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Sensory Information 5/14/09IntroductionWhen we are born, we are born with the natural ability to sense things. Our senses are already established when we are born. They are not fine tuned, but it is through each of these senses that we learn, grow, and live life. Individuals who have sensory dysfunction lose the ability to function normally with the surrounding environment. In many cases, the loss of a particular sense will create fine tuning of the other senses in order to compensate for loss. Example is a blind person who fine tunes auditory , olfactory or tactile senses.Kinesthetic: sense that enables a person to be aware of the position and movement of body parts without seeing themStereognosis: sense that allows a person to recognize an object’s size, shape and textureLanguage: the ability to speak is not considered a sense, but, it is similar in that the loss of speech causes one to lose the ability to interact meaningfully with the environmentHow do Senses WorkReception begins with stimulation of a nerve cell called a receptorEach receptor is designed for only one type of stimulus. Such as light, touch, or soundReceptors of the same kind are grouped together to perform a certain function-examples: taste buds of the tongue, retina of the eye and hair cells of the ear When the person becomes conscious of the stimulus and receives the information, perception takes place. The reticular activating system (brain stem) mediates all sensory stimuli to the cerebral cortex, so even in deep sleep, you are able to receive stimuli. The RAS is highly selective. Example: parent may be awakened in the middle of the night at the slightest murmur of an infant in a bedroom down the hall, but, may sleep through the sound of loud traffic outside the bedroom window. Once the receptors have been stimulated the information follows the nerve pathways to the opposite side of the brain. (That’s why stoke patients have deficits on the opposite side of the brain)Sensory AlterationsThe most common types of sensory alterations are sensory deficits, sensory deprivation, and sensory overload. When a client suffers from more than one sensory alteration, the ability to function and relate effectively within the environment is seriously impaired.A deficit in the normal function of sensory reception and perception is a sensory deficit. When senses are impaired, the sense of self is impaired.Initially, a person may withdraw from others and avoid communicating & socializing to cope with the loss.You can have a decrease in meaningful stimuli, for example, the blind person admitted to the hospital.You can have a change in any kind of sensory input. For example, a person who has visual impairment & loss of tactile perception R/T a neurological illness may change behavior in positive or negative ways, it depends on one’s perception of sensory loss. One person with hearing loss may turn the unaffected ear toward the speaker, while another will isolate himself to avoid embarrassment.When one deficit occurs over time, other senses become more acute & sharp.Sensory Alterations ContinuedReduced sensory input comes from vision or hearing loss, from changes in tactile perception like the person who has a neuropathyIf a patient can’t derive meaning from the environment it can lead to sensory deprivation, blind person in a new environmentRestriction of the environment comes from immobility, bed rest, for example the person in an isolation roomIt is extremely important for nurses to pay attention to things that can cause sensory derivation. Many times it is mistaken for psychological illness, confusion, medications or other disease processes. S/S of sensory deprivation Boredom: excessive yawning, drowsiness, apathy, cognitive problems, inability to think or problem solve, increased need for physical stimulation.Sensory Alterations ContinuedSensory overload happens when a person receives multiple sensory stimuli and can’t selectively ignore some of the stimuli.There can be an increase in the quantity of internal stimuli, such as in anxiety. Contributing factors could be lack of sleep or pain.There can be an increase in the quantity of external stimuli, such as noise, equipment, multiple health care personnel.S/S of sensory overload are racing thoughts, short attention span, irritability, restlessness, inability to concentrate, decreased problem solving performance.People at risk are the acutely ill, patients in pain, patients in ICUs.Sensory overload can be confused with mood swings or confusion. Patients may be seen fingering tubing and /or dressings. Nurses need to be aware of S/S.In contrast to deprivation, overload is individualized, a person’s tolerance to sensory overload vary by level of fatigue, attitude, emotional or physical well-being.For example: ICU psychosis: after 3-4 days in ICUFactors Affecting Sensory FunctionThere are multiple factors that affect an individuals sensory function. It is the nurse's responsibility to try and mange these factors when caring for a patient.Age: vision and hearing changesPersons at risk: Older adults living in a nursing homeMeaningful stimuli: pets, playing music, family pictures, TVAmount of stimuli: frequency of procedures, painFamily factors: ICU, limited visiting hoursSocial interaction: loneliness and decreased hearingEnvironmental factors; occupationsCultural factors; languageBetween 40-50 “short arm syndrome”Infants unable to discriminate sensory stimuli b/c nerve pathways are immature. Nervous systems become more complex with growth and development.Aging adults: visual changes, inability to focus on near objects, Presbyopia, age 40-50. Normal changes are reduced visual fields, increase in glare sensitivity, impaired noc vision, reduced accommodation & depth, reduced color discrimination.Hearing loss begins at 30, includes decreased hearing acuity, called presbycusis, difficulty conversing over background noise, difficulty discriminating consonants (z, t, f, g) and high frequency sounds (s, sh, ph, k)Hear low pitched sounds the best.Decreased number of taste buds, decrease in olfactory fibers.Proprioceptive changes, increased problems with balance, spatial orientation & coordination, risk of falls.Tactile changes including declining sensitivity to pain, pressure & temperature.Older adults are at risk because of normal physiologic changes, and are more prone to disease states that can alter sensory perception, like strokeThose that live in confined environments like nursing centers are at risk, where there may not be appropriate stimulation. If the environment creates monotony, the individual has a reduced capacity to learn, grow, and think.People at risk for hearing problems are those exposed to prolonged and excessive noise.A serious concern for those with a hearing deficit is that they may be inappropriately labeled as confusedFactors Affecting Sensory Function – Meaningful StimuliMeaningful stimuli decrease the risk of sensory deprivation. Examples of meaningful stimuli include: READ SLIDE. But, be aware that the roommate who watches loud TV, leaves lights on, or talk too much, can cause sensory overload.Factors Affecting Sensory FunctionPeople at risk are those who have frequent visitors, procedures, pain, tubes, dressings, hallway noises and restrictions from casts, traction or isolationNurses need to be aware that lack of supportive family members and significant others can adversely affect sensory functioning. Can be a problem in the ICUs with restricted visiting hours, and problem for people in nursing homes who don’t get any visitors. Talking about fears and concerns with family members is therapeutic.Those with hearing loss tend to communicate & socialize less which increases loneliness and results in lowered self-esteem Occupations and leisure activities pose risk for sensory alterations. Individuals whose occupations are exposed to loud noises, exposure to chemicals, or flying object s are at risk for decreased hearing & eye injuries.Occupations with increased repetitive wrist movement are at risk for carpal tunnel syndrome.In the hospital immobilized patients, those in isolation, those on bedrest, restrictions because of casts, traction, all are at risk for sensory alterations, or those in ICUs.Certain sensory deficits occur more frequently in specific ethnic groups:African Americans have increased risk of glaucoma.Hearing deficits are greater in whites compared to Asians or Blacks.Blacks have increased risk of glaucoma compared to whitesOtitis media is greater in Native AmericansMyopia is greater in Jewish AmericansSensory Alterations – AssessmentThe nursing history includes assessment of the nature and characteristics of sensory alterations. Ask the patient to describe the nature of the sensory deficit, including the onset and duration, and specific signs and symptoms.Have the patient self-rate the sensory deficit. The nurse can say rate your hearing as excellent, good, fair, poor. Gives information about the patient’s quality of life.Question the family about any behavior changes, because the client may be unaware of any change. Remember that many adults do not like to admit to losses.Again, sensory deficits are more prominent in some races.Assessment – Sensory Alterations – Health PromotionWhat does the client usually do during a typical day to care for sensory functions, what type of ear & eye hygiene is used. If patients have hearing devices or seeing devices do they care for them properly. If they have eye medications are they given on time and in the proper manner.If they work or play sports in high risk areas do they wear protective devices for the ears and eyes.Does the pt. comply with routine health exams for the eyes and ears. Sensor y Alterations – Assessment – HazardsThe nurse may do an in-home assessment for safety. In the home the nurse assess for uneven floors, rugs, door-mats, extension cords, bathrooms without shower or tub grabs, absence of smoke detectors, cluttered floors, and furniture, or kitchen equipment with hard to read settings.Hospitals, make safety checks of the patient’s rooms, is the call light withing reach, are IV poles on wheels and easy to move, are footstools in the middle of the room?Assessment – Sensory Alterations – Mental StatusAssessing mental status in patients helps to determine if a patient is undergoing sensory deprivation or sensory overload. The nurse will observe for appearance & behavior, & assess the client’s emotional status. The nurse will assess motor activity, posture, facial expression, hygieneLOC, ability to carry on conversation, ability to read & write, recent & remote memory.Assess for agitation, euphoria, irritability, wide mood swings.Assessing a client’s mental status helps the nurse determine if a patient is undergoing sensory deprivation or overload.Box 48-5 gives examples of what to assess for metal statusAssessment – Sensory Alterations – Self-Care AbilitiesThis includes things such as feeding (cooking, grocery shopping, tasting), dressing (buttons, hand grippers), grooming (bathing, brushing teeth combing hair), toileting (BSC, or elevator), mobility (walker, canes, rugs steps, ADL(writing, reading, driving, handling money.Assessment – Sensory Alterations – CommunicationAphasia: inability to understand language or communicate orallyExpressive aphasia: inability to name common objects or express simple ideas, the person understands a question, but, is unable to give an answerReceptive aphasia: inability to understand written or spoken languageExpressive aphasia: ask client to use gestures to assist with understanding or may offer pictures at which to point. Nurse can use a picture chart.Receptive aphasia: it may help to maintain a structed environment to minimize confusion, keep a current calendar, lg. visible clock may help with orientation to time and it may help to use non-verbal gestures.Assessment – Sensory Alterations – Other FactorsSocial Support: The nurse finds out about the patient’s family, how supportive are they and is the patient happy with the support given from family & friends.Assistive devices: The nurse should assess if the patient uses glasses or hearing aids and if they are cared for properly and used in a way that maximizes functioning. Does the person use a wheelchair or walker.The nurse remembers that there are other reasons for impaired perception other than sensory overload or deficit. Certain medications can cause ototoxicity, gentamycin, streptomycin, and analgesics, antidepressants can alter perception. Impt. To consider pain, if in severe pain this will alter perception.Client expectations: expect caregivers to assess sensory problems and adjust environment to meet their sensory needs.Case StudyYou are caring for an elderly pt. who is being maintained on bedrest. What measures by the nurse would be appropriate to decrease risk of sensory deprivation?Rom, backrubs, positioning. Participation in self-care activitiesReading materialsFavorite musicSensory Alterations – ImplementationHealth promotion: Good sensory function begins with preventive strategies, there are commonsense things for people to do to prevent sensory loss.Hearing: Hearing protection devices should be worn by those exposed to continuous excessive noise level from boom-boxes, concerts, care should be taken with I-pods, hearing loss can start at age 20, because of these factors. Vision loss: Second leading cause of blindness is glaucoma in the general population and the primary cause of blindness in Blacks. Recommended eye exams between ages 40-64 every 2-4 years, greater 65 or others at high risk every 1-2 years.Preventive safety: Those in high risk sports & occupations need to wear protective devices, eye goggles, and those with excessive, continuous noise HPD. Care should be taken when Rx ototoxic drugs such as gentamycin.The nurse ensures that assistive aids, contact lenses, eye glasses, hearing aids are clean and in good condition. Nurse discuss ways to minimize glare, selecting satin & no gloss finches for walls, countertops, use of tinted windows, adjustable shades, wearing sunglasses. Pocket magnifier can be used for reading, larger print booksBrighter colors such as red, orange, yellow, easier to see. Nurse offers suggestions ways to decorate room, paint hallways, steps and stairwellsHEARING: TV & phones can be amplified, music recorded in low frequency sound cycles can be heard by client’s with severe hearing lossCheck for impacted cerumen, can cause conductive hearing lossTASTSE & SMELL: Nurse promotes good oral hygiene and allows for foods well seasoned, different textures, eaten separately (so they can taste the food better)Sense of smell heightened by aromas such as coffee, baking breadUse smell such as cologne, fragrant flowers, sachets, can make improvement in pt’s room, individualized, some odors or overdone odors are unpleasantTOUCH: for client’s with reduced tactile perception, hair brushing, back rubsSome have hyperesthesia- overly sensitive to tactile stimulation, nurse can keep bed linens looseBedridden are at risk for sensory deprivation, require routine stimulation, through ROM, positioning, back rubs, washing of face and hands, talking and reading.Bedrest affects spatial discriminationHearing Impaired: Don’t approach from behind, move to a position where you can be seen. Decrease background noise, talk normal tone of voice, be sure person can see your face, talk toward the best ear, avoid speaking while walking out, do not shout, if necessary to raise voice speak in low tones. Address patient directly at the same eye level, speak clearly, slowly, and accurately, move position where you can be seen.VISUALLY IMPAIRED: identify yourself when entering the room, speak in normal tone of voice, explain what you are about to do before touching, indicate when you are leaving the roomSensory Alterations – Implementing – Acute CareClients with sensory deficits have a risk of injury & fallingOrientation to the environment: Those with serious visual problems need a complete orientation to the room, need to walk through a room and feel walls with hands. Nurse explains objects in the room. Keep objects in room in same position.Those on bedrest need stimulation, ROM, assist with self-MUNICATION:Aphasia most common language disorder following stroke. Does not correlate with intellectual impairment Nurse can use communication boardsThose with artificial airways can use lap-top computersCONTROLLING SENSORY STIMULI: meansOrganizing Care: combine activates, doing vs. and dsg. Change at same time, helps prevent sensory overload. A question might be like what do you do for someone with communication problems? Organize care…Nurse controls extraneous noise, may ask roommate to turn down volume. Bedside equipment such as sx turned off when not in use.SAFETY MEASURES: Sighted guide for a client with recent visual impairment. Client grasps arm just above elbow. The guide goes one-half step ahead and slightly to the side of the blind person. Warn client when approaching doorways and narrow spaces. YOU WILL BE DOING THIS IN SENSORY LAB.Case StudyYou are taking a health history on a patient with a major hearing deficit who has been admitted to a medical-surgical unit. What are some appropriate interventions to enhance communication?Address the patient directly, stand or sit on the same level.Speak articulately and clearlyUse normal tone of voice. Do not talk louder than normal, if it is necessary to raise your voice, speak in lower tones.Use visible expressions, speak with hands and face.These are slides that the notes section said to “READ SLIDE,” so I put them down again…Sensory Assessment IncludesVision, hearing, smell, taste, and ability to discriminate touch and positionPhysical Assessment – EyeExternal/Internal structures, Visual acuity, visual fields, and extraocular movementsExternal structures should be assessed using visual inspectionInternal structures should be assessed by using an ophthalmoscopePhysical Assessment – EyeTo assess distant vision, use Snellen chart. Client stands 20 feet away, covers one eye and is asked to read the smallest line on the chart with the other eye. Normal vision is 20/20. The top number is the distance the person stands from the chart, the bottom number is the distance at which a normal eye could have read that particular line. 20/20 means you can read at 20 feet what the normal eye could read at 20 feet. The larger the bottom number, the poorer the eyesight. So if at 20 feet you can only read the 30 line of letters, your vision is 20/30.Near vision: use a handheld vision screener with various sizes of print, called a Jaeger card. A normal result is 14/14 in each eye.MYOPIA IS NEARSIGHTEDNESS. IT MEANS YOU CAN SEE NEAR, BUT NOT FAR.HYPEROPIA IS FARSIGHTEDNESS. IT MEANS YOU CAN SE FAR, BUT NOT NEAR.Confrontation: You sit directly in front of the patient and have the patient look into your eye. Each of you covers the opposite eye. Hold your finger midline between you and the other person and slowly advance it in from the periphery from several directions. Ask person to say now ad the finger is first seen, and this is when you should be seeing it also.Sensory Alterations – Physical Assessment – EyeThere are 6 muscles that control movement of the eye. Damage to muscles or even certain disease processes can affect the movement. You can test for normal eye movement by having the patient perform three testsCorneal Light Reflex: Ask the patient to look straight ahead, shine a penlight on the bridge of the nose from about 1-1 and half feet away, the light should shine on the same spot on each cornea. If it does not , the eye muscles are not holding the eyes in the same position. This occurs in strabismus (crossed eyes) The eye muscles don’t work in coordination with each other = strabismus. This used to be called “lazy eye”Cardinal Positions of Gaze: Ask the patient to sit still while you hold a pencil in from of his nose about 1-1 one half feet away. Ask the patient to follow the object with his eyes without moving his head or body, move the object in the 6 cardinal positions returning to the midpoint before starting a new direction. A normal response is parallel tracking of the object with both eyes. Eye movement not parallel, weakness of the muscles of dysfunction of cranial nerve innervating it.Cover-Uncover Test:Ask the person to stare straight at your nose. With a card cover one eye. As it is covered note the uncovered eye. A normal response is a steady fixed gaze. Now uncover the eye and observe it for movement. It should stare straight ahead. If it jumps to re-establish fixation, eye muscle weakness exists.Case StudyYou are caring for a patient with expressive aphasia. How can you promote communication?Expressive aphasia, inability to name common objects, or express simple ideas. Able to understand questions, unable to express an answer.You may want to use a picture chart for the patient’s response.Sensory Alterations – Assessment – EarConsists of three parts: auricle, consists of moveable cartilage and skin, the outer ear canal and the tympanic membrane which separates the outer ear from the middle ear. Tympanic membrane can be seen with an otoscope and is translucent, shiny & pearly gray in color.There are three bony structures in the middle ear that transfer the vibrations to the inner ear. They are the malleus, incus and stapes. These three structures collect vibrations from the middle ear , send them to the 8th cranial nerve, which sends the message to the cerebral cortex that then interprets the sound. The inner ear structures are also responsible for balance.Acuity tests are used to assess conduction, sensorineural or mixed hearing lossConduction hearing loss interrupts sound waves as they travel from the outer ear to the inner ear, swelling, wax build-upA sensorineural loss is an interruption from the inner ear, nerve or brainMixed involves both (conduction and sensorineural)Case StudyYou are caring for a patient with receptive aphasia. How might you promote communication?Receptive aphasia is the inability to understand written or spoken language. The person may be able to express words but is unable to understand questions or comments of others. Use simple gestures, facial gestures to give additional clues, give patient time to understand and think, don’t rush them, be patient and calm.Mirror what you want the client to do.Sensory Alterations – Physical Assessment – EarAsk the person to stand with feet together and arms to the side, then to close the eyes. Wait about 20 seconds. The person’s position should be steady. You must stand close in case the person loses balance. A mild swaying may occur, this is normal. The Romberg also tests the intactness of the cerebellum and proprioceptionSensory Alterations – Physical Assessment – NoseInspect the nose for position, symmetry & color. Note variations such as discoloration, swelling or deformity. Observe for nasal discharge & flaring (resp. distress). Nasal cavities should be moist, pink to light red, and free from lesions and polyps. Pale mucosa with clear discharge indicates allergy mucous discharge indicates rhinitis, sinus infection results in greenish discharge.If you ever needed to test nasal patency and olfactory nerve function (cranial nerve 1), you could perform a smell test of familiar smells for each nostril.Sensory Alterations – Physical Assessment – MouthLips should be pink, moist, symmetrical and without lesions. A bluish hue may be seen in dark-skinned peopleOral Mucosa: should be pink, smooth, moist and free from lesions. Increased pigmentation is seen in dark-skinned peopleGums & teeth: gums should be pink, moist, and have clearly defined margins, note number of teeth as well as condition, missing, crowded, denturesTongue: should be midline, moist, pink and free from lesions ................
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