Potter and Perry Ch. 49

Sensory Alterations

The Senses

• Sight/visual • Hearing /auditory• Touch/tactile• Smell/olfactory• Taste/gustatory

• Kinesthetics – awareness of position/movement of body parts without having to see them

• Stereognosis – recognition of size, shape, texture of things• Speech…not technically a sense, but can lead to many

problems when lost• How do you think sensory alteration might affect the patient?

How Does Sensation Work?

• Sensory reception involves the stimulation of sensory nerve fibers and the transmission of impulses to higher centers within the brain.

• Normal sensation• Reception: stimulation of a receptor such as light, touch, or

sound• Perception: integration and interpretation of stimuli• Reaction: only the most important stimuli will elicit a reaction

Sensory Alterations

• Sensory Deficit – a deficit in normal sensorium• Withdrawal and avoidance• Adaptation – may be healthy or unhealthy• How would it be different if this happens suddenly vs. gradually?

• Sensory Deprivation (Box 49-2)• Reduction in sensory input• Elimination of patterns or meaning from input• Restrictive environments

• Sensory Overload – excessive sensory stimulation• Keeps the brain from responding or ignoring stimuli• Leads to a picture similar to sensory deprivation• Highly individualized – how do you think you can help?

Common Sensory Deficits

• Visual• Presbyopia • Cataract• Glaucoma • Macular degeneration

• Hearing• Presbycusis

• Balance• Dizziness• Vertigo

• Taste• Xerostomia • Decreased taste

• Neruologic• Peripheral neuropathy • Stroke

• Imbalance• Loss of sensation• Difficult speech • Visual disturbances

Factors Influencing Sensory Function

• Age• The very young • Older patients (usually starting at 40 or 50)

• Presbyopia, impaired night vision• Decrease in visual fields, reduced depth perception• Changes in hearing…which sounds are most often affected?• Changes in the sense of taste and smell• Proprioception changes – coordination, balance, tactile changes

• Meaningful stimuli• What kind of stimuli is the patient receiving?

• Amount of stimuli• How much stimuli is the patient receiving? Is it too much? Not enough?

Factors Influencing Sensory Function

• Social interaction • How much social interaction does the patient get?• What can absence of social interaction lead to?

• Environmental factors• Occupational and recreational risks to sensorium

• Eye injuries • Hearing loss • Carpal tunnel

• What about the hospital environment?• Cultural Factors

• Certain groups may be prone to certain sensory alterations• Box 49-3

Case Study

• Mrs. Alicea is a 73-year-old woman who is at the senior health center for her routine 6-month checkup. She has been visiting the senior center on a regular basis for the past 8 years. Mrs. Alicea has lived alone since her husband died 1 year ago. She lives in a single-story, four-room home a few miles from the health center.

• Her son, Rico, lives 5 minutes away. Rico drives Mrs. Alicea to her visits. Six months ago, Mrs. Alicea reported progressive hearing loss. Today she reports “having trouble seeing.”

Assessment

Persons at risk Sensory alteration history

Mental status Physical assessment

Ability to perform self-care Health promotion habits

Environmental hazards Communication methods

Social support Use of assistive devices

Other factors affecting perception

Case Study (cont’d)

• Mrs. Alicea reports that at her last visit to the ophthalmologist, she was told she had a cataract.

• Peter learns that Hispanic/Latino individuals in the United States have higher rates of visual impairment and blindness compared with members of other ethnic groups. Visual field loss has a negative impact on health-related quality of life: driving, distance and peripheral vision activities, and a sense of independence.

So, How Would You Know?

• How would you assess the following things? How would you know that the patient was having difficulty?• Vision

• Hearing

• Touch

• Taste

Communication Alterations

• What is the nature of the communication problem?• Temporary or permanent• Speaking, understanding, reading, writing…

• Is the patient using any alternative methods to communicate?• Braille• Sign Language • Lip reading • Writing • Electronic devices• Communication board

Types of Aphasia

• Expressive aphasia (motor aphasia)• Understanding with inability to respond (speaking or writing)

• Receptive aphasia (sensory aphasia)• Can speak but can’t understand – word salad

• Global aphasia

Appropriate Sensory Related Nursing Diagnoses

• Risk-prone health behavior

• Impaired verbal communication

• Risk for injury• Impaired physical

mobility• Risk for falls• Social isolation

• Bathing self-care deficit• Dressing self-care deficit• Toileting self-care deficit• Situational low self-

esteem

Case Study

• Mrs. Alicea states, “I’m having difficulty reading and moving around the house. I cannot judge the steps clearly. I have difficulty judging distances between objects, which is worse at night.”

• Results of a home hazard assessment show that Mrs. Alicea’s home has dim lighting, stairs without handrails, and numerous throw rugs on the floor.• What diagnosis would you choose?

Planning

Include family members.

Use standards as guides.

Partner with the patient to set realistic goals and achievable

outcomes.

Make safety a top priority.

Value other professionals’ contributions.

Consider community-based resources.

Case Study

• Goal: Mrs. Alicea’s home environment is safe and free of hazards within 4 weeks.• What expected outcomes would you include?

Health Promotion for the Senses

• Screening • Screening of children• Screening of adults

• Preventive safety• Avoidance of eye trauma • Immunizations • Medication safety

• Assistive devices • Glasses and contacts• Hearing aids

Health Promotion for the Senses

• Promoting meaningful stimulation• Vision• Hearing• Taste and smell• Touch

• Safe environment • What are the inherent dangers in vision changes?• Hearing changes?• How about sense of smell?• Tactile sensation?

• Communication• How can we help promote effective communication in sensory

impaired patients?

What If the Patient is Hospitalized?

• Orientation to the Environment• How can we orient a visually impaired patient to the

environment?• How can we help them remain oriented to the environment?• How can we prevent sensory deprivation while hospitalized?

• Communication • Communication boards• Speech therapy• What about a patient with an artificial airway?

• Controlling Sensory stimuli • How can we help cut down on some of the stimuli in the acute

care environment?

What if the Patient is Hospitalized

• Maintaining safety• Is the impairment recent or chronic• Sighted guidance (page 1248)• Make sure the patient knows where call light is• Where should needed items be placed?• Recognizing alarm sounds• What about decreased tactile sensation, how might that impact

the hospitalized patient? How can we help?

And When the Patient Is Discharged?

• Maintaining healthy lifestyles• Learning ways to adapt to the sensory loss…patients can still be

active • Understanding sensory loss

• How will the impairment affect normal activities?• Various organizations may serve as resources to patient and

family• Socialization

• How can we help reduce loneliness and isolation?• How can we help the patient maintain satisfying interactions?

• Promoting self-care• Safety devices and environmental orientation • Modifications to existing clothing and personal care items can

elevate the patient’s ability to perform self- care

Case Study

• What interventions would apply to these rationales?1. Sensitivity to glare increases because of clouding of

the lens.

2. Light intensity needs to be 3 times as powerful for older adults to produce the same visual acuity as for younger people.

3. Removal of trip hazards prevents falls and promotes a safe environment.

• What fall prevention interventions would you choose?

Evaluation

• Reassess signs and symptoms of sensory alteration

• Determine the patient’s ability to remain functional within the home or health care environment

• Ask the patient to demonstrate or explain newly learned skill

• What if expected outcomes were not met?

Case Study

• What nursing actions would be appropriate for youto take to evaluate Mrs. Alicea’s situation?• Ask Mrs. Alicea at her next visit if she has experienced

any trips or falls since modifications were made to her home.

• Ask Rico if his mother is having any difficulties moving through her home.

• Conduct a home visit, and reassess the home environment.

Question

Which of the following would not provide meaningful stimuli for a client?

a. Interesting magazines and books

b. A clock or calendar with large numbers

c. Family pictures and personal possessions

d. A television that is kept on all day at a low volume

Question

A patient with glaucoma is being discharged from the hospital. When teaching the patient and family ways to improve home safety, the nurse tells the family to:

A. Use throw rugs to prevent tripping

B. Paint the floor black and white to improve perception.

C. Install extra incandescent lighting.

D. Install handrails painted the same color as the walls.

Question

A client who is unable to name common objects or express simple ideas in words or writing suffers from:

A. Global aphasia

B. Receptive aphasia

C. Expressive aphasia

D. Mental retardation

Question

Your elderly client has hearing loss of high frequency tones that may lead to a loss of all hearing frequencies. What type of hearing loss is this?

A. Presbycusis

B. Partial deafness

C. Conductive loss

D. Sensorineural

Question

Your 80 year old client has had a progressive hearing loss over the past 8 months, has refused to participate in activities at the assisted living facility, and has often been found alone in his room. Which nursing diagnosis would be most appropriate?

A. Altered thought processes

B. Social isolation

C. Sensory/perceptual alterations: auditory

D. Self-care deficit