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Alterations in Sensory Stimulation Unit XI. Keith Rischer, RN. Sensory stimulation: P&P ch.49 CVA Sensory losses Eye: Lewis ch.22 Trauma Cataracts Glaucoma Infections Macular degeneration. Ear: Lewis ch.22 Hearing loss Otitis media Meniere’s disease Upper resp. (Lewis ch.27) Skin

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summary of unit
Sensory stimulation: P&P ch.49

CVA

Sensory losses

Eye: Lewis ch.22

Trauma

Cataracts

Glaucoma

Infections

Macular degeneration

Ear: Lewis ch.22

Hearing loss

Otitis media

Meniere’s disease

Upper resp. (Lewis ch.27)

Skin

Basal cell carcinoma

Malignant melanoma

Candiasis

Tinea

Herpes zoster

Cellulitis

Psoriasis

Summary of Unit
obj 1 sensory stimulation
Obj. 1: Sensory Stimulation
  • A human need
  • Maslow’s Hierarchy
  • Senses are necessary for growth, development and survival
  • Any disruption of incoming stimuli can have an effect
  • The human body is adaptable over time
obj 2 components of ss
Obj. 2: Components of SS
  • Reception
    • the receiving of stimuli or data
      • External
      • Internal
  • Perception
    • the conscious organization and translation of the stimuli into meaningful information
  • Reaction
    • we discard unnecessary stimuli and react to meaningful stimuli
obj 3 types of stimulation
Obj. 3: Types of Stimulation
  • External stimuli
    • Visual
    • Auditory
    • Olfactory
    • Tactile
    • Gustatory
factors that affect stimulation needs
Factors that affect stimulation needs
  • Growth and development
  • Culture
  • Stress
factors that affect stimulation needs1
Factors that affect stimulation needs
  • Medications
  • Lifestyle
  • Environment
nightingale on noise
Nightingale on Noise
  • “Unnescesary noise…is that which hurts the patient.”
    • “If he is roused out of his first sleep, he is certain to have no more sleep.”
  • “Unnescessary noise (although slight) injures a sick person much more than nescessary noise.”
  • “ A good nurse will always make sure that no door or window in her patient’s room shall rattle or creak.”
obj 4 sensory types
Obj. 4: Sensory Types
  • Sensory deprivation
    • Decrease in or lack of meaningful stimuli
  • Sensory overload
    • Inability to process or manage the amount or intensity of sensory stimuli
  • Sensory deficit
    • Impaired reception and/or perception
obj 5 sensory deprivation
Obj. 5: Sensory Deprivation
  • Contributing factors
    • Non-stimulating environment
    • Inability to process environmental stimuli
    • Affective disorders
    • Brain damage
    • Medications
obj 5 sensory deprivation1
Obj. 5: Sensory Deprivation
  • Persons at risk

Elderly

Infants

Immobilized

Isolation

obj 5 sensory deprivation2
Obj. 5: Sensory Deprivation
  • Symptoms
    • Yawning
    • Drowsiness
    • Sleeping
    • decreased attention span
    • difficulty concentrating
    • memory problems
    • Disorientation
    • hallucinations
    • emotional lability
          • Effects-see P&P, Box 49-2
sensory deprivation
Sensory Deprivation
  • Nursing actions:
    • Provide books, newspapers
    • Provide objects that are pleasant to touch
    • Encourage visitors
    • Adjust the environment
    • Use eyeglasses/hearing aids
    • Communicate frequently
sensory overload
Sensory Overload
  • Contributing factors

Increased internal stimuli

Increased external stimuli

Inability to disregard stimuli

Changes in daily living

sensory overload1
Sensory Overload
  • Symptoms

Fatigue

Restlessness

Anxiety

sleeplessness

Irritability

Disorientation

Reduced problem solving ability

Hallucinations

Illusions

nursing interventions
Nursing Interventions

Reduce environmental stimuli

Dark glasses

Decrease odors

Provide rest intervals

Decrease visitors

Explain new sounds

Relaxation

Control pain

Private room

Reorient as necessary

sensory deficit
Sensory Deficit
  • A deficit in the normal function of sensory reception and perception
  • Difficult for a person to function in an environment initially
  • P&P, Chapter 49, box 49-1-Common sensory deficits-visual, hearing, balance, taste, and neurological
disorientation nursing priorities
Disorientation: Nursing Priorities
  • Nursing Diagnostic Priorities
    • Risk for injury
    • Disturbed sensory perception
  • Nursing Interventions
    • Re-Orient frequently!
    • Wear a readable name tag
    • Address the person by name
    • Identify name and place
      • place a calendar and clock in the room
    • Provide clear and concise explanations
unconscious nursing interventions
Unconscious: Nursing Interventions
  • Often can hear, even if they can’t respond
  • Talk to the patient as if you are understood
  • Address the patient by name
obj 14 cerebrovascular accident cva
Obj. 14: Cerebrovascular Accident: CVA

Sudden loss of brain function resulting from disruption of the blood supply to a part of the brain

Risk factors

Age

Gender

Race

Heredity

HTN, heart disease, diabetes, increased cholesterol, smoking, (nearly doubles the risk) excessive alcohol, obesity, physical inactivity

obj 14 causes of cva
Obj. 14: Causes of CVA
  • Thrombosis
    • formation or development of a blood clot may be due to cerebral arteriosclerosis
  • Embolism
    • blood clot or plaque, travels to the cerebral arteries (less often air or fat)
    • Atrial Fibrillation
  • Hemorrhagic
    • bleeding in brain tissue or in spaces surrounding the brain
stroke recognition
Stroke Recognition

Any time a patient has sudden onset of neurologic changes, stroke should be suspected.

If a patient wakes up post-anesthesia with new neurologic symptoms, stroke should also be suspected.

stroke recognition1
Stroke Recognition

Hemorrhagic stroke is more likely to present with:

Altered level of consciousness

Decreased level of alertness

Disorientation

Difficulty following commands

Moderate to severe headache

Subarachnoid Hemorrhage

Worst headache of one’s life

“Thunderclap” headache

Intracerebral Hemorrhage

Less severe than in SAH, may develop over time as cerebral edema worsens

stroke recognition2
Stroke Recognition

Ischemic Stroke is more likely to present with:

Hemiparesis/paralysis

Facial Droop

Altered speech

Dysarthria – slurred speech usually associated with face or tongue weakness

Aphasia – altered speech pattern

Hemisensory loss

Numbness most common

Loss of coordination/difficulty walking

Visual changes

Loss of recognition/neglect

stroke recognition3
Stroke Recognition

~80% of ischemic strokes will have one or more of these symptoms

stroke recognition4
Stroke Recognition

If stroke is suspected:

Outside of the hospital CALL 911

For an inpatient, call the Rapid Response Team!

Determine when the patient was last known to be normal or at baseline

IV rtPA – must be started within 4.5 hours of last known well

IA Therapy – no absolute window but generally must be started within 8 hours of last known well

obj 15 types of sensory loss
Obj. 15: Types of Sensory Loss
  • Visual field deficits
    • Homonymous hemianopsia
    • Loss of peripheral vision
    • Diplopia
types of sensory loss w cva
Types of Sensory Loss w/CVA
  • Motor/sensory deficits
    • Hemiparesis
    • Hemiplegia
    • Dysphagia
types of sensory loss w cva1
Types of Sensory Loss w/CVA
  • Verbal deficits
    • Aphasia
    • Expressive aphasia
    • Receptive aphasia
    • Global aphasia
    • Dysarthria
types of sensory loss w cva2
Types of Sensory Loss w/CVA

Cognitive deficits

Short and long term memory loss

Decreased attention span

Impaired ability to concentrate

Altered judgement

types of sensory loss w cva3
Types of Sensory Loss w/CVA

Emotional deficits

Loss of self-control

Emotional lability

Decreased tolerance to stress

Depression, withdrawal, fear, hostility, anger, feelings of isolation

obj 7 visual problems
Obj. 7: Visual Problems
  • Clarity of vision-depends on:

Intact eye structure

Functioning vision center in the brain to transmit visual impulses

obj 7 eye trauma
Obj. 7: Eye Trauma
  • Common cause of unilateral visual loss
  • Foreign body
  • Penetrating injuries
  • Chemical burns
  • Corneal abrasions
cataracts
Cataracts
  • Patho
    • Clouding of lens of eye
    • Cause
  • Primary cause of visual defects on elderly
  • Symptoms
  • Treatment
treatment
Treatment
  • Surgery-out patient
  • Medications
      • Lower IOP (mannitol/carbonic anhydrase)
      • To dilate eye (Mydriatic, cycloplegics)
      • Prevent infection (antibiotic drops)
      • Local anesthetic
    • Lens Replacement
cataract extraction
Cataract Extraction
  • Nursing diagnosis
    • Sensory/perceptual alteration
    • Risk for Injury
    • Knowledge deficit/fear
    • Risk for poor home management
nursing interventions1
Nursing Interventions
  • Post op - teaching
    • Observe pt instilling medications
    • Avoid activities that Increase IOP
    • Dressings/patch/drainage
    • Pain/itching/redness
glaucoma
Glaucoma
  • Patho
    • Pressure increase –
      • Blood supply to retina and optic nerve decreases – ischemic neurons
      • Asymptomatic until vision affected
    • Remember:
      • normal IOP 10-21 mmHg
      • Fluid eliminated through Trabecular mesh work – out through canal of Schlemm
glaucoma classes
Glaucoma: Classes
  • Two classes

1. Open angle glaucoma

2. Angle closure glaucoma

  • Diagnosis
    • tonometry, slit lamp, visual field exam
glaucoma symptoms
Glaucoma: Symptoms
  • PACG:
    • Sudden severe eye pain
    • N/V
    • Colored halos @ light
    • Blurred vision
    • Ocular redness
    • Brow pain
  • POAG:
    • Slow & asymptomatic
    • “tunnel vision”
    • No pain/pressure
obj 8 glaucoma treatment
Obj. 8: Glaucoma: Treatment
  • Goal
    • Keep IOP low to prevent optic nerve damage
  • Medications
    • Beta-adrenergic blockers
    • Prostaglandins
    • Alpha-adrenergic agonists
    • Miotics
    • Carbonic anhydrase inhibitors
eye gtt administration p p p 725 728
Eye gtt Administration (P&P p.725-728)
  • Head back-look at ceiling
  • Place in conjunctival sac
  • Close eyes gently afterwards
  • 30-60 seconds pressure on lacrimal duct for drugs that can cause systemic effects
    • Timolol
  • Wait at least 5” between different eye gtts
glaucoma medications
Glaucoma Medications
  • Cholinergic Agonists (Miotics)
    • Pilocarpine
      • Mech of action
        • Pupillary constriction (miosis) constricting ciliary muscle
        • Reduces IOP with increase of outflow and decrease inflow of aqueous humor
        • Systemic effects
          • Respiratory
          • CV
      • Nursing responsibilities
        • Contraindications with asthma
        • Hold lacrimal sac 1-2”
        • Visual acuity/night vision may be affected
glaucoma medications1
Glaucoma Medications
  • Beta Adrenergic Blockers
    • Timolol (Timoptic)
      • Mech of action
        • Increased outflow and decreases formation of aqueous humor
        • Decrease in IOP
      • Nursing responsibilities
        • Maintain pressure on lacrimal sac for 1-2” after adm.
        • Assess for contraindications with asthma, COPD, HF
        • Assess HR-BP before administering
glaucoma medications2
Glaucoma Medications
  • Prostaglandins
    • Xalatan
      • Mech of action
        • Reduces IOP by increasing outflow of aqueous humor
      • Nursing responsibilities
        • Administer at bedtime to decrease SE of irritation/stinging of eyes
glaucoma medications3
Glaucoma Medications
  • Alpha 2 Adrenergic Agonists
    • Brimonidine (Alphagan)
      • Mech of action
        • Alpha adrenergic receptor agonist w/ocular hypotensive effect
        • Reduces aqueous humor production & increases outflow
      • Nursing responsibilities
        • Use cautiously with CV disease
glaucoma medications4
Glaucoma Medications
  • Carbonic Anhydrase Inhibitors
    • Acetazolamide (Diamox)
      • Mech of Action
        • Inhibits carbonic anhydrase reduces aqueous humor production and decreases IOP
      • Nursing responsibilities
        • Assess for sulfa allergy
        • Has systemic potential for renal effects of diuresis
infections of eye
Infections of Eye
  • Keratitis
    • inflammation or infection of the cornea
      • Bacterial
      • Viral
      • Fungi
      • Exposure
  • Treatment
    • anti-infective drops or systemic med, corneal transplant; if exposure-tape eye, lubrication
infections of eye1
Infections of Eye
  • Acute conjunctivitis
    • Inflammation or infection of conjunctiva
    • Can be very contagious
      • Causes: infectious agent (bacteria or virus), allergen, toxin, irritant
    • Signs and symptoms
      • Allergic
        • Burning, blood shot, tearing, itching
      • Bacterial
        • “pink” eye, conjunctival edema, scratchy gritty feeling, tears and discharge, photophobia
    • Management
      • Antibiotic ointment, drops
      • Pt wash hands frequently
      • Avoid sharing
conjunctivitis sulfacetamide
Conjunctivitis: Sulfacetamide
  • Mechanism of action
    • Active against both gram -/+
  • Nursing responsibilities
    • Assess for allergies to sulfa
conjunctivitis nursing care
Conjunctivitis: Nursing Care
  • Nursing actions:
    • Avoid spread of infection
      • Wash hands frequently
      • Avoid touching eyes
    • Aseptic technique when caring for the eye
    • Warm/cool compresses
    • Teaching – contact care
    • Eye drops properly administered
conjunctival hemorrhage
Conjunctival Hemorrhage
  • Causes:
    • Sneezing, coughing, vomiting
    • Increased B/P
    • Trauma
    • Blood clotting issues
    • Giving birth
  • Management:
    • None. (resolves in about 2 weeks)
macular degeneration
Macular Degeneration
  • Definition
  • Patho
  • Types
    • Dry (atrophic)
    • Wet (exudative)
  • Symptoms
    • Distortion
    • blurring or loss of central vision
treatment1
Treatment
  • Laser photocoagulation for destruction of abnormal blood vessels
    • prevents additional central vision loss
  • Photodynamic therapy
    • for wet macular degeneration
  • Drug treatments
obj 9 hearing
Obj. 9: Hearing

Sound waves enter the ear

Ear drum vibrates

Send impulse to auditory center of the brain

Lasix and tinnitus

obj 9 conductive hearing loss
Obj. 9: Conductive Hearing Loss
  • Mechanical
    • sounds don’t reach the inner ear
    • Involves all sound frequencies, often unilateral
  • Causes
  • Hearing aids
    • Most easily corrected medically/surgically
sensoneural hearing loss
Sensoneural Hearing Loss

Causes

Usually bilateral

not curable

Hearing aids not very helpful amplify all sounds

Treatment

Cochlear implant

obj 9 otitis media
Obj. 9: Otitis media

Infection of the middle ear

Usually a childhood disease

Risk factors

Young age, congenital abnormalities, immune deficiencies, exposure to cigarette smoke, family history, URI, male, allergies

obj 9 meniere s disease
Obj. 9: Meniere’s Disease
  • Definition
  • Cause
  • Symptoms
    • episodic, severe vertigo often with N&V, feeling of pressure or fullness in ear
  • Treatment
  • Nursing care
    • Darken room
nasal problems
Nasal problems
  • Acute rhinitis
    • inflammation of mucus membranes of nose-acute, allergic
  • Sinusitis
    • infection in the sinus cavity
  • Epistaxis
    • nosebleed
taste
Taste
  • Sense of taste has major impact on nutrition
    • Good po care
  • Factors that affect taste
    • Drug therapy
    • tobacco use
    • tooth and gum disease
    • Infections
touch
Touch
  • Allows us to distinguish objects and pressure
  • Allows us to perform ADLs
  • Most sensitive areas of touch are fingertips, thumb, lips, nose, cheeks
  • Decreased touch-serious psychological effects
touch1
Touch
  • Conditions that decrease sense of touch

CVA (strokes)

Diabetes (neuropathy)

MS and other neurologic disorders

Arthritis

Swollen hands or feet

function of skin
Function of Skin

Protection

Sensation

Water balance

Temperature regulation

Vitamin production

Sensory

obj 10 basal cell carcinoma
Obj. 10: Basal Cell Carcinoma

Most common type of skin cancer

Treatment-depends on type of cell and location of lesion

malignant melanoma
Malignant Melanoma
  • Tumor originates in the cells producing melanin
  • Melanoma may metastasize to any organ
    • Most deadly skin cancer
  • Cause?
  • Manifestations
    • Moles that are dark brown or black
  • ABCDE-asymmetry, border irregular, color varied shades, diameter >6 mm, evolving
malignant melanoma1
Malignant Melanoma

Treatment-excisional biopsy

Surgical excision

If spread-chemotherapy or radiation therapy

Melanoma is staged

skin candidiasis
Skin: Candidiasis
  • Candida albicans
    • yeast like fungal infection of skin, mouth, and vagina
  • Symptoms
    • vaginal discharge, itching, burning
    • reddened diffuse rash on skin, white patches in mouth
  • Treatment
    • symptom management
    • Nystatin S&S
skin tinea
Skin: Tinea
  • Fungal infections
  • Differ in appearance, location, and species of the infecting organism
  • Tinea pedis-feet (athlete’s foot)
  • Tinea corporis-body-smooth skin (ringworm)
  • Tinea capitis-head
  • Tinea cruris (jock itch)
  • Treatment
    • topical antifungal cream/solution
skin shingles
Skin: Shingles
  • Shingles-herpes zoster
  • Reactivation of the latent varicella zoster
  • Virus resides in dorsal root of the spinal nerves
  • Inflammatory viral condition
  • Symptoms
    • eruptions/vesicles preceded by pain along nerve path (dermatome)
  • Treatment
    • decrease stress, pain control, steroids, acyclovir and other anti-viral agents
skin cellulitis
Skin: Cellulitis

Inflammation

Cause

Manifestations

Treatment

skin psoriasis
Skin: Psoriasis
  • Chronic non-infectious, inflammatory disease of the skin; rapid epithelial cell reproduction
  • Symptoms
    • red, raised patches of skin covered with scales-common on scalp, elbows, knees
  • Treatment
    • topical therapy, ultraviolet light therapy, immunosuppressive medications
summary of unit1
Summary of Unit

Great challenge to nurses and families

Sensory deficit severity depends on rapidity of onset

Acute care patients must be carefully assessed for sensory loss

Assess on admission

Care plan

Apply nursing process to preserve/enhance sensory function

Sensory stimulation must be meaningful