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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