1. Chapter 49 Sensory Alterations
People learn about the environment from five experiences (sight, hearing, smell, taste, touch).
Human beings rely on a variety of sensory stimuli to give meaning and order to events occurring in their environment.
When sensory function is altered, a person’s ability to relate to and function within the environment changes drastically.
As a nurse, you meet the needs of patients with existing sensory alterations and recognize patients most at risk for developing sensory problems. You also help patients who have partial or complete loss of a major sense to find alternate ways to function safely within their environment.

2. Terminology
Senses:
Sight/visual
Hearing/auditory
Touch/tactile
Smell/olfactory
Taste/gustatory
Position and motion/kinesthetic
Stereognosis is a sense that allows a person to recognize the size, shape, and texture of an object.
You likely all know that the adjective sight is the visual sense, but be sure you know the other descriptors of the senses.
The kinesthetic sense enables a person to be aware of the position and movement of body parts without seeing them.
The ability to speak is not a sense, but it is similar in that some patients lose the ability to interact meaningfully with other human beings if their ability to speak is compromised.

3. Scientific Knowledge Base
Sensory reception involves the stimulation of sensory nerve fibers and the transmission of impulses to higher centers within the brain.
Normal sensation
Reception: stimulation of a receptor such as light, touch, or sound
Perception: integration and interpretation of stimuli
Reaction: only the most important stimuli will elicit a reaction
The nervous system is continually bombarded with thousands of bits of information for the sensory organs. After interpreting the significance of stimuli, the person will react to the most meaningful ones.
A healthy balance between sensory stimuli entering the brain and those that reach a person’s conscious awareness maintains a person’s well-being.
[Review Table 49-1 on text p Normal Hearing and Vision.]

4. Case Study
Mrs. Alicea is a 73-year-old woman who is at the senior health center for her routine 6-month checkup. She has been visiting the senior center on a regular basis for the past 8 years. Mrs. Alicea has lived alone since her husband died 1 year ago. She lives in a single-story, four-room home a few miles from the health center.
Her son, Rico, lives 5 minutes away. Rico drives Mrs. Alicea to her visits. Six months ago, Mrs. Alicea reported progressive hearing loss. Today she reports “having trouble seeing.”
[Ask the class: What assessments are needed for Mrs. Alicea? What questions would you ask her and her son?]

5. Sensory Alterations Sensory deficits Sensory deprivation
Deficit in the normal function of sensory reception and perception
Sensory deprivation
Inadequate quality or quantity of stimulation
Sensory overload
Reception of multiple sensory stimuli
When sensory function is impaired, the sense of self is impaired, and this affects one’s ability to socialize.
Normal sensations consist of reception, perception, and reaction.
Box 49-1 on text p presents common sensory deficits related to sight, hearing, balance, taste, and the neurological system.
Three types of sensory deprivation occur:
Reduced sensory input from sight or hearing
Deprivation resulting from exposure to strange environments
Deprivation resulting from confinement in restrictive environments, such as bed rest, because this produces monotony or boredom.
•Box 49-2 (also on text p. 1235) presents the effects of sensory deprivation on the cognitive, affective, and perceptual well-being of patients.
•Excessive stimuli prevent the brain from responding to or ignoring certain stimuli. Overload prevents meaningful response by the brain. A person’s tolerance to sensory overload can vary according to fatigue, attitude, and physical and emotional well-being. A hospitalized patient or an acutely ill patient can easily become a victim of sensory overload.
•It is easy to confuse the behavioral changes associated with sensory overload with mood swings or simple disorientation.

6. Nursing Knowledge Base: Factors Affecting Sensory Function
Age
Various changes occur across the life span.
Meaningful stimuli
Reduce the incidence of sensory deprivation
Number of stimuli
Can cause sensory overload
Social interaction
Increases with lack of socialization with family
Environmental factors
Occupation, recreation, and sports activities
Cultural factors
Sensory alterations occur in select groups.
Infants and children are at risk for visual and hearing impairment because of a number of genetic, prenatal, and postnatal conditions.
Visual changes occur during adulthood that result in the need for glasses (40 to 50 years old). Glaucoma, reduced visual fields, increased glare sensitivity, impaired night vision, reduced depth perception, and color discrimination can occur.
Aging results in a gradual decline of acuity in all senses. Patients who are older, immobilized, or confined in isolated environments are at risk for sensory alterations. Proprioceptive changes common after age 60 include increased difficulty with balance, spatial orientation, and coordination.
Hearing loss usually begins around 30 years of age. Smell and taste changes usually begin around 50 years old.
Meaningful stimuli include those activities and people who have a positive influence on the patient, such as pets, music, TV, movies, family, clock, and calendar.
A disruptive roommate or too many visitors or too much light or noise in the room can negatively affect the patient.
It is ideal for the nurse to perform activities such as monitoring vital signs and providing assessments, treatments, and medications at the same time, so the patient can have adequate amounts of rest.
Patients need their interactions. Absence of loved ones/significant others/friends can increase incidences of isolation, loneliness, anxiety, and depression.
Occupations and recreational or sports activities can have effects on sight, hearing, and body parts. Hospitalized patients in isolation, with casts, or in traction will be unable to move around in their environment.
Certain sensory alterations occur more commonly in select ethnic groups.
[Box 49-3 on text p presents Cultural Aspects of Care: Disparities in Sensory Alteration.]

7. Case Study (cont’d)
Peter Morris, a 33-year-old nursing student assigned to the senior center, is learning to conduct assessments and to develop health promotion plans for patients.
For the past month, Peter has been attending his clinical rotation and participating in teaching health promotion activities. He is enjoying this rotation because he is learning more about geriatric patients and is finding that they are very independent and capable of having productive lifestyles.
[Ask the class: What sort of health promotion activities do you think Peter will consider for Mrs. Alicea?]

8. Critical Thinking + The Nursing Process
Integrate pathophysiological knowledge about sensory deficits and factors affecting function
Apply evidence-based standards of care:
American Academy of Ophthalmology
American Speech-Language-Hearing Association
Include previous experiences:
To apply critical thinking in the case of sensory alterations, integrate knowledge of the pathophysiology of sensory deficits, factors that affect sensory function, and therapeutic communication principles.
Evidence-based standards of care and practice such as those from the American Academy of Ophthalmology and the American Speech-Language-Hearing Association provide criteria for screening sensory problems and establishing standards for competent, safe, effective care and practice.
Previous experiences in caring for patients with sensory deficits enable nurses to recognize limitations in function in each new patient and to understand how they affect the patient’s ability to carry out daily activities.
[See also Box 49-4 on text p Evidence-Based Practice: Consequences of Waiting for Cataract Surgery.]
Assessment
Nursing Diagnosis
Planning
Implementation
Evaluation

9. Assessment Persons at risk Sensory alteration history Mental status
Physical assessment
Ability to perform self-care
Health promotion habits
Environmental hazards
Communication methods
Social support
Use of assistive devices
Other factors affecting perception
When assessing patients, you need to identify whether any pathology exists. If the patient has a hearing impairment, you will need to adjust your voice. You need to assess how any sensory deficits affect the patient’s psychosocial, developmental, and self-care abilities, as well as threaten the patient’s safety.
Some patients benefit from referral to an audiologist or otolaryngologist if assessment reveals serious hearing problems.
•Assessment of a patient’s health promotion habits reveals risks for sensory impairment, including age and living in a confined environment.
The Hearing Handicap Inventory for the Elderly (HHIE-S) effectively identifies in 5 minutes with 10 questions patients who need audiological intervention. Ask friends and family about any changes in behavior.
Assessment of mental status is valuable when you suspect sensory deprivation or overload.
To identify sensory deficits and their severity, use physical assessment techniques to assess vision, hearing, olfaction, taste, and the ability to discriminate light touch, temperature, pain, and position.
Assess patients’ functional abilities in their home environment or health care setting, including the ability to perform feeding, dressing, grooming, and toileting activities.
To assess health promotion habits, assess daily routines that patients follow to maintain sensory function.
•Assessment of hazards in the environment requires the nurse to tour living areas in the home and look for conditions that increase the chances of injury, such as by falls.
To understand the nature of a communication problem, you need to know whether a patient has trouble speaking, understanding, naming, reading, or writing. (More information on the types of aphasia is given on the next slide.)
Assess whether a patient lives alone, and whether family or friends frequently visit. Assess the use of assistive devices (hearing aid or glasses) and the sensory effects of their use for the patient.
Assess the patient’s medication history, which includes prescribed and over-the-counter medications and herbal products. Some antibiotics are ototoxic.
[Review Figure 49-1 on text p Critical thinking model for sensory alterations assessment.]
[Box 49-5 on text p presents nursing history assessment questions.]

10. Case Study (cont’d)
Mrs. Alicea reports that at her last visit to the ophthalmologist, she was told she had a cataract.
Peter learns that Hispanic/Latino individuals in the United States have higher rates of visual impairment and blindness compared with members of other ethnic groups. Visual field loss has a negative impact on health-related quality of life: driving, distance and peripheral vision activities, and a sense of independence.
Peter uses this information to develop a culturally competent plan that focuses on Mrs. Alicea’s visual impairment.
[Ask the class: What are some possible nursing assessment steps for Peter to use with Mrs. Alicea? Discuss. Possibilities include:
Review with Mrs. Alicea at each visit the importance of early intervention through regular vision examinations.
Provide information about side effects of visual impairment, and encourage the use of visual and adaptive devices when possible.
Ask Mrs. Alicea how she is coping with visual alterations.
Ask Mrs. Alicea about her social networks and supportive relationships.
Assess for changes in mood and depression.
Determine whether Mrs. Alicea has experienced new limitations of activities of daily living or a change in participation in leisure activities.
Refer her to community resources and activities.]

11. Quick Quiz!
1. An elderly patient who lives in an adult assisted-living facility mentions that he is experiencing hearing and vision changes. During your assessment, you would associate this type of sensory deprivation with
A. Stable affect.
B. Altered perception.
C. Improved task completion.
D. Increased need for social interaction.
Answer: B

12. Aphasia Definitions
Patients with aphasia have varied degrees of inability to speak, interpret, or understand language.
Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing.
Sensory or receptive aphasia is the inability to understand written or spoken language.
Temporary or permanent loss of the ability to speak is extremely traumatic for an individual. Assess a patient’s alternate communication method, and note whether it causes anxiety.
Global aphasia is the inability to understand language or to communicate orally.

13. Nursing Diagnosis (examples)
Risk-prone health behavior
Impaired verbal communication
Risk for injury
Impaired physical mobility
Risk for falls
Social isolation
Bathing self-care deficit
Dressing self-care deficit
Toileting self-care deficit
Situational low self-esteem
Examples of nursing diagnoses that apply to patients with sensory alterations are listed on the slide.
The etiology or related factor of a nursing diagnosis is a condition that nursing interventions can affect. The etiology needs to be accurate; otherwise nursing therapies are ineffective.
[Discuss possible “related to” factors for several diagnoses.]
[Review Box 49-6 on text p Nursing Diagnostic Process: Risk for Injury Related to Visual Impairment from Cataract Formation.]
[Also review the concept map on text p ]

14. Case Study (cont’d)
Mrs. Alicea states, “I’m having difficulty reading and moving around the house. I cannot judge the steps clearly. I have difficulty judging distances between objects, which is worse at night.”
Results of a home hazard assessment show that Mrs. Alicea’s home has dim lighting, stairs without handrails, and numerous throw rugs on the floor.
What diagnosis do you think Peter will choose?
[Discuss.]
Risk for falls related to visual alterations from cataracts

15. Planning Include family members. Use standards as guides.
Partner with the patient to set realistic goals and achievable outcomes.
Make safety a top priority.
Value other professionals’ contributions.
Consider community-based resources.
The plan of care for patients with sensory alterations needs to include participation by family members. The extent of support from family members and significant others influences the quality of sensory experiences.
An example of using a standard for planning is for patients who have visual deficits and are hospitalized; they are often placed on a fall prevention protocol that incorporates research-based precautions to ensure patient safety.
Valuing intraprofessional and interprofessional collaboration is an essential nurse competency and plays a role in quality patient care.
[See Figure 49-4 on text p Critical thinking model for sensory alterations planning; and Nursing Care Plan: Risk for Injury on text p ]

16. Case Study (cont’d)
Goal: Mrs. Alicea’s home environment is safe and free of hazards within 4 weeks.
What expected outcomes would you include?
[Discuss. Possibilities include:
Mrs. Alicea will report an increased sense of home safety and independence within 2 weeks.
Mrs. Alicea and her son will make recommended changes to home environment within 4 weeks.]

17. Implementation
Patients can learn to adjust to sensory impairments at any age with the proper support and resources.
Health promotion
Screening
Preventive safety (trauma, vaccines)
Use of contact lenses, eyeglasses, hearing aids
Promotion of meaningful stimuli
Creating a safe environment
Communication
The most effective interventions enable a patient with sensory alterations to function safely with existing deficits and continue a normal lifestyle.
Preventable blindness is a worldwide health issue that begins with children and requires appropriate screening.
The most common visual problem is a refractive error such as nearsightedness. The nurse’s role is one of detection, education, and referral.
Because aging is associated with degenerative changes in the ear, patients need to have hearing screenings at least every decade through age 50 and every 3 years thereafter.
Children and adults are vulnerable to eye injuries.
Reinforce proper lens care in any health maintenance discussion.
Older adults are often reluctant to use hearing aids. Acknowledging a need to improve hearing is a person’s first step. Excessive cerumen occluding the ear canal causes conductive hearing loss.
[See also Box 49-7 on text p Patient Teaching: Troubleshooting Hearing Aid Malfunction.]
When promoting meaningful stimuli, it will be important to take into consideration the environment. You will want to take measures to improve lighting, hearing, and tactile, taste, and smell sensations. If a patient is overly sensitive to tactile stimuli (hyperesthesia), minimize irritating stimuli.
In creating a safe environment, adaptations will be needed for those with visual loss and reduced hearing, olfaction, and tactile sensation.
The ability to speak with people allows patients to interact with others. When sensory alterations do not allow a patient to communicate, feelings of loneliness and decreased self-esteem can occur.
Patients with sensory deficits often develop alternate ways of communicating that rely on other senses. For example, patients with artificial airways are able to communicate effectively with communication boards, laptop computers, and written messages.

18. Acute Care Orientation to the environment Communication
Address the patient by name, place call light within reach, use nightlight, reduce clutter.
Communication
Control of stimuli
Reduce sensory overload.
Combine nursing activities.
Control extraneous noise.
Safety measures
[Tell the class: In the acute care environment, think how you would feel if you had alterations in hearing and vision. You might want to conduct an exercise with students. Collect old eyeglasses or sunglasses. Place tape or petroleum jelly over glasses to represent glaucoma, partial vision, total blindness, or other visual impairment. Have them stuff cotton in their ears. This exercise may give students the ability to experience what their patients experience.]
The patient with recent sensory impairment requires a complete orientation to the immediate environment. It is important to keep all objects in the same position and place.
The most common language disorder following a stroke is aphasia.
[Box 49-8 on text p reviews communication methods for patients with sensory deficits.]
Patients need time for rest and freedom from stress caused by frequent monitoring and repeated tests. To prevent sensory overload, control stimuli and orient the patient to the environment.
It is wise to note on the intercom system at the nurse’s station and in the medical record that the patient is deaf and/or blind. Patients with reduced tactile sensation risk injury when their conditions confine them to bed because they are unable to sense pressure on bony prominences or the need to change position.

19. Safety Measures
The patient with recent visual impairment often requires help with walking. A sighted guide gives confidence to patients with visual impairments and ensures safe mobility.
[Shown is Figure 49-5 from text p [From Sorrentino SA, Remmert LN: Mosby’s textbook for nursing assistants, ed 8, St Louis, 2012, Mosby.]

20. Restorative and Continuing Care
Maintaining healthy lifestyles
Understanding sensory loss
Socialization
Promoting self-care
Increases self-esteem
Enhances safety awareness
Many of the interventions applicable to health promotion such as adapting the home environment are useful after a patient leaves an acute care setting.
Patients who have experienced a recent sensory loss need to understand how to adapt so their living environments are safe and appropriately stimulating.
When sensory alterations hinder interactions, a person feels ineffective and loses self-esteem.
[Box 49-9 on text p presents principles for reducing loneliness.]
When we promote self-care, the patient’s self-esteem will be bolstered. For example, patients with decreased vision can still feed themselves, if the nurse places food on the plate according to the face of a clock. Also, the use of incandescent lighting and shades will help to reduce glare.
Any sensory impairment has a significant influence on body image, and it is important for the patient to feel well groomed and attractive.
The use of Velcro and zippers or pullover shirts and elasticized waists will make dressing easier.
For patients with balance and strength issues, safety bars in the bathroom can be helpful, as can placing nonskid surfaces on the floor.

21. Case Study (cont’d)
What interventions would apply to these rationales?
1. Sensitivity to glare increases because of clouding of the lens.
2. Light intensity needs to be 3 times as powerful for older adults to produce the same visual acuity as for younger people.
3. Removal of trip hazards prevents falls and promotes a safe environment.
What fall prevention interventions would Peter choose?
[Discuss:
1. Recommend that Rico install a nonglare work surface in the kitchen area.
2. Recommend that Rico install incandescent lights in the home.
3. Help Rico identify potential trip hazards, such as throw rugs, and suggest that they be modified or removed.
For fall prevention, teach Rico methods to improve environmental safety, such as installing handrails along stairs, securing carpeting, removing throw rugs, and painting stairs. Suggest that Rico place a nonslip surface such as a nonskid mat in the bathtub and shower.]

22. Promoting Self-Care
Location of food using clock as frame of reference.
To help with meals, arrange food on the plate and condiments, salad, or drinks according to numbers on the face of a clock. It is easy for the patient to become oriented to these items after the nurse or family member explains the location of each item.
[Shown is Figure 49-6 from text p ]

23. Quick Quiz!
2. A patient with glaucoma is being discharged from the hospital. When teaching the patient and family ways to improve home safety, the nurse tells the family to:
A. Use throw rugs to prevent tripping.
B. Paint the floor black and white to improve perception.
C. Install extra incandescent lighting.
D. Install handrails painted the same color as the walls.
Answer: C

24. Case Study (cont’d)
What nursing actions would be appropriate for Peter to take to evaluate Mrs. Alicea’s situation?
Ask Mrs. Alicea at her next visit if she has experienced any trips or falls since modifications were made to her home.
Ask Rico if his mother is having any difficulties moving through her home.
Conduct a home visit, and reassess the home environment.
[Discuss what responses would indicate that outcomes had been achieved and, if not, what additional steps are advised.]

25. Evaluation
The patient is the only person who can tell you if sensory ability has improved as a result of nursing interventions.
[Ask the class: Can you read all three sections? Just as some of you may be able to read the text in all three sections and some of you may not, I had to ask you whether you could read them. Thus it is the patient who can tell you whether a sensory ability has improved.]
Collaborate with family members to determine whether the patient’s ability to function within the home has improved.
Working closely with the patient and family enables you to redefine expectations that can be realistically met within the limits of the patient’s condition and therapies.
[See also Figure 49-7 on text p Critical thinking model for sensory alterations evaluation.]