Sensory Alterations
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NRS320/105 Foundations/Collings2011
Sensory Sensory AlterationsAlterations
Chapter 49Chapter 49
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NRS320/105 Foundations/Collings2011
Normal SensationNormal Sensation
Depends on intact CNSDepends on intact CNS 3 Components of sensation:3 Components of sensation:
Reception [nerve transmission]Reception [nerve transmission] Perception [awareness]Perception [awareness] Reaction [meaning]Reaction [meaning]
LOC impacts perception & reactionLOC impacts perception & reaction ↓ ↓ LOC impairs perceptionLOC impairs perception May react inapropriatelyMay react inapropriately
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NRS320/105 Foundations/Collings2011
Sensory AlterationsSensory Alterations
Sensory deficitsSensory deficits Sensory Sensory deprivationdeprivation Sensory Sensory overloadoverload
ICUICU New info [cochlear implant, preemie]New info [cochlear implant, preemie] Cannot ignore stimuli – no senseCannot ignore stimuli – no sense
PAIN, monitors, touch, soundPAIN, monitors, touch, sound Cannot benefit from interventionsCannot benefit from interventions Looks like mood disorder, disorientationLooks like mood disorder, disorientation
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NRS320/105 Foundations/Collings2011
Common Sensory DeficitsCommon Sensory Deficits
VisualVisual PresbyopiaPresbyopia CataractCataract Dry eyesDry eyes Open-angle glaucomaOpen-angle glaucoma Diabetic retinopathyDiabetic retinopathy Macular degenerationMacular degeneration
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NRS320/105 Foundations/Collings2011
Common Sensory DeficitsCommon Sensory Deficits
AuditoryAuditory Presbycusis [progressive hearing Presbycusis [progressive hearing
loss]loss] Cerumen [wax] accumulationCerumen [wax] accumulation
BalanceBalance Dizziness and disequilibriumDizziness and disequilibrium
TasteTaste Xerostomia [Xerostomia [↓ ↓ saliva, thick mucoussaliva, thick mucous]]
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NRS320/105 Foundations/Collings2011
Common Sensory DeficitsCommon Sensory Deficits
NeurologicalNeurological Peripheral neuropathyPeripheral neuropathy Stroke (CVA)Stroke (CVA)
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NRS320/105 Foundations/Collings2011
Factors Affecting Sensory Factors Affecting Sensory FunctionFunction
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
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NRS320/105 Foundations/Collings2011
Factors Influencing Sensory Factors Influencing Sensory FunctionFunction
Social interaction - coping Environmental factors
job exposure to noise, ergonomics, immobility, isolation
Cultural factors Some groups have ↑ risk Meaning, effect: isolation?
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NRS320/105 Foundations/Collings2011
Nursing ImplicationsNursing Implications
Focus: Safety & prevention of injurySafety & 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
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NRS320/105 Foundations/Collings2011
AssessmentAssessment
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
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NRS320/105 Foundations/Collings2011
AssessmentAssessment
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
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NRS320/105 Foundations/Collings2011
Nursing DiagnosesNursing Diagnoses
Impaired communicationImpaired communication Risk for injuryRisk for injury Situational low self-esteemSituational low self-esteem Disturbed sensory perceptionDisturbed sensory perception Social isolationSocial isolation
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NRS320/105 Foundations/Collings2011
Nursing DX - exampleNursing DX - example
Risk for injury R/T altered tactile Risk for injury R/T altered tactile perception 2* to PVD AEB numbness perception 2* to PVD AEB numbness in Rt foot, pressure ulcer on Rt footin Rt foot, pressure ulcer on Rt foot
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NRS320/105 Foundations/Collings2011
PlanningPlanning
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
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NRS320/105 Foundations/Collings2011
Implementation: Implementation: Health PromotionHealth 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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NRS320/105 Foundations/Collings2011
Interventions: VisionInterventions: 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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NRS320/105 Foundations/Collings2011
Intervention: Visual Intervention: Visual AlterationsAlterations
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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NRS320/105 Foundations/Collings2011
Interventions: HearingInterventions: 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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NRS320/105 Foundations/Collings2011
Interventions:Hearing Interventions:Hearing AlterationsAlterations
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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NRS320/105 Foundations/Collings2011
Interventions: Taste and Interventions: Taste and SmellSmell
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
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NRS320/105 Foundations/Collings2011
Intervention: Olfactory Intervention: Olfactory AlterationsAlterations
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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NRS320/105 Foundations/Collings2011
Interventions: TouchInterventions: Touch
Provide touch therapy Turn and reposition client Avoid / reduce excessive stimuli
for overloaded client Provide positive touch –
pet therapy, personal blankets, clothing
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NRS320/105 Foundations/Collings2011
Intervention: Tactile Intervention: Tactile AlterationsAlterations
Providing a safe environment Reduce the temperature of the water
heater Clearly mark faucets as “hot” and
“cold”
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NRS320/105 Foundations/Collings2011
Interventions: Promoting Interventions: Promoting CommunicationCommunication
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
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NRS320/105 Foundations/Collings2011
Implementation: Acute Implementation: Acute CareCare
Orientation to the environment Comfort measures -↑ or
↓stimulation Communication Control sensory stimuli: noise,
light, smells Safety measures
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NRS320/105 Foundations/Collings2011
Implementation: Long-termImplementation: 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
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NRS320/105 Foundations/Collings2011
Interventions: sensory Interventions: sensory alterationalteration
Assess/ monitor/document alterationAssess/ monitor/document alteration and effect on client function, ADL’sand effect on client function, ADL’s
Teach adaptive behaviors, infoTeach adaptive behaviors, info Collaborate/ refer for help [OT]Collaborate/ refer for help [OT] Evaluate environmental risksEvaluate environmental risks ↑ ↑ safety, coping, support, social safety, coping, support, social
interaction interaction Access to resourcesAccess to resources
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NRS320/105 Foundations/Collings2011
EvaluationEvaluation
Client’s ability to function Social isolation Safety, freedom from harm Coping Client expectations Goal Met? AEB… PLAN?