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Mosby items and derived items © 2005 by Mosby, Inc.
Chapter 48
Sensory Alterations
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Normal Sensation
• Reception– Perception– Reaction
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Sensory Alterations
• Sensory deficits
• Sensory deprivation
• Sensory overload
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Common Sensory Deficits
• Visual– Presbyopia– Cataract– Dry eyes– Open-angle glaucoma– Diabetic retinopathy– Macular degeneration
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Common Sensory Deficits (cont'd)
• Auditory– Presbycusis– Cerumen accumulation
• Balance– Dizziness and disequilibrium
• Taste– Xerostomia
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Common Sensory Deficits (cont'd)
• Neurological– Peripheral neuropathy– Stroke (CVA)
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Factors Affecting Sensory Function
• Age
• Persons at risk—older adults
• Meaningful stimuli
• Amount of stimuli
• Family factors
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Factors Influencing Sensory Function
• Social interaction
• Environmental factors
• Cultural factors
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Assessment
• Sensory alterations history
• Mental status
• Physical assessment
• Ability to perform self-care
• Health promotion habits
• Presence of hazards
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Assessment (cont'd)
• Communication methods
• Social support
• Use of assistive devices
• Other factors: pathology, medications
• Client expectations
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Nursing Diagnoses
• Impaired communication
• Risk for injury
• Situational low self-esteem
• Disturbed sensory perception
• Social isolation
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Planning
• Goals and outcomes– Client will demonstrate technique for
cleaning hearing aid within 1 week– Client will use appropriate
communication skills within 2 weeks
• Setting priorities
• Continuity of care
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Implementation: Health Promotion
• Screenings: prenatal, hearing, vision
• Preventive safety at home, school, recreational activities, and work
• Use of eyeglasses, contact lenses, and hearing aids
• Promoting meaningful stimulation
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Vision
• Minimize glare
• Encourage use of eyeglasses, contact lenses, magnifiers
• Obtain large-print reading materials
• Use brighter colors (red, yellow, orange)
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Hearing
• Amplify telephones, televisions, and radios
• Reduce extraneous noise
• Check for impacted cerumen
• Encourage use of hearing aid
• Speak directly at the client
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Taste and Smell
• Provide oral hygiene
• Prepare well-seasoned foods of different textures
• Avoid mixing or blending foods
• Provide aromas of coffee, bread, flowers
• Remove unpleasant odors
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Touch
• Provide touch therapy
• Turn and reposition client
• Avoid excessive stimuli for hyperesthetic client
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Visual Alterations
• Providing a safe environment– Adequate lighting– Promotion of safe driving principles– Removal of clutter and loose items– Use of color contrasts– Removal of or caution with flammable
items– Administration of eye medications
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Hearing Alterations
• Providing a safe environment– Amplification of important environmental
sounds– Use of lights for alert– Special telephone communication
system (TTD or TTY)
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Olfaction Alterations
• Providing a safe environment– Use of smoke and carbon monoxide
detectors– Visually check gas stove– Check appearance and dates of foods
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Tactile Alterations
• Providing a safe environment– Reduce the temperature of the water
heater– Clearly mark faucets as “hot” and “cold”
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Promoting Communication
• Approaching clients
• Use of alternative methods (sign language)
• Client education
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Implementation: Acute Care
• Orientation to the environment
• Comfort measures—stimulation
• Communication
• Control sensory stimuli: noise, light, smells
• Safety measures
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Implementation: Restorative Care
• Maintaining a healthy lifestyle
• Understanding sensory loss
• Socialization
• Self-care
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Evaluation
• Client care
• Client expectations
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