Download Alterations in Sensory Stimulation Unit XIV

Keith Rischer, RN
Summary of Unit


Sensory stimulation:
P&P ch.49

 Hearing
loss
 Otitis media
 Meniere’s disease
 Upper resp. (Lewis ch.27)
CVA
 Sensory
losses


Eye: Lewis ch.22
 Trauma
 Cataracts
 Glaucoma
 Infections
 Macular
Ear: Lewis ch.22
degeneration
Skin
 Basal
cell carcinoma
 Malignant melanoma
 Candiasis
 Tinea
 Herpes zoster
 Cellulitis
 Psoriasis
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
 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
 External
stimuli
 Visual
 Auditory
 Olfactory
 Tactile
 Gustatory
Factors that affect stimulation needs
 Growth
 Culture
 Stress
and development
Factors that affect stimulation needs
 Medications
 Lifestyle
 Environment
Nightingale on Noise
 “Unnescesary
the patient.”
noise…is that which hurts
 “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
 Sensory
deprivation
 Decrease
 Sensory
in or lack of meaningful stimuli
overload
 Inability
to process or manage the amount or
intensity of sensory stimuli
 Sensory
deficit
 Impaired
reception and/or perception
Obj. 5: Sensory Deprivation
 Contributing
factors
 Non-stimulating
environment
 Inability to process environmental stimuli
 Affective disorders
 Brain damage
 Medications
Obj. 5: Sensory Deprivation
 Persons
at risk
Elderly
Infants
Immobilized
Isolation
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
 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
 Contributing
factors
Increased internal stimuli
Increased external stimuli
Inability to disregard stimuli
Changes in daily living
Sensory Overload
 Symptoms
Fatigue
Restlessness
Anxiety
sleeplessness
Irritability
Disorientation
Reduced problem solving ability
Hallucinations
Illusions
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
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
 Nursing


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


Diagnostic Priorities
place a calendar and clock in the room
Provide clear and concise explanations
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
 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
 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
 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 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 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 Recognition
~80% of ischemic strokes will have one or more of these symptoms
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
 Visual
field deficits
 Homonymous
hemianopsia
 Loss of peripheral
vision
 Diplopia
Types of Sensory Loss w/CVA
 Motor/sensory
deficits
 Hemiparesis
 Hemiplegia
 Dysphagia
Types of Sensory Loss w/CVA
 Verbal
deficits
 Aphasia
 Expressive
aphasia
 Receptive aphasia
 Global aphasia
 Dysarthria
Types of Sensory Loss w/CVA
 Cognitive
 Short
deficits
and long term memory loss
 Decreased attention span
 Impaired ability to concentrate
 Altered judgement
Types of Sensory Loss w/CVA
 Emotional
 Loss
deficits
of self-control
 Emotional lability
 Decreased tolerance to stress
 Depression, withdrawal, fear, hostility, anger,
feelings of isolation
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
 Common
cause of unilateral visual loss
 Foreign body
 Penetrating injuries
 Chemical burns
 Corneal abrasions
Cataracts

Patho
Clouding of lens of eye
 Cause

Primary cause of visual
defects on elderly
 Symptoms
 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
Nursing
diagnosis
Sensory/perceptual
Risk
alteration
for Injury
Knowledge deficit/fear
Risk for poor home management
Nursing Interventions
 Post
op - teaching
 Observe
pt instilling medications
 Avoid activities that Increase IOP
 Dressings/patch/drainage
 Pain/itching/redness
Glaucoma
 Patho
increase –
Blood supply to retina and optic nerve decreases –
ischemic neurons
Asymptomatic until vision affected
 Pressure


 Remember:


normal IOP 10-21 mmHg
Fluid eliminated through Trabecular mesh work –
out through canal of Schlemm
Glaucoma: Classes
 Two
classes
1. Open angle
glaucoma
2. Angle closure
glaucoma
 Diagnosis

tonometry, slit lamp,
visual field exam
Glaucoma: Symptoms
PACG:
 POAG:
 Slow
& asymptomatic
“tunnel
vision”
No pain/pressure
Sudden
pain
severe eye
N/V
Colored
Blurred
Ocular
Brow
halos @ light
vision
redness
pain
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)
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
 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 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 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 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 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
 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 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
 Mechanism
 Active
of action
against both gram -/+
 Nursing
 Assess
responsibilities
for allergies to sulfa
Conjunctivitis: Nursing Care
 Nursing
 Avoid


actions:
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
 Causes:





Sneezing, coughing, vomiting
Increased B/P
Trauma
Blood clotting issues
Giving birth
 Management:

None. (resolves in about 2
weeks)
Macular Degeneration



Definition
Patho
Types
 Dry
(atrophic)
 Wet (exudative)

Symptoms


Distortion
blurring or loss of
central vision
Treatment
 Laser
photocoagulation for destruction of
abnormal blood vessels
 prevents
additional central vision loss
 Photodynamic
 for
 Drug
therapy
wet macular degeneration
treatments
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

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
 Causes
 Usually

bilateral
not curable
 Hearing
aids not very
helpful amplify all
sounds
 Treatment

Cochlear implant
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
 Definition
 Cause
 Symptoms

episodic, severe vertigo
often with N&V, feeling
of pressure or fullness
in ear
 Treatment
 Nursing

care
Darken room
Nasal problems
 Acute

rhinitis
inflammation of
mucus membranes
of nose-acute,
allergic
 Sinusitis

infection in the sinus
cavity
 Epistaxis

nosebleed
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
 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
Touch
 Conditions
that decrease sense of touch
CVA (strokes)
Diabetes (neuropathy)
MS and other neurologic disorders
Arthritis
Swollen hands or feet
Function of Skin
 Protection
 Sensation
 Water
balance
 Temperature
regulation
 Vitamin production
 Sensory
Obj. 10: Basal Cell Carcinoma
 Most
common type
of skin cancer
 Treatment-depends
on type of cell and
location of lesion
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 Melanoma
 Treatment-excisional
biopsy
 Surgical excision
 If spreadchemotherapy or
radiation therapy
 Melanoma is staged
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
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
 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 antiviral agents
Skin: Cellulitis
 Inflammation
 Cause
 Manifestations
 Treatment
Skin: Psoriasis
Chronic non-infectious,
inflammatory disease of
the skin; rapid epithelial
cell reproduction
 Symptoms



red, raised patches of skin
covered with scalescommon on scalp,
elbows, knees
Treatment

topical therapy, ultraviolet
light therapy,
immunosuppressive
medications
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