Alterations in Sensory Stimulation Unit XI

Keith Rischer, RN

Summary of Unit Sensory stimulation:

P&P ch.49

CVA Sensory losses

Eye: Lewis ch.22 Trauma Cataracts Glaucoma Infections Macular degeneration

Ear: Lewis ch.22 Hearing loss Otitis media Meniere’s disease Upper resp. (Lewis ch.27)

Skin Basal cell carcinoma Malignant melanoma Candiasis Tinea Herpes zoster Cellulitis Psoriasis

Obj. 1: Sensory Stimulation

A human needMaslow’s HierarchySenses are necessary for growth,

development and survivalAny disruption of incoming stimuli can

have an effectThe 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 stimuliVisualAuditoryOlfactoryTactileGustatory

Growth and development

Culture

Stress

Factors that affect stimulation needs

Factors that affect stimulation needs

Medications

Lifestyle

Environment

Nightingale on Noise

“Unnescesary noise…is 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 patient’s room shall rattle or creak.”

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

Obj. 5: Sensory Deprivation

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


Persons at riskElderlyInfantsImmobilizedIsolation


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, newspapersProvide objects that are pleasant to touchEncourage visitorsAdjust the environmentUse eyeglasses/hearing aidsCommunicate frequently

Sensory Overload

Contributing factorsIncreased internal stimuliIncreased external stimuliInability to disregard stimuliChanges in daily living

Sensory Overload Symptoms

FatigueRestlessnessAnxietysleeplessnessIrritabilityDisorientationReduced problem solving abilityHallucinationsIllusions

Nursing Interventions

Reduce environmental stimuli

Dark glasses Decrease odors Provide rest intervals Decrease visitors

Explain new sounds

RelaxationControl painPrivate roomReorient 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 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

Unconscious: Nursing Interventions

Often can hear, even if they can’t respondTalk to the patient as if you are

understoodAddress 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

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

Obj. 14: Causes of CVA

Stroke RecognitionStroke 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 RecognitionStroke 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 RecognitionStroke Recognition Ischemic Stroke is more likely to present with:

Hemiparesis/paralysisFacial DroopAltered speech

Dysarthria – slurred speech usually associated with face or tongue weakness

Aphasia – altered speech patternHemisensory loss

Numbness most commonLoss of coordination/difficulty walkingVisual changesLoss of recognition/neglect

Stroke RecognitionStroke Recognition

~80% of ischemic strokes will have one or more of these symptoms

Stroke RecognitionStroke RecognitionIf stroke is suspected:

Outside of the hospital CALL 911For 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

Visual field deficitsHomonymous

hemianopsiaLoss of peripheral

visionDiplopia

Obj. 15: Types of Sensory Loss

Motor/sensory deficitsHemiparesisHemiplegiaDysphagia

Types of Sensory Loss w/CVA

Verbal deficitsAphasiaExpressive aphasiaReceptive aphasiaGlobal aphasiaDysarthria



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


Emotional deficits Loss 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 structureFunctioning vision center in the brain

to transmit visual impulses

Obj. 7: Eye Trauma

Common cause of unilateral visual lossForeign bodyPenetrating injuriesChemical burnsCorneal abrasions

Patho Clouding of lens of eye Cause

Primary cause of visual defects on elderly

Symptoms Treatment

Cataracts

Treatment

Surgery-out patientMedications

Lower IOP (mannitol/carbonic anhydrase) To dilate eye (Mydriatic, cycloplegics) Prevent infection (antibiotic drops) Local anesthetic

Lens Replacement

Cataract Extraction

Nursing diagnosisSensory/perceptual alterationRisk for InjuryKnowledge deficit/fearRisk for poor home management

Nursing Interventions

Post op - teachingObserve pt instilling medicationsAvoid activities that Increase IOPDressings/patch/drainagePain/itching/redness

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

Two classes1. Open angle

glaucoma

2. Angle closure glaucoma

Diagnosis tonometry, slit lamp,

visual field exam

Glaucoma: Classes

Glaucoma: Symptoms

POAG:Slow & asymptomatic“tunnel vision”No pain/pressure

PACGPACG::

Sudden severe eye Sudden severe eye painpain

N/VN/V

Colored halos @ lightColored halos @ light

Blurred visionBlurred vision

Ocular rednessOcular redness

Brow painBrow 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


Beta Adrenergic BlockersTimolol (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


ProstaglandinsXalatan

Mech of action Reduces IOP by increasing outflow of aqueous humor

Nursing responsibilities Administer at bedtime to decrease SE of irritation/stinging of

eyes


Alpha 2 Adrenergic AgonistsBrimonidine (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


Carbonic Anhydrase InhibitorsAcetazolamide (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

Keratitisinflammation or infection of the cornea

Bacterial Viral Fungi Exposure

Treatmentanti-infective drops or systemic med, corneal

transplant; if exposure-tape eye, lubrication

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

Infections of Eye

Conjunctivitis: Sulfacetamide

Mechanism of actionActive against both gram -/+

Nursing responsibilitiesAssess for allergies to sulfa

Conjunctivitis: Nursing Care

Nursing actions:Avoid spread of infection

Wash hands frequently Avoid touching eyes

Aseptic technique when caring for the eyeWarm/cool compressesTeaching – contact careEye drops properly administered

Causes: Sneezing, coughing, vomiting Increased B/P Trauma Blood clotting issues Giving birth

Management: None. (resolves in about 2

weeks)

Conjunctival Hemorrhage

DefinitionPathoTypes

Dry (atrophic)Wet (exudative)

SymptomsDistortionblurring or loss of

central vision

Macular Degeneration

Treatment

Laser photocoagulation for destruction of abnormal blood vessels prevents additional central vision loss

Photodynamic therapy for wet macular degeneration

Drug treatments

Obj. 9: Hearing

Sound waves enter the ear

Ear drum vibrates Send impulse to

auditory center of the brain

Lasix and tinnitus

Mechanical sounds don’t reach the

inner ear Involves all sound

frequencies, often unilateral

Causes Hearing aids

Most easily corrected medically/surgically

Obj. 9: Conductive Hearing Loss

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

Definition Cause Symptoms

episodic, severe vertigo often with N&V, feeling of pressure or fullness in ear

Treatment Nursing care

Darken room

Obj. 9: Meniere’s Disease

Acute rhinitis inflammation of

mucus membranes of nose-acute, allergic

Sinusitis infection in the sinus

cavity Epistaxis

nosebleed

Nasal problems

Sense of taste has major impact on nutrition Good po care

Factors that affect taste Drug therapy tobacco use tooth and gum disease Infections

Taste

Touch

Allows us to distinguish objects and pressure

Allows us to perform ADLsMost sensitive areas of touch are

fingertips, thumb, lips, nose, cheeksDecreased touch-serious psychological

effects

Touch

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

Protection Sensation Water balance Temperature

regulation Vitamin production Sensory

Function of Skin

Most common type of skin cancer

Treatment-depends on type of cell and location of lesion

Obj. 10: Basal Cell Carcinoma

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 spread-

chemotherapy or radiation therapy

Melanoma is staged

Malignant Melanoma

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: Candidiasis

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: Tinea

Shingles-herpes zosterReactivation of the latent

varicella zosterVirus resides in dorsal root of

the spinal nerves Inflammatory viral conditionSymptoms

eruptions/vesicles preceded by pain along nerve path (dermatome)

Treatment decrease stress, pain control,

steroids, acyclovir and other anti-viral agents

Skin: Shingles

Inflammation

Cause

Manifestations Treatment

Skin: Cellulitis

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

Skin: Psoriasis

Summary of Unit

Great challenge to nurses and familiesSensory deficit severity depends on

rapidity of onsetAcute care patients must be carefully

assessed for sensory lossAssess on admissionCare planApply nursing process to preserve/enhance

sensory functionSensory stimulation must be meaningful

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Alterations in Sensory Stimulation Unit XI