Transcript Nursing Interventions for Common Sensory Alterations

JUDITH M. WILKINSON LESLIE S. TREAS
KAREN BARNETT MABLE H. SMITH
FUNDAMENTALS OF
NURSING
Chapter 30:
Sensation, Perception, & Cognition
Chapter 46, 47 and 48 in Iggy
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Learning Outcomes
• Identify the components of the sensory experience
• Describe sensory deprivation & overload
• List risk factors for altered sensory perception
• Discuss the hazards of sensory deficits
• Describe nursing interventions for patients with sensory
deprivation, overload, and deficits
• Describe the etiology, pathophysiology, treatments and
nursing assessments, diagnoses, and interventions for the
sensory impairments of glaucoma, macular degeneration,
cataracts, and hearing loss
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Sensory Systems & The Senses
Pg 772
• Vision
• Hearing
• Taste
• Smell
• Touch
• Provide information about
• Internal environment

• External environment
• Enable people to experience
the world
• Allow response to changes
• Help body maintain
homeostasis
• Necessary for human growth
and development
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Components of the Sensory Experience
Reception
• Process of receiving stimuli
• Trigger that stimulates
from nerve endings
receptor
• Occurs through receptors
• Meaning depends on
reception and processing
(e.g., mechanoreceptors,
thermoreceptors,
(e.g., loud noise, bright
light, sour fruit)
proprioceptors,
photoreceptors, chemo and
olfactory receptors)
Stimulus
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Components of the Sensory Experience
(cont’d)
Perception
• Ability to interpret
sensory impulses
• Ability to give meaning to
impulses
• Affected by
– Location of receptor
– Number of
receptors activated
– Frequency of
action potentials
– Changes in above
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Components of the Sensory Experience
(Cont’d) Pg. 773-HF
Arousal
Response to Sensations
• Composed of
consciousness and
alertness
• Mediated by reticular
activating system (RAS)
• Affected by
• Factors affecting response
• Environment
• Medications
• Intensity of stimulus
• Contrasting stimuli
• Adaptation to stimuli
• Previous experience
• Requires people to be
• Alert
• Receptive to stimulation
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Factors Affecting Sensory Function
Pg 774 – 775 HF
• Age/stage of life
• Culture
• Illness
• Medications
• Stress
• Personality
• Lifestyle
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Sensory Alterations
• Sensory deprivation
• Sensory overload
• Impaired vision
• Impaired hearing
• Impaired taste
• Impaired smell
• Impaired
tactile perception
• Impaired
kinesthetic sense
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Nursing Interventions for Common Sensory
Alterations
Sensory deprivation
• Focus is prevention.
• Support senses (e.g., glasses, hearing aids).
• Orientation
– Calendar; view of environment
• Provide stimuli.
–
–
–
–
Regular contact; touch
Television/radio
Pet therapy
Smells
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Nursing Interventions for Common
Sensory Alterations (Cont’d) Box 30-1 HF
Sensory Overload
• Minimize stimuli
• Less light, noise
• Provide rest
• Teach stress reduction
• Less television/radio
• Calm tone
• Reduce noxious odors
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Nursing Interventions for Common
Sensory Alterations (Cont’d) Box 30-2 HF
Impaired Vision
•
•
•
•
Attend to glasses
Sufficient light
Protect eyes in sunlight
Magnifying lens/
large-print books
• Evaluate
• Ability to perform ADLs
• Ability to remain safe in the
environment
• Need for assistance 
seeing eye dog
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Nursing Interventions for Common
Sensory Alterations (Cont’d) Pg 777-779 HF
• Impaired Taste
• Impaired Smell
– Dry mouth
– Vital to the sense of taste
– Medications
– Nerve damage
– Common cold
– Genetics
– Smoking
– Zinc deficiency
– Vitamin B & zinc
– Heavy smoking
– Dementia
– Cocaine
– Head injuries
– Rhinitis, sinusitis
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Nursing Interventions for Common
Sensory Alterations (Cont’d) Pg 779-780 HF
• Impaired Tactile
Perception
• Impaired Kinesthetic
Sense
– Hands and Face
– Inner ear problems
– 2 point discrimination
– Parkinson’s disease
– CVA
– Tumors
– Spinal injury or tumor
– CVA
– Diabetes
– Medications
– Chronic alcoholism
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Assessment for changes in sensory function
Pg 781-782 HF
• Mental status/LOC
• Use of Sensory aids
• Environment
• Support network
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Interventions for sensory deprivation
• Visual Stimulation
– Art, color, sunlight
• Auditory Stimulation
– Hearing aide with
↓background noise
• Olfactory Stimulation
– Good aromas
• Tactile Stimulation
– Touch
• Audiovisual Media
– TV or radio
• Social Interaction
– Get for meals, activities
• Minimizing Anxiety &
confusion
• Communication
– Boards, pictures
• Pet Therapy
• Collaboration
– Multi-disciplinary approach
• Self-Stimulation
– Reading, games, singing
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Interventions for sensory overload
• Control visual stimuli
• Use TV & radio
appropriately
– Decrease light
• Control auditory stimuli
– Turn off when not in use
• Minimize stress
– Talk in moderate tones
– Ear plugs for patients
– Calm presence
• Control olfactory stimuli
– Private room
– Empty bed pans/urinals
– Control pain, nausea
– Remove old meal trays
– Relaxing music
• Control tactile stimuli
– Minimize irritating stimuli
• Promote adequate rest &
sleep
– Schedule of uninterrupted times
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Interventions for visual deficits
• Eyeglasses clean and proper
prescription
• Offer large print books
• Provide enough light
• Make sure staff is aware of
the visual deficit
• Unclutter the environment
• Place call light within reach
• Ask which side they prefer
you to stand on
Announce your presence
Call the patient by their name
Stay in the field of vision
Speak normally
Explain unfamiliar sounds
Explain before touching
Indicate when you are done and
leaving
• Avoid expressions such as ‘over
there” or “right here”, guide them
instead to the object
•
•
•
•
•
•
•
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Interventions for hearing deficits
• Support auditory function
– Hearing aides
• Are they wearing them?
• Are they working?
• Provide written instruction
• Move to the less effected ear if
possible
• Don’t shout!
• Use simple, plain language
•
•
•
•
•
•
•
•
Move to where you can be seen
Don’t chew gum
↓ background noise
Talk in normal tones &
articulate- don’t shout
Address them directly
Keep your voice at a constant
volume and speak clearly
Don’t mumble or “overarticulate”
Use gestures
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Nursing Interventions for the Confused
Client
• Reorient frequently
• Communicate clearly,
slowly
• State your name; day,
date, time
• Provide clocks, calendars
• Visual clues to time
• Use personal belongings
• Maintain safe
environment
• Respond to feelings
• Use gestures
• Limit choices
• Promote feelings of
security
• Use alternative therapies
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Nursing Interventions for the Unconscious
Client
• Continue orientation to
reality
• Safety measures
• Bed in low position
• Side rails up
• Attend to body systems
•
•
•
•
•
•
Eye care
Range of motion
Skin care/mouth care
Urinary drainage
Bowel management
Nutrition
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Glaucoma
Patho = Iggy Pg 985
• Liquid filled Aqueous
Humor
• Fluid drains from a
spongy outlet (trabecular
meshwork)
• Too much liquid
production = pressure 
inside the eye = pressure
on optic nerve =
destruction
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Glaucoma
• Chronic Open Angle
– Most common type
– Over 40, symptomless
– Decreasing drainage capacity
• Acute Angle-closure
– Immediate, complete blockage of the drainage area
– Rainbow like halos or circles, pain in the eyes and forehead,
nausea, and blurred vision
– Medical emergency! Blindness in 1-2 days
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Medical & Surgical Management
Pg 987-989 Iggy
• Early Detection: tonometer
– https://www.youtube.com/watch?v=TTnLVw6yzB8
• Non-surgical Mgmt:
– Medical management relies on systemic and
topic ocular medications that lower IOP
• Surgical Mgmt:
– Surgical management is laser procedures,
filtering procedures, drainage implants or
shunts
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Glaucoma Nursing Management
•Strict adherence to medication
regime
•Teaching: eye drop application
and side-effects of medications
•Loss of peripheral vision
management
•Support and assistance coping
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Cataracts
Pg 982 – Iggy Patho
• Lens opacity or cloudiness
• Medical management may include
antioxidants, glasses, contact lenses,
bifocals or magnifying lenses to slow
progression
• Surgical management is
lens removal and lens
replacement (only “cure”)
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Cataract Nursing Management
Pg 984 Iggy (Table 47-4)
•Post-op care
–Analgesics
–Antibiotics
–Anti-inflammatory eye gtts
–Corticosteroid eye gtts
•Teaching self-care of eye shields and
sunglasses
•Avoid activity that may ↑ IOP
•(table 47-1/Iggy)
•Follow up with physician
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Macular Degeneration
Pg 989 Iggy-Patho
• Loss of central vision, or
• Dim, distorted vision while reading
• Accounts for 90% of all legal blindness
• “Dry”
– Tiny yellow spots
– More common and progresses quickly
especially for smokers
• “Wet”, 10% of cases
–  abnormal blood vessels– leak fluid or blood
– Collaborative Management: Maximize
remaining vision
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Retinopathy
Pg. 1303-1304 Iggy
• Disease of the retina
– Damage to the tiny blood vessels (microvascular) in the back of the eye
• Caused by Diabetes
– Few manifestations until vision loss
occurs
• Fragile new blood vessels form
– Proliferative diabetic retinopathy
• Diagnosis:
– Visual acuity test
– Pupil dilation
– Opthalmoscopy
– Tonometry
• Treatment: laser surgery, vitrectomy
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Hearing loss
• Anatomy of the ear
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Assessment
Pg. 1001 Iggy & 1010 Chart 48-7
• Inspection of the External Ear
• Otoscope Examination
• Evaluation of Gross Auditory
Acuity
– Whisper Test
– Weber Test
– Rinne Test
– https://www.youtube.com/watch?v=uI6
_nPCkdK4
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Hearing Loss
(Pg 778-HF Box 30-3)
•Care of a hearing aid (Chart 48-8 Iggy)
•Use closed-caption television
•Regular inspection of ear canals (cerumen build up)
•Communication Techniques (Pg 604/SF & Pg 1014 Iggy Chart 4810)
•Promote safety
•Assess for social isolation
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Aural Rehabilitation
•Hearing Aids
•Implanted Hearing
Devices
•Hearing Guide
Dogs
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Think Like a Nurse
How would you assess Joshua and Richard (Meet Your
Patients) for sensory alterations? You may need to
review the Meet Your Patients scenario at the beginning
of the chapter in the book to answer this question. (See
the next slide.)
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Think Like a Nurse (cont’d)
• Joshua is a 28-year-old patient in the intensive care unit
(ICU). He had a car accident 3 weeks ago and has had
several surgeries to repair a fractured femur, ruptured
spleen, and intracranial bleeding. He was ventilated
mechanically for 10 days and has had numerous invasive
procedures. The nurses report that he is very confused
and has been hallucinating.
• Richard is a 90-year-old man who has been a resident at a
skilled nursing facility for 10 yr. He has no visitors, never
leaves his room, has no television or radio in the room,
and no longer speaks. He does not respond to verbal or
tactile stimulation. He lies in bed in a fetal position. When
staff try to move him, he moans and howls.
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