Perception And Coordination Revised

PERCEPTION AND

COORDINATION

Sensory Perception

• Sensory perception- involves the conscious organization and translation of the data or stimuli into meaningful information

• Sensory reception- process of receiving stimuli or data

• Kinesthetics- awareness of the position and movement of body parts

• Stereognosis- ability to perceive and understand an object through its size, shape and texture

• Visceral - any large organ within the body

Four aspects of sensory process• Stimulus – an agent or act that stimulates a nerve

receptor • Receptor- a nerve cell that concerts stimulus to a

nerve impulse • Impulse conduction- the impulse travels along nerve

pathways to the spinal cord or directly to the brain • Perception- perception, or awareness and

interpretation of stimuli happens in the brain where specialized brain cells interpret the nature and quality of the sensory stimuli. The LOC affects the perception of stimuli

PROMOTING NORMAL SENSORY PERCEPTION

• STRUCTURE and FUNCTION of SENSORY PERCEPTIONSensory Awareness

-Reticular activating system-responsible for bringing together information from the cerebellum and other parts of the brain with that obtained from the sense organs

Input by senses-Special senses-vision, hearing, smell and

taste-Somatic senses-touch, kinesthetics (or

proprioceptive) sensation, and visceral sensation


SENSORISTASIS state of optimum arousal-not too much not too little

ADAPTATION beyond the point of sensoristasis

AWARENESS ability to perceive environmental stimuli and body

reactions and to respond appropriately through thought and action.


• LIFESPAN CONSIDERATION– Newborn and Infant– Toddler and Preschooler– Child and adolescent– Adult and Older Adult

FACTORS AFFECTING SENSORY PERCEPTION

• Environment• Previous Experience• Lifestyle and Habits• Illness• Medications• Variations in Stimulation• Sensory deprivation

SENSORY ALTERATIONS

• SENSORY DEPRIVATION- decrease in or lack of meaningful stimuli

• SENSORY DEFICIT- impaired reception, perception, or both, of one or more of the senses.

• SENSORY OVERLOAD- occurs when a person unable to process or manage the amount or intensity of the sensory stimuli – Factors:

• Increased quality and quantity of internal stimuli• Increased quality and quantity of external stimuli • Inability to disregard stimuli selectively

ALTERED SENSORY PERCEPTION FUNCTION

• Manifestations of Altered Sensory Perception function– Anxiety– Cognitive Dysfunction– Hallucinations and delusions– Sensory deficits– Depression and withdrawal

NURSING PROCESS• ASSESSMENT– Normal pattern identification– Risk identification

• Sensory overload- – Lengthy verbal explanations before the procedure– Room close to the nurses station– Bright lights– Use of ECG monitor, mechanical ventilators, Oxygen ,IV tubes other

equipment– Frequent treatments

• Sensory deprivation• Private room, eyes bandaged, bedrest, sensory aid not available isolation

precautions, few visitors

ASSESSMENT • CHARACTERISTICS OF NORMAL SENSORY PERCEPTION

Normal vision-visual acuity at or near 20/20, full field of vision and tricolor vision (red, green and blue)

Normal hearing-auditory acuity of sounds at an intensity of 0 to 25 dB, at frequencies of 125 to 8000 cycles per second

Normal taste- ability to discriminate sour, salty, sweet and bitter

Normal smell-discrimination of primary odours such as musky, floral, pepperminty, pungent

Somatic senses-discrimination of touch, pressure, vibration, position, tickling, temperature and pain

State of AwarenessState Description

Full consciousness Alert; oriented to time, place, person; understands verbal and written words

Disoriented Not oriented to time, place, or person

Confused Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment

Somnolent Extreme drowsiness but will respond to stimuli

Semicomatose Can be aroused by extreme or repeated stimuli

Coma Will not respond to verbal stimuli

NURSING PROCESS

• PHYSICAL ASSESSMENT– Vision-use of snellen chart to measure visual acuity (or

have the client read newspaper, menu or whatever)

– Smell-with eyes closed, have client identify 3 odors, such as coffee, tobacco and cloves, one nostril at a time, while occluding the other nostril

• Hearing-whisper numbers in each ear, while occluding the other; ask the client to repeat; perform Weber and Rinne tuning fork test

– WEBER’S TEST- assesses bone conduction by testing the lateralization ( sideward transmission) of sounds.

– RINNE TEST- test compares air conduction to bone conduction

• Sound conducted by air is heard more readily than sound conducted by bone.

NURSING PROCESS

• PHYSICAL ASSESSMENT– Taste-with eyes closed, have client identify 3 tastes such

as lemon, salt, and sugar, waiting 1 minute and giving sips of water in between.

– Somatic sensations-Test light touch of extremities with a wisp of cotton; test sharp and dull sensation using the point and blunt end of a pin; test two-point discrimination using two pins held close together; test hot and cold sensation using test tube filled with warm and cold water; test position sense by moving the client’s fingers or toes

Diagnosing

• Disturbed sensory perception • Risk for injury • Impaired home maintenance • Risk for impaired skin integrity • Impaired verbal communication • Self care deficit • Social isolation

Planning

• The overall outcome criteria for clients with sensory-perception alterations are to: – Maintain the function of existing senses– Develop an effective communication mechanism – Prevent injury – Prevent sensory overload or deprivation – Reduce social isolation – Perform ADLs independently and safely

IMPLEMENTATION

• HEALTH PROMOTION– Client Teaching– Procedure preparation– Nurse-client Interaction

NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION

FUNCTION• Stimulation Provision• Stimulation Reduction• Sensory Aids

• SENSORY AIDS– VISION

• Eyeglasses with proper prescription, clean and in good repair• Adequate room lighting, drapes open• Sunglasses or window shades to reduce glare• Literature with large print• Uncluttered environment, no furniture arrangement• Clock with large numbers• Telephone dial with large numbers• Magnifying glass• Bright, contrasting colors in environment


FUNCTION

• SENSORY AIDS– Hearing• Hearing aid in good repair with working battery• Speaking slowly and distinctly in client’s full view, no

mouth covering or gum chewing• Avoidance of background noise• Amplified phone ringer, doorbell, smoke alarm • Headset for telephone communication• Closed-caption television


FUNCTION

• SENSORY AIDS– Smell• Fresh food served for meals• Fresh flower or fragrance in the room• Others wearing light perfume or fragrance• Notice of environmental smells


FUNCTION

• SENSORY AIDS– TASTE• Fresh food, seasoned, appropriately, not overcooked or

overprocessed to preserve texture• Foods served at appropriate temperature and time of a

day• Note smell and taste of food• Sips of water between foods• No mixing of foods


FUNCTION

• SENSORY AIDS– Touch• Therapeutic touch• Massage (self or Nurse)• Turning and repositioning• Hairbrushing and grooming (self or nurse)• Activity around the environment• Amount of pressure individualized to client’s comfort

level• Clothing of various texture


FUNCTION


FUNCTION• Promoting the use of other Senses• Communicating effectively – Conscious and unconscious client

• Ensuring client safety

Evaluation

Coordination Activity, Mobility and

Exercise

Definition:• Body Mechanism• Activity• Exercise

• Body mechanics – is the safe use of muscles of the body to accomplish mechanical task

Principles of Body Mechanism

»Bend knees to lift objects form the floor»Use a wide base of support by placing the

feet 12-18 inches apart when moving objects»Pulling is easier than pushing»Work is best accomplished at the center of

gravity.»Working at the waist level is most

efficient.

APPLIED PRINCIPLES OF BODY MECHANICS

• Hold objects close to the body when lifting• Use rhythmic, smooth, and coordinated

motions at a reasonable speed• Use elbows, hips and knees as levers when

lifting• Use mechanical devices when appropriate• Holding the breath during a physical activity is

an indication of muscle strain and inefficient use of body mechanics

APPLIED PRINCIPLES OF BODY MECHANICS

• Adjust the height of the work area when possible• Assume a starting position that will permit freedom of

movement in range, direction and position• Keep body balanced over the base of support with

knees relaxed and trunk erect (in relation to the pelvis)Bend hips and knees to alter position of body, widening

the base of support as needed, for effective leverage and use of energy

Face the direction of motion, using the muscles of the lower extremities and shifting body weight for lifting, pushing and pulling actions

PRINCIPLES OF BODY MECHANICS

– Reducing friction between the object moved and the surface on which it moved requires less energy

– Holding an object close to the body requires less energy than holding it farther away

– Muscle strain can be avoided by using the strong leg muscles when lifting, pushing and pulling

– Smooth continuous movements are easier and safer than sudden, sharp or uncontrolled movements

– Using rhythmic movements at normal speed requires less energy

• Diet – a balance diet is important in maintaining the bones or muscles for optimum activity should be contain adequate sources of calcium, phosphorus and vitamin D for bone growth and prevention of osteoporosis. The diet should contain adequate sources of the following;

• Calcium – for bone and teeth formation, blood clotting, muscle activity and nerve function.

• High Calcium – dried and fresh dilis, dried and fresh alamang, fried fish, shell fish, certain fresh fishes such as silinyasi, tunsoy, milk, cheese, ice cream, soy beans, monggo and other dried beans, leafy vegetables.

• Low Calcium – cereal and cereal products without milk, fruit and fruit juices, vegetables, lean meat. Poultry sugar starchy roots and tubers, young coconut.

Phosphorus – for bone and teeth formation, important in energy transfer, component of nucleic acid.– High Phosphorus – Meat, fish, poultry, egg yolk, milk,

cheese, beans and bean products, nuts and seeds, dried banana and flowers, cocoa, chocolate, undermilled rice, pinipig, whole grain cereal, cookies and sweet made with nuts.

• Low Phosphorus – Egg white, sugar, fats and oil, fruits, kaong, gabi stem, sayote, bihon, sotanghon, kusinta and nata de coco

EXERCISE

CLASSIFICATIONSource of Energy

-Aerobic Exercise-Anaerobic Exercise

Type of Muscle Tension-Isotonic Exercise-Isometric Exercise

Effects of Exercise on:• Cardiovascular System• Respiratory System• Endocrine System• Immune System• Muscular System• Metabolic Rate

FACTORS AFFECTING MOBILITY

• Lifestyle and habits• Intact musculoskeletal system• Nervous system control• Circulation and Oxygenation• Energy• Congenital problems• Therapeutic modalities

Manifestations of Altered Mobility

• Decreased muscle tone and strength• Lack of coordination• Altered gait• Falls• Decreased joint flexibility• Pain on movement• Activity intolerance

Impact of Immobility on Function

• Activity and Exercise-muscle atrophy and weakness-contractures and joint pains-increased cardiac workload-orthostatic hypotension-thrombus formation and embolism-decreased lung expansion


• Nutrition and Metabolism• Decreased metabolic rate• Negative nitrogen balance• Anorexia• Disuse osteoporosis• Impaired immunity• Pressure ulcers


ELIMINATION-Urinary stasis

-urinary tract infection-renal calculi-constipation


• SLEEP and REST• COGNITION and PERCEPTION• SELF-PERCEPTION and SELF-CONCEPT• ROLES and RELATIONSHIP• COPING and STRESS TOLERANCE• SEXUALITY

Nursing Assessment• Health History• Physical Exam

– Inspection and Palpation The muscles are inspected for bulk, palpated for tenderness, consistency and contractures.

– Tone Muscle tone is assessed by putting selected muscle groups through passive range of motion. The most commonly used maneuvers for the upper extremities are flexion and extension at the elbow and wrist. The most commonly used maneuvers for the lower extremities are flexion and extension at the knee and ankle.

PHYSICAL ASSESSMENT

• Muscle Strength Grading0 – No contraction1 – Slight contraction, no movement2 – Full range of motion without gravity3 – Full range of motion with gravity4 – Full range of motion , some resistance5 – Full range of motion, full resistance

PHYSICAL ASSESSMENT • Stretch or Deep Tendon Reflexes

A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's is listed below.

Grading DTR's0 – Absent1 – Decreased but present2 – Normal3 – Brisk and excessive4 – With clonus

Nursing AssessmentLaboratory findings

Nursing AssessmentLaboratory findings

IMPLEMENTATION

• Health Promotion– Physical Fitness Program– Osteoporosis Prevention– Injury Prevention

NURSING INTERVENTIONS for ALTERED MOBILITY

• POSITIONING– Think through the task before beginning– Ensure that all needed equipment is within reach– Explain to the client exactly what will happen before the

beginning of position change– Enlist the client’s assistance whenever possible, giving

instructions and encouragement as necessary– When the position change has been completed, ask if the

client is comfortable. Reposition as necessary– Tell the client how long he or she will remain in the position.

Provide a call device within reach. Document position changes and the client’s tolerance.


• JOINT MOBILITY MAINTENANCE– Types of ROM– General Principles of ROM Exercises• Guidelines for moving clients

– Assess the client’s abilities and limitations– Medicate client to provide optimal pain relief– Organize environment and request needed help to ensure

safety– Explain what you are going to do and how you expect your

client to help


• General Principles of ROM Exercises– Permit client to do as much as his or her capabilities

allow– Consider safety precautions– Follow the principles of body mechanics– Keep movements smooth and rhythmic– Prevent trauma (e.g. Friction against skin, pulling

joints)– Check client for proper body alignment and comfort,

and provide client with call bell before leaving


• AMBULATION– Dangling of the legs– Assisting the client with ambulation– Transfer belts– Mechanical aids– Muscle strengthening to facilitate ambulation


• ASSISTIVE DEVICE for WALKING– CANES• Types- single, tripod cane, quadripod cane• Patient must hold the cane in hand opposite affected

extremity. Advance cane as the affected leg is moved forward


• ASSISTIVE DEVICE for WALKING– WALKER• Hip level• Lift and walk• Positioned at the back when going up the stairs• Positioned in front when going down stairs


• ASSISTIVE DEVICE for WALKING– CRUTCHES• Assure proper length

» With patient standing: top of the crutch is 2 inches below the axilla and the tip of each crutch is 6 inches in front and to the side of the feet ( 2 inches forward, then 4 inches to the side)

» Patients elbows should be slightly flexed when hand is on bar (30 degrees)

» Weight must be borne by axillae, but on palms of the hand to prevent crutch palsy


• ASSISTIVE DEVICE for WALKING– CRUTCHES

• CRUTCH GAIT– Four point gait. Advance right crutch followed by the left foot, then left

crutch followed by right foot– Two point Gait- Advance right crutch and left foot together, then the

left crutch and the right foot together– Three point Gait- Advance both crutches and the affected leg together,

followed by the unaffected leg. None or little weight-bearing is allowed.

– Swing to gait-Advance both crutches, swing the body so that the feet will be at the level of crutches

– Swing through gait-Advance both crutches, swing the body so that the feet will be past the level of crutches


• ASSISTIVE DEVICE for WALKING– CRUTCHES• Going up and down the stairs

– Up with the good (good leg first, then the bad leg and crutches)

– Down with the bad ( bad leg and crutches first, then good leg)


• TRANSFERS– Two or three persons lift– Hydraulic lifts– Stand-up assists lifts

• Safety alert: The under-axilla lift techniques, where care providers pull the client by grasping the arms and under the axilla should never be employed. This technique exerts pressure on the brachial plexus that can affect the nerve function to the neck, shoulder, arms and hands. It can also subluxate the shoulder. Also this technique is the cause of poor body mechanics for the nurse and has been associated with L5-S1 back injuries.

Transport of Clients• Guidelines for Safe Lifting• 1. Consider the weight of the patient together with the weight of the

stretcher or other equipment being carried and determine if additional help is needed.

• 2. Know your physical ability and limitations. Know your combined ability with your partner. If absolutely necessary, you can ask bystanders to help. You or your partner must be in charge and give the orders, not the bystander.

• 3. Lift without twisting. Avoid any kind of swinging motion when lifting as well. • 4. Position your feet shoulder width apart with one foot slightly in front of the

other. Wear proper boots that go above the ankle to protect your feet and help keep a firm footing. Boots should have nonskid soles.

• 5. Communicate clearly and frequently with your partner. Decide ahead of time how you will move the patient and what verbal commands will be used. Also, tell the patient what you will be doing ahead of time. A startled patient may reach out or grab something and cause a loss of balance.

• Position the stretcher at a right angle to the patient's bed with the head end of the stretcher at the foot of the bed.

• Prepare the stretcher by unbuckling the straps, removing other items, and lowering the closest railing.

• Both EMTs stand between the stretcher and the bed, facing the patient. • The EMT at the head end of the stretcher slides one arm under the

patient's neck and shoulders, cupping the far shoulder with his or her hand and cradling the head.

• The second EMT slides one arm under the small of the patient's back, slides the arm under the buttocks and lifts slightly to allow the first EMT to slide an arm under the waist.

• The second EMT reaches under the patient's lower legs. • The patient is pulled to the edge of the bed, then lifted and curled toward

the EMT's chest. • The EMTs rotate to be in line with the stretcher, then place the patient

gently on to it.

Draw Sheet Method

Nursing Intervention to Promote Activity and Exercise

Technology

Perception And Coordination Revised