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)
Factors Affecting Sensory
Functioning
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Developmental level
Culture
Stress
Meds
Illness & Therapies
Personality
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?
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
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 )