SENSORY ALTERATIONS NUR116
senses Give meaning and order to events occurring in environment Stimuli allows person to learn about environment and interact with other humans Necessary for healthy functioning and normal development
senses Hearing Touch Sight Smell Taste Kinesthetic sense Stereonosis
Sensory alterations May be present at birth or aquired May result from medical or surgical treatment People may change behaviour in adaptive or maladaptive ways
Sensory deprivation Reduced sensory input Restrictive environments Elimination of meaning of input Effects include reduced capacity to learn, disorientation, bizarre thinking, anxiety, lability, panic, increased need for physical stimulation, decrease in spatial awareness, reduced color perception
Sensory overload Tolerance varies with fatigue, attitude, emotional and physical well-being Constant pain “ICU psychosis”
Visual deficits Presbyopia Cataract Dry eyes Glaucoma Diabetic retinopathy Macular degeneration
Hearing deficits Presbycusis Cerumen accumulation
QUICK!!!! What nursing diagnoses apply to a person with age-related vision and hearing sensory deficits?
Balance deficit Dizziness and disequilibrium, usually resulting in vestibular dysfunction
Taste deficit Xerostomia- dry mouth
Neurological Deficits Peripheral neuropathy Stroke- affects coordination and balance. Loss of sensation in affected extremities
Assessment of sensory alterations Sensory alteration history Mental status Physical assessment (table 49-2) Observe interaction with others Observe self-care, ADLs Use of assistive device
Safety Uneven walkways Phone cords or electric cords Area rugs Bathrooms without grab bars Unmarked water faucets Unlit stairways Unmarked food
Nursing considerations Multiple avenues of education and communication Light or label equipment Assess communication needs Assess value of glasses, hearing aids Assess support system Provide adaptive ADL aids
QUICK!!! Identify one physiological and one psychosocial nursing diagnosis for a person with sensory alterations