Download Sensory

+
Sensory
Human beings have the ability to sense different stimuli within their environment,
perceive and organize those stimuli, and respond. Stimulation comes from many
sources in and outside the body; the senses of sight, hearing, touch, smell, taste; the
body’s kinesthetic sense of position and movement of body parts; and the ability to
speak. When a client’s sensory function is altered, either before or after entering
the health care setting, the ability to relate to and function within the environment
changes drastically.
The general types of sensory alterations are deficits, deprivation and overload.
1. Deficits— Makes other senses more acute to compensate.
2. Sensory deprivation—the result of inadequate quantity or quality of
stimulation. (Example-elderly patient with no bright colors or visitors—
may become disoriented).
3. Sensory overload—Individualistic
When cannot perceptually disregard or ignore multiple stimuli.
Several factors influence sensory function:
1. Sensory function develops through infancy; in middle and old age the senses
decline at different times.
2. Certain medications may have temporary or permanent effects on different
senses.
3. Environmental conditions, particularly a lack or an excess of stimulation
may lead to sensory alterations.
4. Some illnesses. Anxiety, cognitive dysfunction, hallucination and delusions,
depression.
5. Smoking may impair gustation.
6. High noise levels may impair hearing.
7.
Interventions such as endotracheal intubation prevent speech, often causing
frustration and anxiety.
Clients with preexisting sensory alterations and clients at risk for developing
sensory problems must be assessed for possible effects on life style and relation to
the environment.
1. Physical assessment includes tests of each sensory function, neuro
assessment, and observation for behaviors showing sensory alterations.
2. If hearing impaired-face the patient squarely and speak slowly.
3. the nurse assesses the ability of clients with sensory alterations to perform
activity of daily living (self care).
4. The quality and quantity of stimuli and, for clients with deficits, the safety of
the environment must be assessed.
5. the nurse assesses the amount of support possible from family members and
significant others.
6. The nurse assesses a client’s alternative ways of communicating if sensory
impairments affect communication.
The client with aphasia is either unable to produce language or unable to
understand it.
Expressive aphasia- inability to name common objects or express simple ideas in
words.
Receptive aphasia-inability to understand written or spoken language.
Nurse should speak slowly in short, simple sentences and ask the client to respond
with a nod of blink of eye.
Nursing diagnoses of sensory-perceptual alterations include both contributing
factors and related problems such as risk of injury, self care deficits, and
communication alterations.
Nursing interventions focus on helping the client adapt to existing sensory
alterations and on preventing conditions that may create sensory disturbances.
1. Use specific techniques for each sense to promote the function of existing senses.
An example would be: offering large print.
2. To control environmental stimuli, nursing interventions are designed to provide
meaningful stimuli while planning activities to prevent or reduce sensory overload.
(Maybe better organization of delivery of care.)
3. The nurse employs safety precautions to minimize risks related to altered sense
for client with sensory deficits. (Example: when ability to sense temperature is
reduced, the nurse should use extra caution in applying heat or cold therapies and
frequently check on the condition of the skin).
4. Preventive interventions may be designed for clients at risk for sensory loss because of
occupation or life style factors. Use special techniques to communicate with hearing
impaired, aphasic, and intubated clients. A deficit can cause a person to feel isolated
because of inability to communicate with others.
5. To promote self care activities, the nurse assists or teaches techniques for eating,
dressing, grooming, and toilet activities. Always encourage them to do whatever
they can for themselves.
Older adults are particularly prone to sensory deprivation.
Watching TV not as good as playing cards.
Homework is good cognitive stimulation.
Other management of existing sensory disturbances in:
1. Acute sensory deprivation-Increase interaction with staff. Use TV. Provide
touch. Help clients choose menus that are varied in aroma, texture, taste,
colors, temperature.
`
2.
Sensory overload.—Restrict number and length of visitation. Reduce noise
and lights. Have a routine . Organize care to provide for extended rest
periods with minimal stimulation.
3. Sensory deficits—report observations about hearing, vision, etc.
May imply need for new glasses, medical diagnoses, or therapy.