NRS320/105 Foundations/Collings2011 Sensory Alterations Chapter 49 NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Normal Sensation Depends on intact CNS 3 Components of sensation: Reception [nerve transmission] Perception [awareness] Reaction [meaning] LOC impacts perception & reaction ↓ LOC impairs perception May react inapropriately NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Sensory Alterations Sensory deficits Sensory deprivation Sensory overload ICU New info [cochlear implant, preemie] Cannot ignore stimuli – no sense PAIN, monitors, touch, sound Cannot benefit from interventions Looks like mood disorder, disorientation NRS320/105 Foundations/Collings2011

Common Sensory Deficits Visual Presbyopia Cataract Dry eyes Open-angle glaucoma Diabetic retinopathy Macular degeneration NRS320/105 Foundations/Collings2011

Common Sensory Deficits Auditory Presbycusis [progressive hearing loss] Cerumen [wax] accumulation Balance Dizziness and disequilibrium Taste Xerostomia [↓ saliva, thick mucous] NRS320/105 Foundations/Collings2011

Common Sensory Deficits Neurological Peripheral neuropathy Stroke (CVA) NRS320/105 Foundations/Collings2011

Factors Affecting Sensory Function 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 NRS320/105 Foundations/Collings2011

Factors Influencing Sensory Function Social interaction - coping Environmental factors job exposure to noise, ergonomics, immobility, isolation Cultural factors Some groups have ↑ risk Meaning, effect: isolation? NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Nursing Implications Focus: Safety & 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 NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Assessment 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 NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Assessment 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 NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Nursing Diagnoses Impaired communication Risk for injury Situational low self-esteem Disturbed sensory perception Social isolation NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Nursing DX - example Risk for injury R/T altered tactile perception 2* to PVD AEB numbness in Rt foot, pressure ulcer on Rt foot NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Planning 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 NRS320/105 Foundations/Collings2011

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 NRS320/105 Foundations/Collings2011

Interventions: Vision Minimize glare Encourage use of eyeglasses, contact lenses, magnifiers Obtain large-print reading materials Use brighter colors (red, yellow, orange) NRS320/105 Foundations/Collings2011

Intervention: 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 NRS320/105 Foundations/Collings2011

Interventions: Hearing Amplify telephones, televisions, and radios Reduce extraneous noise Check for impacted cerumen Encourage use of hearing aid Speak directly at the client NRS320/105 Foundations/Collings2011

Interventions:Hearing Alterations Providing a safe environment Amplification of important environmental sounds Use of lights for alert Special telephone communication system (TTD or TTY) NRS320/105 Foundations/Collings2011

Interventions: Taste and Smell 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 NRS320/105 Foundations/Collings2011

Intervention: Olfactory Alterations Providing a safe environment Use of smoke and carbon monoxide detectors Visually check gas stove Check appearance and dates of foods NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Interventions: Touch Provide touch therapy Turn and reposition client Avoid / reduce excessive stimuli for overloaded client Provide positive touch – pet therapy, personal blankets, clothing NRS320/105 Foundations/Collings2011

Intervention: Tactile Alterations Providing a safe environment Reduce the temperature of the water heater Clearly mark faucets as “hot” and “cold” NRS320/105 Foundations/Collings2011

Interventions: Promoting Communication 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 NRS320/105 Foundations/Collings2011

Implementation: Acute Care Orientation to the environment Comfort measures -↑ or ↓stimulation Communication Control sensory stimuli: noise, light, smells Safety measures NRS320/105 Foundations/Collings2011

Implementation: 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 NRS320/105 Foundations/Collings2011

Interventions: sensory alteration Assess/ monitor/document alteration and effect on client function, ADL’s Teach adaptive behaviors, info Collaborate/ refer for help [OT] Evaluate environmental risks ↑ safety, coping, support, social interaction Access to resources NRS320/105 Foundations/Collings2011

NRS320/105 Foundations/Collings2011 Evaluation Client’s ability to function Social isolation Safety, freedom from harm Coping Client expectations Goal Met? AEB… PLAN? NRS320/105 Foundations/Collings2011