53 a focus 11 neurosensory & protective needs

Neurosensory and Protective

• Describe the normal sensory regulation process. • Explain the importance for daily survival.

• Describe conditions and situation responsible for the development of sensory deprivation and sensory overload. • List the ways of assisting the client at risk for these problems.

• Discuss the significance of neurosensory findings.• Identify the 4 major body functions responsible for

meeting one’s protection need.• Describe conditions responsible for the development

of disruptions in the protection need.• Discuss the related nursing interventions.

• 4 aspects must be present:

• Stimulus• Receptor• Impulse

conduction• Perception• Arousal

mechanism

• Reception: • stimulus is received through the receptors of the nervous

system• becomes a sensation

• Perception:• conscious mental recognition or registration of the sensory

stimulus• input received and interpreted in a meaningful way

• Reaction:• the action or response a person takes after identifying the

sensation

• Inadequate reception or perception of environmental stimuli

• Physical or environmental causes

• Developmental stage• Culture• Level of stress• Medications and illness• Lifestyle

• Excessive yawning, drowsiness, and sleeping• Decreased attention span, difficulty

concentrating, and decreased problem solving• Impaired memory; periodic disorientation,

general confusion, or nocturnal confusion• Preoccupation with somatic complaints, such

as palpitations• Hallucinations or delusions• Crying, annoyance over small matters and

depression• Apathy and emotional liability

• Increased in modern society.• Excessive stimuli • Unfamiliar routine• Altered sleep rest pattern

• Effects: • interferes with ability to focus:

• mood swings • exaggerated emotional responses

• Complaints of fatigue, sleeplessness• Irritability, anxiety, and restlessness• Periodic or general disorientation• Reduced problem-solving ability and task

performance• Increased muscle tension• Scattered attention and racing thoughts

• Impaired reception / perception or both• one or more of the senses

• Blindness• Deafness• Change tactile perception

• Nursing history• Mental status examination• Physical examination• Identification of clients at risk• Environment• Social support network

• CNS changes:

• Impaired judgment• Inability to problem

solve• Confusion• Disorientation• Hallucinations• Delusions

• Subtle changes for hearing loss (speech delay)

• Other senses sharpen to overcome loss

• Can impair relationships, withdraws socially

Effects of sensory deprivation and sensory overload:

• Nonstimulating or monotonous environment

• Impaired vision or hearing• Mobility restrictions• Inability to process stimuli• Emotional disorders • Limited social contact

Therapeutic nursing actions to prevent sensory deprivation:

• Encourage family to bring in personal items• Position bed for maximal visualization of the

environment• Encourage the use of glasses, hearing aids, to

reduce sensory deprivation

• Pain or discomfort• Admission to an acute care facility• Monitoring in intensive care units• Invasive tubes • Decreased cognitive ability

Therapeutic nursing actions to prevent sensory overload:

• Minimize unnecessary stimuli• Pain control• Privacy• Periods of rest and sleep• Low tones of voice• Remove odors• Give information gradually

Therapeutic nursing actions for managing sensory deficits:

• Encourage client to use sensory aids• One sense is lost supplement with other senses• Communicate effectively with clients sensory deficits - visually impaired - hearing impaired

• Levels of consciousness

• Glasgow Coma Score = scoring eye movement + verbal response + motor response

• Pupillary response

• Upper and lower body strength

Drugs

Multiple losses

Psychological trauma

Physiological disturbances

Neurological imbalances

• Prevent injury• Maintain the function of existing senses• Develop an effective communication

mechanism• Prevent sensory overload or deprivation• Reduce social isolation• Perform ADLs independently and safely

• Promote healthy sensory function• Appropriate sensory stimulation• Prevention of sensory disturbances

• Adjust environmental stimuli• Prevent sensory overload• Prevent sensory deprivation

• Manage acute sensory deficits• Use of sensory aids• Use of other senses• Effective communication

• Wear a readable name tag• Address the person by name• Introduce yourself frequently• Identify time and place as indicated• Ask the client “Where are you?” • Orient the client to place if indicated• Place a calendar and clock in the client’s room • Mark holidays with ribbons, pins or other

means

• Speak clearly and calmly, allowing time for words to be processed and for a response

• Encourage family to visit frequently• Provide clear, concise explanations of each

treatment, procedure or task• Eliminate unnecessary noise• Provide adequate sleep• Keep glasses and hearing aids within reach• Ensure adequate pain management• Keep room well lit during waking hours

• Auditory• Introduce yourself to the client• Orient the client to time, month, year,

location• Inform client beforehand the care to be

provided• Read literature to client• Play a tape recording of familiar voice• Converse directly to client

• Visual• Sit client upright in a chair or bed

• Olfactory• Provide aromatic stimuli that may include client’s favorites

• Gustatory• Provide mouth care• Place different tastes on tongue

• Tactile• Incorporate during bath activities

• Kinesthetic • Perform range-of-motion exercises

• Change client’s position

Protection Needs

• Protects against: • Dehydration• Infection• Pressure• Friction• Temperature extremes

• Radiation• Toxins

• Skin consists of several layers:

• Epidermis • Dermis • Subcutaneous Tissue connective layer

• Disruption in skin integrity:• from abrasions• tape blisters• pressure ulcers• major abdominal wounds

• Wound. . . • a type of lesion• a disruption of normal anatomical structure and function

• results from bodily injury or pathological process

• Inflammatory Phase • Immediate to 2-5 days • Hemostasis

• Vasoconstriction • Platelet aggregation • Thromboplastin makes clot

• Inflammation • Vasodilation • Phagocytosis •

• Proliferative regeneration phase• 2 days to 3 weeks • Granulation

• Fibroblasts lay bed of collagen • Fills defect and produces new capillaries

• Contraction • Wound edges pull together to reduce defect

• Epithelialization • Crosses moist surface • Cell travel about 3 cm from point of origin in all

directions

• Remodeling phase 3, weeks to 2 years

• New collagen forms which increases tensile strength to wounds

• Scar tissue is only 80 percent as strong as original tissue

• Acute surgical wound • heal by primary intention• wound edges approximated• secured using sutures, staples, tape.

• Wound bed fills in with granulation tissue and the

scar is thin and flat

• Extensive tissue loss• Edges cannot be closed• Repair time longer• Scarring greater• Susceptibility to infection greater

• Usually deep• Extensive damage and drainage• High risk of infection• Initially left open• Edema, infection, or exudate resolves• Then closed

• Clean wounds

• Clean contaminated wounds

• Contaminated wounds

• Dirty of infected wounds

• Material such as fluid and cells that have escaped from blood vessels during inflammatory process

• Deposited in tissue or on tissue surface• 3 major types

• Serous• Purulent• Sanguineous (hemorrhagic)

• Mostly serum• Watery, clear of cells• E.g., fluid in a blister

• Thicker• Presence of pus• Color varies with organisms

• Hemorrhagic• Large number of RBCs• Indicates severe damage to capillaries

• Serosanguineous•Clear and blood-tinged drainage

• Purosanguineous•Pus and blood

• Incisions

• Contusions

• Abrasions

• Punctures

• Lacerations

• Penetrating wounds

Acute vs. Chronic

Partial Thickness vs. Full Thickness

• Appearance

• Drainage

• Size

• Depth

• Swelling

• Pain

• Drains or Tubes

Davol JP

Hemovac

• Infection

• Hemorrhage

• Fistula

• Dehiscence

• Evisceration

• Malnutrition

• Diabetes

• Dressings

• Transparent film

• Hydrogel and Alginate

• Leeches and Maggots

• Wound VAC

• Wound bed must be free of infection and clean

• Cleansing solution

• Irrigate with NS 30 ml syringe and 19 angiocath

• Keep wound be moist

• Clean to dirty from incision outward in a circular

motion changing swabs

Development in pressure ulcer: • Pathogenesis

• Stage I Non-blanchable erythema of intact skin heralding lesion

of skin ulceration. • Stage II Partial thickness skin loss involving epidermis, dermis, or

both. • Stage III Full thickness skin loss involving damage to or necrosis

of subQ tissue that may extend down to, but not through underlying fascia.

• Stage IV Full thickness skin loss with extensive destruction, tissue

necrosis, or damage to muscle, bone, or supporting structures

Stage related treatmentsStage I Relieve pressure

Stage II Maintain moist healing environment

Stage III Debridement

Stage IV Wound Coverage

Prevention

• Braden skin risk assessment- photograph wounds

• Clean and dry skin

• Promote nutrition

• Manage tissue loads

• Repositioning schedule

• HOB low as possible to decrease shearing forces

Prevention

Beds!

Heel protectors

RISK FACTORS • Immobility

• Malnutrition

• Fecal and urinary incontinence

• Impaired mental status

• Diminished sensation

• Elevated temperature

• Peripheral vascular disease

• Localized edema

• Elderly

Nursing management

- bathing

- skin care and assessment

- bed linen

- bed choice

- provide adequate nutrition and fluids