Alterations in Sensory Stimulation Unit XI

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Alterations in Sensory StimulationUnit XI

• Keith Rischer, RN

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Summary of Unit

• Sensory stimulation PP ch.49
• CVA
• Sensory losses
• Eye Lewis ch.22
• Trauma
• Cataracts
• Glaucoma
• Infections
• Macular degeneration

• Ear Lewis ch.22
• Hearing loss
• Otitis media
• Menieres disease
• Upper resp. (Lewis ch.27)
• Skin
• Basal cell carcinoma
• Malignant melanoma
• Candiasis
• Tinea
• Herpes zoster
• Cellulitis
• Psoriasis

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Obj. 1 Sensory Stimulation

• A human need
• Maslows 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

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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

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Obj. 3 Types of Stimulation

• External stimuli
• Visual
• Auditory
• Olfactory
• Tactile
• Gustatory

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Factors that affect stimulation needs

• Growth and development
• Culture
• Stress

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Factors that affect stimulation needs

• Medications
• Lifestyle
• Environment

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Nightingale on Noise

• Unnescesary noiseis 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 patients room shall rattle or
  creak.

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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

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Obj. 5 Sensory Deprivation

• Contributing factors
• Non-stimulating environment
• Inability to process environmental stimuli
• Affective disorders
• Brain damage
• Medications

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Obj. 5 Sensory Deprivation

• Persons at risk
• Elderly
• Infants
• Immobilized
• Isolation

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Obj. 5 Sensory Deprivation

• Symptoms
• Yawning
• Drowsiness
• Sleeping
• decreased attention span
• difficulty concentrating
• memory problems
• Disorientation
• hallucinations
• emotional lability
• Effects-see PP, Box 49-2

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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

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Sensory Overload

• Contributing factors
• Increased internal stimuli
• Increased external stimuli
• Inability to disregard stimuli
• Changes in daily living

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Sensory Overload

• Symptoms
• Fatigue
• Restlessness
• Anxiety
• sleeplessness
• Irritability
• Disorientation
• Reduced problem solving ability
• Hallucinations
• Illusions

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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

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Sensory Deficit

• A deficit in the normal function of sensory
  reception and perception
• Difficult for a person to function in an
  environment initially
• PP, Chapter 49, box 49-1-Common sensory
  deficits-visual, hearing, balance, taste, and
  neurological

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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

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Unconscious Nursing Interventions

• Often can hear, even if they cant respond
• Talk to the patient as if you are understood
• Address the patient by name

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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

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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

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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.

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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 ones life
• Thunderclap headache
• Intracerebral Hemorrhage
• Less severe than in SAH, may develop over time as
  cerebral edema worsens

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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

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Stroke Recognition
80 of ischemic strokes will have one or more of
these symptoms
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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

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Obj. 15 Types of Sensory Loss

• Visual field deficits
• Homonymous hemianopsia
• Loss of peripheral vision
• Diplopia

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Types of Sensory Loss w/CVA

• Motor/sensory deficits
• Hemiparesis
• Hemiplegia
• Dysphagia

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Types of Sensory Loss w/CVA

• Verbal deficits
• Aphasia
• Expressive aphasia
• Receptive aphasia
• Global aphasia
• Dysarthria

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Types of Sensory Loss w/CVA

• Cognitive deficits
• Short and long term memory loss
• Decreased attention span
• Impaired ability to concentrate
• Altered judgement

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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

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Obj. 7 Visual Problems

• Clarity of vision-depends on
• Intact eye structure
• Functioning vision center in the brain to
  transmit visual impulses

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Obj. 7 Eye Trauma

• Common cause of unilateral visual loss
• Foreign body
• Penetrating injuries
• Chemical burns
• Corneal abrasions

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Cataracts

• Patho
• Clouding of lens of eye
• Cause
• Primary cause of visual defects on elderly
• Symptoms
• Treatment

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Treatment

• Surgery-out patient
• Medications
• Lower IOP (mannitol/carbonic anhydrase)
• To dilate eye (Mydriatic, cycloplegics)
• Prevent infection (antibiotic drops)
• Local anesthetic
• Lens Replacement

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Cataract Extraction

• Nursing diagnosis
• Sensory/perceptual alteration
• Risk for Injury
• Knowledge deficit/fear
• Risk for poor home management

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Nursing Interventions

• Post op - teaching
• Observe pt instilling medications
• Avoid activities that Increase IOP
• Dressings/patch/drainage
• Pain/itching/redness

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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

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Glaucoma Classes

• Two classes
• 1. Open angle glaucoma
• 2. Angle closure glaucoma
• Diagnosis
• tonometry, slit lamp, visual field exam

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Glaucoma Symptoms

• PACG
• Sudden severe eye pain
• N/V
• Colored halos _at_ light
• Blurred vision
• Ocular redness
• Brow pain

• POAG
• Slow asymptomatic
• tunnel vision
• No pain/pressure

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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

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Eye gtt Administration (PP 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

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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

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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

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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

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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

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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

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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

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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

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Conjunctivitis Sulfacetamide

• Mechanism of action
• Active against both gram -/
• Nursing responsibilities
• Assess for allergies to sulfa

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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

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Conjunctival Hemorrhage

• Causes
• Sneezing, coughing, vomiting
• Increased B/P
• Trauma
• Blood clotting issues
• Giving birth
• Management
• None. (resolves in about 2 weeks)

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Macular Degeneration

• Definition
• Patho
• Types
• Dry (atrophic)
• Wet (exudative)
• Symptoms
• Distortion
• blurring or loss of central vision

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Treatment

• Laser photocoagulation for destruction of
  abnormal blood vessels
• prevents additional central vision loss
• Photodynamic therapy
• for wet macular degeneration
• Drug treatments

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Obj. 9 Hearing

• Sound waves enter the ear
• Ear drum vibrates
• Send impulse to auditory center of the brain
• Lasix and tinnitus

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Obj. 9 Conductive Hearing Loss

• Mechanical
• sounds dont reach the inner ear
• Involves all sound frequencies, often unilateral
• Causes
• Hearing aids
• Most easily corrected medically/surgically

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Sensoneural Hearing Loss

• Causes
• Usually bilateral
• not curable
• Hearing aids not very helpful amplify all sounds
• Treatment
• Cochlear implant

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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

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Obj. 9 Menieres Disease

• Definition
• Cause
• Symptoms
• episodic, severe vertigo often with NV, feeling
  of pressure or fullness in ear
• Treatment
• Nursing care
• Darken room

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Nasal problems

• Acute rhinitis
• inflammation of mucus membranes of nose-acute,
  allergic
• Sinusitis
• infection in the sinus cavity
• Epistaxis
• nosebleed

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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

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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

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Touch

• Conditions that decrease sense of touch
• CVA (strokes)
• Diabetes (neuropathy)
• MS and other neurologic disorders
• Arthritis
• Swollen hands or feet

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Function of Skin

• Protection
• Sensation
• Water balance
• Temperature regulation
• Vitamin production
• Sensory

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Obj. 10 Basal Cell Carcinoma

• Most common type of skin cancer
• Treatment-depends on type of cell and location of
  lesion

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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 gt6 mm, evolving

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Malignant Melanoma

• Treatment-excisional biopsy
• Surgical excision
• If spread-chemotherapy or radiation therapy
• Melanoma is staged

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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 SS

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Skin Tinea

• Fungal infections
• Differ in appearance, location, and species of
  the infecting organism
• Tinea pedis-feet (athletes foot)
• Tinea corporis-body-smooth skin (ringworm)
• Tinea capitis-head
• Tinea cruris (jock itch)
• Treatment
• topical antifungal cream/solution

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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

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Skin Cellulitis

• Inflammation
• Cause
• Manifestations
• Treatment

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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

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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