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
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
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
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]]
NRS320/105 Foundations/Collings2011
Common Sensory DeficitsCommon Sensory Deficits
NeurologicalNeurological Peripheral neuropathyPeripheral neuropathy Stroke (CVA)Stroke (CVA)
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
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?
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
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
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
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
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
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
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
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)
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
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
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)
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
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
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
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”
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
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
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
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