Chapter 49 Sensory Alterations COPY Flashcards
5 Senses =
Visual Auditory Tactile (touch) Olfactory Gustatory (taste)
Kinesthetic sense =
enables a person to be aware of the position and movement of body parts without seeing them
Stereognosis =
sense that allows a person to recognize the size, shape, and texture of an object
Meaningful stimuli allow
a person to learn about the environment and is necessary for healthy functioning and normal development.
Normal sensation:
continually receives thousands of bits of info from sensory nerve organs, relays the info through appreciate channels, and integrates the info into a meaningful response
Sensory Alterations:
Sensory Deficits
Sensory Deprivation
Sensory Overload
Sensory Deficits:
a deficit in the normal function of sensory reception and perception
-A person loses a sense of self with impaired senses.
Sensory Deprivation: 3 types
- Reduced sensory input (cognitive)
- Elimination of patterns or meaning from input (affective)
- Restrictive environments that produce monotony and boredom (perceptual)
Sensory stimulation must be of sufficient…
quality and quantity
Effects of sensory deprivation:
Psychological illness, confusion, severe electrolyte imbalance, or influence of psychotropic drugs
Sensory Overload =
When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli
Overload is
individualized based on level of fatigue, attitude, emotional and physical well-being.
Common sensory deficits:
Visual Deficits Hearing Balance Taste Neurological
Factors Influencing Sensory Function:
Age Meaningful Stimuli Amount of Stimuli Social Interaction Environmental Factors Cultural Factors
Infants and children are at risk due to
genetic, prenatal, and postnatal conditions
Hearing changes begin at age
30
Glustatory and Olfactory changes begin at age
50
Proprioceptive changes common after age
60
-increased difficulty with balance, spatial orientation, and coordination
Meaningful stimuli reduce the incidence of
sensory deprivation
Ex. pets, music, TV, pictures, calendar, clock = same for home and health care
Amount of Stimuli: excessive stimuli can cause
overload
Ex. patient is in pain or restricted by a cast, in a room near repetitive or loud noises
Social Interaction:
absence of visitors/conversation = isolation, loneliness, anxiety, and depression
Environmental factors:
A person’s occupation places put them at risk
Ex. Factory = high noise levels, repetitive wrist movement = pressure on median nerve
Cultural Factors:
African ethnicity perform significantly worse than European descent on tests of visual function
Assessment:
Health promotion practices Nursing history = look at risks Review factors Extent of lifestyle and self-care alterations Patient's expectations
Persons at Risk:
Older adults - do not automatically assume
Otolarynogologist =
Doctors who treat serious hearing problems
During history it is useful to assess the patient’s
self rating for a sensory deficit
Assessment also includes:
Mental Status Physical Assessment - 5 senses Ability to Perform Self-Care Health Promotion Habits Environmental Hazards Communication Methods Social Support Use of Assistive Devices
HHIE-S =
Hearing Handicap Inventory for the Elderly
MMSE =
Mini-Mental State Examination
IADL:
Instrumental Activities of Daily Living
Ex. reading bills, writing checks, driving
Common hazards include:
Uneven walkways Extension cords in walking route Loose area rugs BRs w/o bath grab bars Water faucets unmarked H or C Unlit stairways, lack of rails
Look for safety hazards, this includes:
Call light w/in reach?
Are IV poles on wheels and easy to move?
Are IV pumps positioned so a patient can rise from a bed or chair easily?
Patients with aphasia have varied degrees of
inability to speak, interpret, or understand language
Expressive aphasia:
motor type, inability to name common objects or express simple ideas in words or writing
Receptive aphasia:
inability to understand written or spoken language - a patient is able to understand words but unable to understand questions or comments of others
Global aphasia:
inability to understand language or communicate orally
Some antibiotics are ototoxic which means it
permanently damages the auditory nerve
Opioid analgesics, sedatives, and antidepressant medications often alter
perception of stimuli
Nursing Diagnosis :
Risk-prone health behavior Impaired verbal communication Risk for injury Impaired physical mobility Bathing self-care deficit Dressing self-care deficit Toileting self-care deficit Situational low self-esteem Risk for falls Social Isolation
Goals and Outcomes:
- The patient and family will report using communication to send and receive messages in 2 days.
- The patient will successfully demonstrate correct technique for cleaning a hearing aid within 1 week.
- The patient will self-report improved hearing acuity.
Health Promotion:
Screening Preventive Safety Use of Assistive Devices Promoting Meaningful Stimulation Establishing Safe Env. Communication
Four recommended interventions for screening children for preventing blindness =
- Screening for rubella, syphilis, chlamydia, & gonorrhea in women who are considering pregnancy
- Advocating adequate prenatal care to prevent premature birth (excessive O2)
- Administering eye prophylaxis in the form of erythromycin ointment apprx. 1 hr after infants birth
- Periodic screening of all children
Refracted error =
common visual problem
Ex. near sightedness
Trauma is a common cause of
blindness in children
Promoting meaningful stimulation: Vision
Sensitive ti glare
- Suggest use of amber or yellow shaded lenses and shades or blinds on windows to minimize glare
- Include warm incandescent lighting and colors with shard contrast and intensity
Promoting meaningful stimulation: Hearing
- Recorded music can be heard in low-frequency cycles
- Cerumen thickens and builds up in ear - inserting warm mineral oil plus 3% hydrogen peroxide in warm water removes this
Conductive hearing loss=
excessive cerumen occluding the ear canal
Promoting meaningful stimulation: Taste and Smell
- Good oral hygiene
- Differently textured food
- Aromas - brewed coffee, garlic, baked breads
- Avoid mixing foods
- Cologne, deodorizer, flowers, etc.
Promoting meaningful stimulation: Touch
- Touch therapy
- Hair brushing, back rub, touching arms/shoulders
Hyperesthesia:
overly sensitive to tactile stimuli
-keep bed linens loose
dorsiflex= relieve nerve pressure
Environment: Adaptions for Visual Loss -Driving
Do not drive during rush hour Avoid interstate highways Drive defensively Use rear view and side view mirrors when changing lanes Avoid driving at night Go slow but not too slow Car in good conditions Carry a preprogrammed cell phone
Environment: Adaptions for Reduced Hearing
-Change env. sounds to amplified or lower pitched
Environment: Adaptions for Reduced Olfaction
- Use smoke detectors
- checking ash trays
- check food dates and appearance
Environment: Adaptions to Reduced Tactile Sensation
- use caution when using water bottles or heating pads
- Temp on home water heater, no higher than 120 F/ 48.8 C
Acute Care:
Orientation to the Environment
Communication
Controlling Sensory Stimuli
Safety Measures
Acute Care: Orientation to the Environment
-Provide reorientation: name tags are visible, addressing patient by name, explaining patient where they are, cues for time or location
Patients confined to bed are at risk for
sensory deprivation
The most common language disorders are
stroke and aphasia
Reduce sensory overload by
organizing patient’s plan of care
- rest periods
- doing dressings, vitals, and bathing all at once reduces fatigue
Safety measures: 3 suggestions for a sighted guide=
- Ask the patient if they want a sighted guide. Instruct patient to grasp your arm just above the elbow
- Go one-half step ahead and slightly to the side of the person. The shoulder of the person need to be directly behind your shoulder, If patient is frail, place their hand on your forearm.
- Relax and walk at a comfy pace. Warn patient when you approach doorways or narrow spaces
A sighted guide =
gives patients with visual issues confidence and ensures safe mobility
Restorative and Continuing Care:
Maintaing healthy lifestyles
Understanding sensory loss
Socialization
Promoting Self Care
The ability to perform self-care is essential for
self esteem
Evaluation:
Reassess signs and symptoms of sensory alteration
Determine the patient’s ability to remain functional within the home or health care environment
Ask patient to demonstrate new skills
Ask if expectations are met
If outcomes are not met, ask patient these questions:
How often do you wear your hearing aids/corrective lens?
Are you able to participate in a small group discussion?
Are you able to read the newspaper without squinting?
