Sensory
• Sensory Stimulation
• Sight (visual)
• Hearing (auditory)
• Touch (tactile)
• Smell (olfactory)
• Taste (gustatory)
•Sensory Stimulation
•Kinesthetic (awareness)sense that enables a person to be aware of the position and movement of body parts without seeing them
•Stereognosis (recognition)sense that allows a person to recognize an object’s size, shape and texture
• Language (speech
How Do Senses Work
Three components of sensory experience
• Reception – nerve cell (receptor)
• Perception
• Reaction
Sensory Alterations
•Sensory deficits
•Impaired reception, perception or both
•Box 48-1, pg. 1568 (P&P): Examples of sensory deficits
•Examples: blindness, deafness, change in tactile perception
•Terms (presbyopiapresbycusis)
•(test Question) Initially, a person may withdraw from others and avoid communicating & socializing to cope with the loss.
•One person with hearing loss may turn the unaffected ear toward the speaker, while another will isolate himself to avoid embarrassment
•Sensory Deprivation: Three types
• Reduced sensory input
• Elimination of order or meaning from input
• Restriction of the environment
• Effects of sensory deprivation
•S/S of sensory deprivation Boredom: excessive yawning, drowsiness, apathy, cognitive problems, inability to think or problem solve, increasedneed for physical stimulation
• Sensory Overload
– Multiple sensory stimuli
– Increased quantity of internal stimuli; anxiety, pain, lack of sleep
– Increased quantity of external stimuli; noise, from hospital equipment, patient , nurses, ex
– Person receives multiple sensory
– Individualized
•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.
Factors Affecting Sensory Function
Age:
•Infants have immature nerve pathways
•Aging Adults, visual, hearing, gustatory, olfactory & proprioceptive changes
•Aging adults: visual changes, inability to focus on near objects, Presbyopia, age 40-50 “short arm syndrome”
•Hearing loss begins at age 30, includes decreased hearing acuity, calledpresbycusis
•difficulty discriminating consonants (z, t, f, g) and high frequency sounds (s, sh, ph, k)
•Hear low pitched sounds the best., hve more vibration
•Tactile changes including declining sensitivity to pain, pressure & temperature.
•Persons at Risk
• Older adults
•Exposure to excessive noise
•Living in confined environments
Family Factors:
• Encourage discussion of fears and concerns
• Amount & quality of contact with family
•Social Interaction:
• Decreased verbal communication with
hearing loss
•Those with hearing loss tend to have lowered self-esteem
Cultural factors:
• Assess ethnic factors\
•Hearing deficits are greater in whites compared to Asians or Blacks.
•Blacks have increased risk of glaucoma compared to whites
Sensory Alterations - Assessment
History
• including onset & duration
• have patient self-rate alteration
• assess nature of sensory alteration,
• behavior information from family
• consider ethnic background
•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.
Assessment-Sensory Alterations-Health Promotion
•Assess daily routines to maintain sensory function
•Compliance with screening
Sensory Alterations – Assessment-Hazards
• Environmental Hazards
• Home
• Hospital
• Increased risk for injury
Assessment – Sensory Alterations – Includes
•Mental status
–MMSE (Mini Mental Status Examination)
• Tool used to measure disorientation, altered conceptualization & abstract thinking & change in problem solving
•Self-care abilities
•Health promotion, doctors appt
•Hazards
•Social Support
•Communication methods
•Assess method of communication
•Hearing Loss
•Visually impaired
•Aphasia; inability to understand language or communicate orally
• Expressive Aphasia (use a picture chart); inability to name common objects or express simple ideas, the person understands a question, but, is unable to give an answer, ask client to use gestures. Offer them pictures thay can point to
–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 (non-verbal gestures, repeated behaviors)inability to understand written or spoken language, maintain structured environment,.. Big clock, use non verbal gesture
–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.
•Use of assistive devices
•Other factors affecting perception
•Social support
•Assistive devices
•Perception, some antibiotics toxic
•Client expectations
•Certain medications can cause ototoxicity, gentamycin, streptomycin, and analgesics, antidepressants can alter perception.
Sensory Alterations, Nursing Diagnosis
•Impaired verbal communication
•Risk for injury
•Impaired physical mobility
•Disturbed sensory perception
•Social isolation
Sensory Alterations-Implementation
•Health promotion
•Hearing loss
•Vision loss – glaucoma
• Blacks, and those > 65, every 1-2 years
•Preventive safety
•Assistive aids & good hygiene
•Adjust environment for increase stimulation
•Vision, hearing, taste & smell, touch
•HEARING: TV& phones can be amplified, music recorded in low frequency sound cycles can be heard by client’s with severe hearing loss, Check for impacted cerumen, can cause conductive hearing loss
•TASTSE & SMELL: Nurse promotes good oral hygiene and allows for foods well seasoned, different textures, eaten separately, Sense of smell heightened by aromas such as coffee, baking bread
•SEEING: colors, red, orange, yellow;Brighter colors such as red, orange, yellow, easier to see. Nurse offers suggestions ways to decorate room, paint hallways, steps and stairwells
•TOUCH: for client’s with reduced tactile perception, hair brushing, back rubs
Some have Hyperesthesia, overly sensitive to tactile stimulation; loose bed linens
• pocket magnifier
• back rubs, ROM exercises
• clockwise orientation to food
• oral hygiene, foods different
• texture
Sensory Alterations-Implementing-Acute Care
•High risk for injury
•Orientation 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.
•Communication
•Controlling sensory stimuli; : means what can you do for a patient that has a sensory overload ; Organizing Care: combine activates, doing vs. and dsg,Change at same time, helps prevent sensory overload
•Safety measures (warn approaching doorways & narrow spaces)
Sensory Alterations-Physical Assessment
•Sensory Assessment Includes:
– Vision
– Hearing
– Smell
– Taste
– Ability to discriminate touch & position; cerebellum part of the brain that gives us position and balance
Physical Assessment-EYE
•External structures should be assessed using visual inspection
•Internal structures should be assessed by using an ophthalmoscope
•Central visual acuity-distance vision
• Measured with Snellen Eye Chart ; Client stands 20 feet away
•Central visual acuity-near vision-Jaeger card
•Myopia; NEARSIGHTEDNESS. IT MEANS YOU CAN SEE NEAR, BUT NOT FAR.
•Hyperopia;FARSIGHTEDNESS. IT MEANS YOU CAN SE FAR, BUT NOT NEAR.
Sensory Alterations-Assessment-EYE
•Visual fields
•Confrontation is a gross measure of peripheral vision;;;cardianal 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.
•Abnormal finding suggests peripheral field loss
Sensory Alterations-Physical Assessment-EYE
• Extraocular Muscle Function
• Six muscles control eye movement
• Corneal 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; in Strabismus (crossed eyes)the eye muscles are not holding the eyes in the same position.
• 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.
Sensory Alterations-Assessment-Ear
•External ear
– Auricle ( big part)
– Outer ear canal
– Tympanic membrane (ear Drum)
•Middle Ear:
– Three bony ossiclesThere are three bony structures in the middle ear that transfer the vibrations to the inner ear. They are the malleus, incus and stapes.
– malleus
– incus
– Stapes
•Inner Ear:
– 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
– cochlea
– vestibule
– semicircular canals
Sensory Alterations-Physical Assessment-Ear
•Three Types of Hearing Loss:
– conduction, Conduction hearing loss interrupts sound waves as they travel from the outer ear to the inner ear, swelling, wax build-up (serumen)
– SensorineuralConduction hearing loss interrupts sound waves as they travel from the outer ear to the inner ear, swelling, wax build-up (serumen)loss is an interruption from between the inner ear, nerve or brain
– mixed
Tuning fork tests, Weber & Rinne tests, measure hearing by air conduction or bone conduction, determines if there is conduction or sensorineural hearing loss
Sensory Alterations-Physical Assessment-Ear
•Assess the vestibular apparatus
• Romberg test, assess balance
Ask 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 cerebellumand proprioception.
Sensory Alterations-Physical Assessment-Nose
•Nose
– Inspect
– Nasal patency & olfactory nerve function