Transcript Sensory Alterations

Stressors that affect
Cognition &Perception
Sensory
Sleep
NUR101
FALL 2008
LECTURE # 18
K. BURGER
PPP By
Sharon Niggemeier RN MS
Sensory Needs
• Senses- needed for survival, growth &
development and bodily pleasure
• Give meaning to events in the
environment
• Alterations in senses- affect ability to
function in the environment
Sensory Experience
• When we sense things: process of sensory
reception (receive stimuli) and sensory
perception (organization and transmission
of stimuli into meaningful data…influenced
by experiences, knowledge, attitudes)
• Sensory reception – stimuli can be visual,
auditory, olfactory, tactile or gustatory. Also
can be kinesthetic, stereognosis or visceral.
• RAS(reticular activating system)responsible for stimulus arousal (monitors
& regulates incoming stimuli)
Consider this….
Sensory Adaptation
• Stimulus must be variable to create a response,
otherwise it is gradually ignored.
• Think about when you are in a client’s room on
the clinical unit to which you are assigned:
Do you hear all the overhead pages?
Do you hear all the beeping IV pumps?
Do you hear the rattling of garbage pails being
emptied?
Do you hear the roommate’s TV?
• Important! Nurses adapt to unit noises and may
not realize stimuli affecting their clients.
Factors Affecting Sensory
Functioning
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Developmental level
Culture
Stress
Meds
Illness & Therapies
Personality
Think-Pair-Share
• Think about some of the unit noises we
discussed on the Consider this… Slide
• Which noises bother YOU the most?
What could you do to decrease this sensory
overload?
• Share your experience with a classmate and
discuss other interventions.
Sensory Alterations
• A change in environment can lead to MORE
or LESS normal stimuli.
• When stimuli is different from what one is
used to it leads to sensory alterations.
• Hospitalized patients will experience sensory
alterations due to different stimuli loads.
• Can result in sensory overload or sensory
deprivation
Sensory Overload
• Results from being unable to manage
sensory stimuli: (too much stimuli)
• Pain, dyspnea, anxiety (internal)
• Noise, intrusive procedures, contact
with many strangers (external)
• Inability to disregard stimuli: for
example meds that stimulate the
arousal mechanism, may prevent one
from ignoring noise
Assessment: Sensory Overload
• Unrealistic perceptions, ineffective coping
• Acts bewildered,disoriented, difficulty
concentrating, muscle tension
• Reduced problem-solving ability, scattered
attention, racing thoughts
Interventions: Sensory Overload
• Prevent sensory alteration
• Reduce environmental stimuli,
promote sleep
• Establish a routine for care
• Speak calmly and slowly with
simple explanations
• Eliminate personal stimuli
Sensory Deprivation
• Results from decreased sensory input or
meaningless input: (too little stimuli)
• Isolation/non-stimulating monotonous
environment
• Impaired ability to receive and/or send
stimuli IE: vision, hearing deficits,
speech deficits ( expressive or receptive aphasia)
• Inability to cognitively process stimuliconfused, brain injury, meds affecting
CNS
Sensory Deficits
• Impaired reception, perception or both of
the senses
• Blindness, deafness, loss of taste, smell,
touch
• One sense may become more acute to
compensate for deficit
• At risk for sensory overload in the
compensated sense or deprivation overall
Assessing: Sensory Deprivation
• Drowsiness/sleeping/yawning
• Decreased attention span, difficulty
concentrating, impaired memory
• Disorientation, confusion,
hallucinations RAS needs stimulus; body may
produce hallucinations to maintain optimal arousal
• Crying, annoyance over small matters,
depression
• Apathy, daydreaming, boredom, anger
Assessment: Sensory Deficit
• Assess loss of one or more senses
• Note behaviors to compensate for
deficit-always turns right ear toward
person speaking to compensate for
hearing loss
• Assess for diseases that can affect
senses, inner ear infection causes loss of
kinesthetic sense, neurological disease
can effect tactile perception
NURSING DIAGNOSIS
• Disturbed sensory perception
• Social Isolation
• OTHERS in which decreased sensory perception
may be an etiology?
Situational low self-esteem
Disturbed thought processes
WHAT IS A PRIORITY NURSING DIAGNOSIS
for the client with altered sensory perception?
RISK FOR INJURY
PLANNING
• Client will:
Demonstrate understanding by a verbal,
written, or signed response (SENSORY DEFICIT)
• Client will:
Demonstrate relaxed body movements and
facial expressions (SENSORY OVERLOAD)
• Client will:
Increase and maintain personal interactions
(SENSORY DEVICIT)
• Client will:
Remain free from injury
Interventions: Sensory Deprivation
• Prevent sensory alteration
• Teach self stimulation methodsreading, singing etc.
• Provide stimulation – visual, auditory,
gustatory, tactile and cognitive
• Provide reality orientation
• Utilize interpreters for communication
barriers
Interventions: Sensory Deficit
• Deficit may be new- determine ability
to compensate
• Provide care to facilitate sense
• Provide glasses, hearing aids, adaptive
equipment etc. to reduce sensory
deficit
• Utilize all health care team members to
assist with sensory deficit…dietary for
loss of gustatory sense
Which of the following are
guidelines that should be followed
when caring for visually impaired
clients? (select ALL that apply)
a.
b.
c.
d.
e.
f.
Wait for the person to sense your presence in the room
before identifying yourself
Speak in a normal tone of voice
Explain the reason for touching the person after doing so
Orient the person to the arrangement of the room and its
furnishings
Assist with ambulation by walking slightly behind the
person
Sit in the person’s field of vision if he or she has partial
or reduced peripheral vision
Which of the following are
guidelines to follow when caring for
clients with hearing impairments
(select ALL that apply)
a.
b.
c.
d.
e.
f.
Increase the noise level in the room
Clean ears on a daily basis
Position yourself so that the light is on your face when
you speak
Talk to the person from a distance so that he/she may
read your lips
Demonstrate or pantomime ideas you wish to express
Write any ideas that you cannot convey to the person in
another manner.
Communication Methods
for
Clients with Special Needs
• Review Box 24-10 in Potter & Perry
Page 357
Evaluation: Sensory alterations
• Were outcomes met ?
• Is patient compensating ?
• Sensory deprivation hasn’t become
sensory overload?
• Does nursing care plan need modifying
if goals not met?
Sleep/Rest
• Essential for health
• Illness requires increased need for
sleep/rest
• Rest – calmness, free from
stress/anxiety
• Sleep – altered state of consciousness
in which reaction and perception is
decreased
• Effects of sleep on the body not
completely understood
Sleep
• Circadian synchronization- sleep-wake
pattern follows the body’s biologic clock
• RAS and Bulbar synchronizing region of Pons work
together to control sleep/wake cycles
• Restores balance to nervous system
• Promotes physiological & psychological restoration
• Lack of sleep- irritable, poor
concentration, difficulty making
decisions
Sleep Stages
• NREM- non-rapid eye
movement
• 75-80% of adult sleep
• Has 4 stages
I – sl. Awareness
II- easily aroused
III – less easily
aroused
IV – Delta sleep;
arousal difficult
• REM(Stage V)
- rapid eye movement
• 20-25% of adult sleep
• Dreaming
Eyes darting
facial muscles flacid
• Essential for
emotional equilibrium
Sleep Requirements
• Individualized
• Less sleep required the older one
is…newborns sleep 16-18 hr/day (with
more Delta & REM sleep) whereas
elders sleep 6 hr/day ( with less Delta
& REM sleep)
Factors Affecting Sleep
• Health/illness (CAD pain, GI secretions increased
in REM sleep,
• Environment
• Exercise and Fatigue
• Lifestyle
• Emotional stress
• Stimulants/Alcohol (decrease Delta & REM sleep)
• Diet
• Smoking
• Medication
• Motivation
Sleep Disorders
• Insomnia
• Narcolepsy
• Sleep apnea
• Parasomnias
Assessing: Sleep
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Pattern
Quality
Energy level
Sleeping aids
Sleep disturbances
-nature
-onset
-causes
-symptoms (Do you snore? Do you wake up with HA?)
Assessing Sleep
What are some objective signs of inadequate
sleep the nurse should be observant to?
 Physical signs of fatigue: facial drooping, lids
swollen, eyes reddened
 Behavioral signs: yawning, slowed speech, slumped
posture
 Also check for obesity, large thickened neck,
enlarged tonsils
Nursing Dx
• Sleep pattern disturbance R/T physical
discomfort AEB s/p L hip arthroplasty,
positioning restrictions and client statement
“I can’t sleep on my back; I like to sleep on
my side”
• Sleep deficit R/T shift changes at work AEB
“ I’m tired going to work but when I get
home I can’t fall asleep”
Nursing Diagnoses with Sleep
Deprivation as etiology
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Anxiety r/t
Activity intolerance r/t
Ineffective coping r/t
Risk for injury r/t
Outcome Criteria
Client will:
• Wake up less frequently during the night
• Fall asleep without difficulty
• Verbalize plan that provides adequate time
for sleep
• Identify actions that can be taken to
improve quality of sleep
• Awaken refreshed and be less fatigued
during the day
Implementing: Promote Sleep
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Restful environment
Comfort/relaxation
Bedtime rituals
Sleep pattern
Medications
Pharmacological Approaches
• Herbals: Melatonin, Chamomile
• Sedatives: Temazepam (Restoril)
Triazolam ( Halcion )
Zolpidem ( Ambien)
Alprazolam ( Xanax)
Diazepam ( Valium )