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Sensory Alterations

Sensory Alterations. Chapter 49. Normal Sensation. Depends on intact CNS 3 Components of sensation: Reception [nerve transmission] Perception [awareness] Reaction [meaning] LOC impacts perception & reaction ↓ LOC impairs perception May react inapropriately. Sensory Alterations.

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Sensory Alterations

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  1. Sensory Alterations Chapter 49 NRS320/105 Foundations/Collings2011

  2. Normal Sensation • Depends on intact CNS • 3 Components of sensation: • Reception [nerve transmission] • Perception [awareness] • Reaction [meaning] • LOC impacts perception & reaction • ↓ LOC impairs perception • May react inapropriately NRS320/105 Foundations/Collings2011

  3. Sensory Alterations • Sensory deficits • Sensory deprivation • Sensory overload • ICU • New info [cochlear implant, preemie] • Cannot ignore stimuli – no sense • PAIN, monitors, touch, sound • Cannot benefit from interventions • Looks like mood disorder, disorientation NRS320/105 Foundations/Collings2011

  4. Common Sensory Deficits • Visual • Presbyopia • Cataract • Dry eyes • Open-angle glaucoma • Diabetic retinopathy • Macular degeneration NRS320/105 Foundations/Collings2011

  5. Common Sensory Deficits • Auditory • Presbycusis [progressive hearing loss] • Cerumen [wax] accumulation • Balance • Dizziness and disequilibrium • Taste • Xerostomia [↓ saliva, thick mucous] NRS320/105 Foundations/Collings2011

  6. Common Sensory Deficits • Neurological • Peripheral neuropathy • Stroke (CVA) NRS320/105 Foundations/Collings2011

  7. Factors Affecting Sensory Function • Age: • Infants – • lack experience, ability to ignore stim. • Older adults • Multiple alterations; vision, hearing, balance, • Safety risk • Meaningful stimuli – reduces deprivation • Amount of stimuli - overload NRS320/105 Foundations/Collings2011

  8. Factors Influencing Sensory Function • Social interaction - coping • Environmentalfactors • job exposure to noise, ergonomics, • immobility, isolation • Cultural factors • Some groups have ↑ risk • Meaning, effect: isolation? NRS320/105 Foundations/Collings2011

  9. Nursing Implications • Focus: • Safety & prevention of injury • Adaptation to alterations • ↑ Knowledge, access to resources • Healthy coping behaviors • Habits – safety [hearing protection, VSE] • Environment modification • Call light in reach, label meds clearly, remove hazards, grab bars, lighting, phone/ alarm NRS320/105 Foundations/Collings2011

  10. Assessment • Sensory alterations history • Onset, change, severity, coping/ adaptation • change in behavior, social isolation • Mental status – effect of altered sense • Physical assessment- • Ability to perform self-care - functional • Health promotion habits – safety, aids • Environmental hazards – in home, room • Throw rugs, labels, lighting, labels, meds • IV lines, bed rails, call light, Foley NRS320/105 Foundations/Collings2011

  11. Assessment • Communication methods • limitations & adaptations • Social support • Social & family interactions • Use of assistive devices • Dependence, care, effectiveness • Other factors: pathology, meds • Ototoxic ABX, dizziness, blurred vision NRS320/105 Foundations/Collings2011

  12. Nursing Diagnoses • Impaired communication • Risk for injury • Situational low self-esteem • Disturbed sensory perception • Social isolation NRS320/105 Foundations/Collings2011

  13. Nursing DX - example • Risk for injury R/T altered tactile perception 2* to PVD AEB numbness in Rt foot, pressure ulcer on Rt foot NRS320/105 Foundations/Collings2011

  14. Planning • Goals and outcomes • Client will demonstrate technique for cleaning hearing aid within 1 week • Client will perform visual self exam [VSE] each morning & evening to assess for injury to numb areas • Setting priorities – 1. safety • Client control – adaptation and power. Focus on pt needs/wants NRS320/105 Foundations/Collings2011

  15. Implementation: Health Promotion • Screenings: prenatal, hearing, vision • Preventive safety at home, school, recreational activities, and work • Use of eyeglasses, contact lenses, and hearing aids • Promoting meaningful stimulation NRS320/105 Foundations/Collings2011

  16. Interventions: Vision • Minimize glare • Encourage use of eyeglasses, contact lenses, magnifiers • Obtain large-print reading materials • Use brighter colors (red, yellow, orange) NRS320/105 Foundations/Collings2011

  17. Intervention: Visual Alterations • Providing a safe environment • Adequate lighting • Promotion of safe driving principles • Removal of clutter and loose items • Use of color contrasts • Removal of or caution with flammable items • Administration of eye medications NRS320/105 Foundations/Collings2011

  18. Interventions: Hearing • Amplify telephones, televisions, and radios • Reduce extraneous noise • Check for impacted cerumen • Encourage use of hearing aid • Speak directly at the client NRS320/105 Foundations/Collings2011

  19. Interventions:Hearing Alterations • Providing a safe environment • Amplification of important environmental sounds • Use of lights for alert • Special telephone communication system (TTD or TTY) NRS320/105 Foundations/Collings2011

  20. Interventions: Taste and Smell • Provide oral hygiene • Prepare well-seasoned foods of different textures • Avoid mixing or blending foods • Provide aromas of coffee, bread, flowers, favorite scent [lotion] • Remove unpleasant odors NRS320/105 Foundations/Collings2011

  21. Intervention: Olfactory Alterations • Providing a safe environment • Use of smoke and carbon monoxide detectors • Visually check gas stove • Check appearance and dates of foods NRS320/105 Foundations/Collings2011

  22. Interventions: Touch • Provide touch therapy • Turn and reposition client • Avoid / reduce excessive stimuli for overloaded client • Provide positive touch – • pet therapy, personal blankets, clothing NRS320/105 Foundations/Collings2011

  23. Intervention: Tactile Alterations • Providing a safe environment • Reduce the temperature of the water heater • Clearly mark faucets as “hot” and “cold” NRS320/105 Foundations/Collings2011

  24. Interventions: Promoting Communication • Reduce Isolation • Involve client in safe activities • Stay with them • Speak clearly, good light, facing pt • Teach family • Use of alternative methods • sign language, computer, pad, audio • Client/ family education • Risks and resources NRS320/105 Foundations/Collings2011

  25. Implementation: Acute Care • Orientation to the environment • Comfort measures -↑ or ↓stimulation • Communication • Control sensory stimuli: noise, light, smells • Safety measures NRS320/105 Foundations/Collings2011

  26. Implementation: Long-term • Maintaining a healthy lifestyle • Understanding sensory loss • Socialization • Self-care • Safety issues: adapting to alterations • smells of gas, fire [alarms, dog] • personal alarms for falls • Home environment, driving NRS320/105 Foundations/Collings2011

  27. Interventions: sensory alteration • Assess/ monitor/document alteration • and effect on client function, ADL’s • Teach adaptive behaviors, info • Collaborate/ refer for help [OT] • Evaluate environmental risks • ↑ safety, coping, support, social interaction • Access to resources NRS320/105 Foundations/Collings2011

  28. Evaluation • Client’s ability to function • Social isolation • Safety, freedom from harm • Coping • Client expectations • Goal Met? AEB… PLAN? NRS320/105 Foundations/Collings2011

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