sensory alterations

NRS320/105 Foundations/Collings2011

Sensory Sensory AlterationsAlterations

Chapter 49Chapter 49


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


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


Common Sensory DeficitsCommon Sensory Deficits

VisualVisual PresbyopiaPresbyopia CataractCataract Dry eyesDry eyes Open-angle glaucomaOpen-angle glaucoma Diabetic retinopathyDiabetic retinopathy Macular degenerationMacular degeneration



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]]



NeurologicalNeurological Peripheral neuropathyPeripheral neuropathy Stroke (CVA)Stroke (CVA)


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


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?


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


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


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


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


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


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


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


Interventions: VisionInterventions: Vision

Minimize glare Encourage use of eyeglasses, contact

lenses, magnifiers Obtain large-print reading materials Use brighter colors (red, yellow,

orange)


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


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


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)


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


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


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


Intervention: Tactile Intervention: Tactile AlterationsAlterations

Providing a safe environment Reduce the temperature of the water

heater Clearly mark faucets as “hot” and

“cold”


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


Implementation: Acute Implementation: Acute CareCare

Orientation to the environment Comfort measures -↑ or

↓stimulation Communication Control sensory stimuli: noise,

light, smells Safety measures


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


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


EvaluationEvaluation

Client’s ability to function Social isolation Safety, freedom from harm Coping Client expectations Goal Met? AEB… PLAN?

sensory alterations

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