Care Assistance; Unilateral Neglect Management

Reference

Macko, R. F., et al. (2005, Winter). Task-oriented aerobic exercise in chronic

hemiparetic stroke: Training protocols and treatment effects. Topics in
Stroke Rehabilitation, 12(1), 45–57.

Leave a Reply