Mosby items and derived items © 2005 by Mosby, Inc. Chapter 48 Sensory Alterations

Preview:

Citation preview

Mosby items and derived items © 2005 by Mosby, Inc.

Chapter 48

Sensory Alterations

Mosby items and derived items © 2005 by Mosby, Inc.

Normal Sensation

• Reception– Perception– Reaction

Mosby items and derived items © 2005 by Mosby, Inc.

Sensory Alterations

• Sensory deficits

• Sensory deprivation

• Sensory overload

Mosby items and derived items © 2005 by Mosby, Inc.

Common Sensory Deficits

• Visual– Presbyopia– Cataract– Dry eyes– Open-angle glaucoma– Diabetic retinopathy– Macular degeneration

Mosby items and derived items © 2005 by Mosby, Inc.

Common Sensory Deficits (cont'd)

• Auditory– Presbycusis– Cerumen accumulation

• Balance– Dizziness and disequilibrium

• Taste– Xerostomia

Mosby items and derived items © 2005 by Mosby, Inc.

Common Sensory Deficits (cont'd)

• Neurological– Peripheral neuropathy– Stroke (CVA)

Mosby items and derived items © 2005 by Mosby, Inc.

Factors Affecting Sensory Function

• Age

• Persons at risk—older adults

• Meaningful stimuli

• Amount of stimuli

• Family factors

Mosby items and derived items © 2005 by Mosby, Inc.

Factors Influencing Sensory Function

• Social interaction

• Environmental factors

• Cultural factors

Mosby items and derived items © 2005 by Mosby, Inc.

Assessment

• Sensory alterations history

• Mental status

• Physical assessment

• Ability to perform self-care

• Health promotion habits

• Presence of hazards

Mosby items and derived items © 2005 by Mosby, Inc.

Assessment (cont'd)

• Communication methods

• Social support

• Use of assistive devices

• Other factors: pathology, medications

• Client expectations

Mosby items and derived items © 2005 by Mosby, Inc.

Nursing Diagnoses

• Impaired communication

• Risk for injury

• Situational low self-esteem

• Disturbed sensory perception

• Social isolation

Mosby items and derived items © 2005 by Mosby, Inc.

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

Mosby items and derived items © 2005 by Mosby, Inc.

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

Mosby items and derived items © 2005 by Mosby, Inc.

Vision

• Minimize glare

• Encourage use of eyeglasses, contact lenses, magnifiers

• Obtain large-print reading materials

• Use brighter colors (red, yellow, orange)

Mosby items and derived items © 2005 by Mosby, Inc.

Hearing

• Amplify telephones, televisions, and radios

• Reduce extraneous noise

• Check for impacted cerumen

• Encourage use of hearing aid

• Speak directly at the client

Mosby items and derived items © 2005 by Mosby, Inc.

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

Mosby items and derived items © 2005 by Mosby, Inc.

Touch

• Provide touch therapy

• Turn and reposition client

• Avoid excessive stimuli for hyperesthetic client

Mosby items and derived items © 2005 by Mosby, Inc.

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

Mosby items and derived items © 2005 by Mosby, Inc.

Hearing Alterations

• Providing a safe environment– Amplification of important environmental

sounds– Use of lights for alert– Special telephone communication

system (TTD or TTY)

Mosby items and derived items © 2005 by Mosby, Inc.

Olfaction Alterations

• Providing a safe environment– Use of smoke and carbon monoxide

detectors– Visually check gas stove– Check appearance and dates of foods

Mosby items and derived items © 2005 by Mosby, Inc.

Tactile Alterations

• Providing a safe environment– Reduce the temperature of the water

heater– Clearly mark faucets as “hot” and “cold”

Mosby items and derived items © 2005 by Mosby, Inc.

Promoting Communication

• Approaching clients

• Use of alternative methods (sign language)

• Client education

Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Acute Care

• Orientation to the environment

• Comfort measures—stimulation

• Communication

• Control sensory stimuli: noise, light, smells

• Safety measures

Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Restorative Care

• Maintaining a healthy lifestyle

• Understanding sensory loss

• Socialization

• Self-care

Mosby items and derived items © 2005 by Mosby, Inc.

Evaluation

• Client care

• Client expectations

Recommended