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Chapter 48

Sensory Alterations

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Normal Sensation

• Reception– Perception– Reaction

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Sensory Alterations

• Sensory deficits

• Sensory deprivation

• Sensory overload

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Common Sensory Deficits

• Visual– Presbyopia– Cataract– Dry eyes– Open-angle glaucoma– Diabetic retinopathy– Macular degeneration

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Common Sensory Deficits (cont'd)

• Auditory– Presbycusis– Cerumen accumulation

• Balance– Dizziness and disequilibrium

• Taste– Xerostomia

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Common Sensory Deficits (cont'd)

• Neurological– Peripheral neuropathy– Stroke (CVA)

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Factors Affecting Sensory Function

• Age

• Persons at risk—older adults

• Meaningful stimuli

• Amount of stimuli

• Family factors

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Factors Influencing Sensory Function

• Social interaction

• Environmental factors

• Cultural factors

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Assessment

• Sensory alterations history

• Mental status

• Physical assessment

• Ability to perform self-care

• Health promotion habits

• Presence of hazards

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Assessment (cont'd)

• Communication methods

• Social support

• Use of assistive devices

• Other factors: pathology, medications

• Client expectations

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Nursing Diagnoses

• Impaired communication

• Risk for injury

• Situational low self-esteem

• Disturbed sensory perception

• Social isolation

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Planning

• Goals and outcomes– Client will demonstrate technique for

cleaning hearing aid within 1 week– Client will use appropriate

communication skills within 2 weeks

• Setting priorities

• Continuity of care

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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

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Vision

• Minimize glare

• Encourage use of eyeglasses, contact lenses, magnifiers

• Obtain large-print reading materials

• Use brighter colors (red, yellow, orange)

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Hearing

• Amplify telephones, televisions, and radios

• Reduce extraneous noise

• Check for impacted cerumen

• Encourage use of hearing aid

• Speak directly at the client

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Taste and Smell

• Provide oral hygiene

• Prepare well-seasoned foods of different textures

• Avoid mixing or blending foods

• Provide aromas of coffee, bread, flowers

• Remove unpleasant odors

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Touch

• Provide touch therapy

• Turn and reposition client

• Avoid excessive stimuli for hyperesthetic client

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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

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Hearing Alterations

• Providing a safe environment– Amplification of important environmental

sounds– Use of lights for alert– Special telephone communication

system (TTD or TTY)

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Olfaction Alterations

• Providing a safe environment– Use of smoke and carbon monoxide

detectors– Visually check gas stove– Check appearance and dates of foods

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Tactile Alterations

• Providing a safe environment– Reduce the temperature of the water

heater– Clearly mark faucets as “hot” and “cold”

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Promoting Communication

• Approaching clients

• Use of alternative methods (sign language)

• Client education

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Implementation: Acute Care

• Orientation to the environment

• Comfort measures—stimulation

• Communication

• Control sensory stimuli: noise, light, smells

• Safety measures

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Implementation: Restorative Care

• Maintaining a healthy lifestyle

• Understanding sensory loss

• Socialization

• Self-care

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Evaluation

• Client care

• Client expectations