1. NRS320/105 Foundations/Collings2011
Sensory Alterations
Chapter 49
NRS320/105 Foundations/Collings2011

2. NRS320/105 Foundations/Collings2011
Normal Sensation
Depends on intact CNS
3 Components of sensation:
Reception [nerve transmission]
Perception [awareness]
Reaction [meaning]
LOC impacts perception & reaction
↓ LOC impairs perception
May react inapropriately
NRS320/105 Foundations/Collings2011

3. NRS320/105 Foundations/Collings2011
Sensory Alterations
Sensory deficits
Sensory deprivation
Sensory overload
ICU
New info [cochlear implant, preemie]
Cannot ignore stimuli – no sense
PAIN, monitors, touch, sound
Cannot benefit from interventions
Looks like mood disorder, disorientation
NRS320/105 Foundations/Collings2011

4. Common Sensory Deficits
Visual
Presbyopia
Cataract
Dry eyes
Open-angle glaucoma
Diabetic retinopathy
Macular degeneration
NRS320/105 Foundations/Collings2011

5. Common Sensory Deficits
Auditory
Presbycusis [progressive hearing loss]
Cerumen [wax] accumulation
Balance
Dizziness and disequilibrium
Taste
Xerostomia [↓ saliva, thick mucous]
NRS320/105 Foundations/Collings2011

6. Common Sensory Deficits
Neurological
Peripheral neuropathy
Stroke (CVA)
NRS320/105 Foundations/Collings2011

7. Factors Affecting Sensory Function
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

8. Factors Influencing Sensory Function
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

9. NRS320/105 Foundations/Collings2011
Nursing Implications
Focus:
Safety & 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

10. NRS320/105 Foundations/Collings2011
Assessment
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

11. NRS320/105 Foundations/Collings2011
Assessment
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

12. NRS320/105 Foundations/Collings2011
Nursing Diagnoses
Impaired communication
Risk for injury
Situational low self-esteem
Disturbed sensory perception
Social isolation
NRS320/105 Foundations/Collings2011

13. NRS320/105 Foundations/Collings2011
Nursing DX - example
Risk for injury R/T altered tactile perception 2* to PVD AEB numbness in Rt foot, pressure ulcer on Rt foot
NRS320/105 Foundations/Collings2011

14. NRS320/105 Foundations/Collings2011
Planning
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

15. Implementation: Health 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

16. Interventions: 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

17. Intervention: Visual Alterations
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

18. Interventions: 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

19. Interventions:Hearing Alterations
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

20. Interventions: Taste and Smell
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

21. Intervention: Olfactory Alterations
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

22. NRS320/105 Foundations/Collings2011
Interventions: 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

23. Intervention: Tactile Alterations
Providing a safe environment
Reduce the temperature of the water heater
Clearly mark faucets as “hot” and “cold”
NRS320/105 Foundations/Collings2011

24. Interventions: Promoting Communication
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

25. Implementation: Acute Care
Orientation to the environment
Comfort measures -↑ or ↓stimulation
Communication
Control sensory stimuli: noise, light, smells
Safety measures
NRS320/105 Foundations/Collings2011

26. Implementation: 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

27. Interventions: sensory alteration
Assess/ monitor/document alteration
and effect on client function, ADL’s
Teach adaptive behaviors, info
Collaborate/ refer for help [OT]
Evaluate environmental risks
↑ safety, coping, support, social interaction
Access to resources
NRS320/105 Foundations/Collings2011

28. NRS320/105 Foundations/Collings2011
Evaluation
Client’s ability to function
Social isolation
Safety, freedom from harm
Coping
Client expectations
Goal Met? AEB… PLAN?
NRS320/105 Foundations/Collings2011