Chapter 49: Sensory Alterations

Source of Stimulation

-stimulation comes from many sources in and outside of the body particularly though senses of sight (visual), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory)
-kinesthetic sense: enables a person to be aware of the position an

Scientific Knowledge Base

sensory reception involves the stimulation of sensory nerve fibers and the transmission of impulses to higher centers within the brain

Normal Sensation

reception
: stimulation of a receptor such as light, touch, or sound
perception
: integration and interpretation of stimuli based on the person's experience
reaction
: only the most important stimuli will elicit a reaction

Sensory Alterations
(Sensory Deficits)

-deficit in the normal function of sensory reception and perception
-individuals will withdraw by avoiding communication or socialization to cope with sensory loss
-patients with sensory deficit often change behavior in adaptive or maladaptive ways

Sensory Alterations
(Sensory Deprivation)

-inadequate quality or quantity of stimulation
-3 types: reduced sensory input (sensory deficit from visual or hearing loss), the elimination of patterns or meaning from input (exposure to strange environments), and restrictive environments that produce m

Sensory Alterations
(Sensory Overload)

-reception of multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli
-excessive sensory stimulation prevents the brain from responding appropriately to or ignoring certain stimuli
-a patients thoughts race, attention

Factors Affecting Sensory Function

Age: various changes across the life span
Meaningful stimuli: reduce the incidence of sensory deprivation (
include pets, music, television, pictures, and a calendar and clock
these should be present in home and health care settings to offer positive stim

Critical Thinking + Nursing Process

-integrate pathophysiological knowledge about sensory deficits and factors affecting function
-apply evidence-based standards of care (American Academy of Ophthalmology & American Speech-Language-Hearing Association)
-include previous experiences

Assessment

Persons at risk, sensory alteration history, mental status, physical assessment, ability to perform self-care, health promotion habits, environmental hazards, communication methods, social support, use of assistive devices, other factors affecting percept

Communication Methods

-patients with
aphasia
have varied degrees of inability to speak, interpret, or understand language
-
expressive aphasia
, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing
-sensory or
receptive a

Nursing Diagnosis

risk-prone health behavior, impaired verbal communication, risk for injury, impaired physical mobility, risk for falls, social isolation, bathing self-care deficit, dressing self-care deficit, toiling self-care deficit, situational low self-esteem

Planning

include family members, use standards a guides, partner with patient to set realistic goals and achievable outcomes that can be measurable, make safety a top priority, value other professional's contributions, and consider community based resources

Implementation

-patients can learn to adjust to sensory impairments at any age with the proper support and resources
-health promotion: screening, preventive safety (trauma/vaccines), use of contact lenses, eyeglasses, hearing aids, promotion of meaningful stimuli, crea

Acute Care

-orientation to the environment: address the patient by name, place call light within reach, use nightlight, reduce clutter
-communication
-control of stimuli: reduce sensory overload, combine nursing activities, and control extraneous noise
-safety measu

Restorative and Continuing Care

-maintaining healthy lifestyle
-understanding sensory loss
-socialization
-promoting self-care (increases self-esteem and enhances safety awareness)

Evaluation

the patient is the only person who can tell you if sensory ability has improved as a result of nursing interventions

Visual
Sensory Changes Occurring with Aging

-visual changes including presbyopia and need for glasses to read occurs around ages 40-50
-the cornea which assists light refraction to retina becomes flat and thick leading to astigmatism
-pigment lost from iris and collagen fibers build up in anterior

Other Common Sensory Changes Occurring with Age

-hearing changes begin at the age of 30
-gustatory and olfactory changes begin around 50
-proprioceptive changes common after 60 include increased difficulty with balance, spatial orientation, and coordination

Safety Hazards for Patients with Sensory Alterations

-uneven, cracked walkways leading to front/back door
-extension and phone cords in the main route of walking traffic
-loose area rugs runners placed over carpeting
bathrooms without shower or tub grab bars
-water faucets unmarked to designate hot and cold