Nursing Fundamentals

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chapter 49 sensory alterations
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1

sensory deficit

A deficit in the normal function of sensory reception and perception

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Presbyopia

A gradual decline in the ability of the lens to accommodate or focus on close objects. Individual is unable to see near objects clearly.

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Glaucoma

A slowly progressive increase in intraocular pressure that, if left untreated, causes progressive pressure against the optic nerve, resulting in peripheral visual loss, decreased visual acuity with difficulty adapting to darkness, and a halo effect around lights

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Diabetic retinopathy

Pathological changes occur in the blood vessels of the retina, resulting in decreased vision or vision loss caused by hemorrhage and macular edema

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Macular degeneration

Condition in which the macula (specialized portion of the retina responsible for central vision) loses its ability to function efficiently. First signs include blurring of reading matter, distortion or loss of central vision, and distortion of vertical lines

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Presbycusis

A common progressive hearing disorder in older adults

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Cerumen accumulation

Buildup of earwax in the external auditory canal. Cerumen becomes hard and collects in the canal and causes conduction deafness.

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Dizziness and disequilibrium

Common condition in older adulthood, usually resulting from vestibular dysfunction. Frequently a change in position of the head precipitates an episode of vertigo or disequilibrium

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Xerostomia

Decrease in salivary production that leads to thicker mucus and a dry mouth. Often interferes with the ability to eat and leads to appetite and nutritional problems.

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Peripheral neuropathy

Disorder of the peripheral nervous system, characterized by symptoms that include numbness and tingling of the affected area and stumbling gait

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Stroke

Cerebrovascular accident caused by clot, hemorrhage, or emboli disrupting blood flow to the brain. Creates altered proprioception with marked incoordination and imbalance. Loss of sensation and motor function in extremities controlled by the affected area of the brain also occurs. A stroke affecting the left hemisphere of the brain results in symptoms on the right side such as difficulty with speech. A stroke on the right hemisphere has symptoms on the left side, which includes visual spatial alterations such as loss of half of a visual field or inattention and neglect, especially to the left side

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cognitive deficit effects

• Reduced capacity to learn
• Inability to think or problem solve
• Poor task performance
• Disorientation
• Bizarre thinking
• Increased need for socialization, altered mechanisms of attention

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Affective deficit effects

• Boredom
• Restlessness
• Increased anxiety
• Emotional lability
• Panic
• Increased need for physical stimulation

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Perceptual deficit effects

• Changes in visual/motor coordination
• Reduced color perception
• Less tactile accuracy
• Changes in ability to perceive size and shape
• Changes in spatial and time judgment

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three types of sensory deprivation

three types of sensory deprivation are reduced sensory input (sensory deficit from visual or hearing loss), the elimination of patterns or meaning from input (e.g., exposure to strange environments), and restrictive environments (e.g., bed rest) that produce monotony and boredom

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sensory overload

When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation prevents the brain from responding appropriately to or ignoring certain stimuli. Because of the multitude of stimuli leading to overload, a person no longer perceives the environment in a way that makes sense. Overload prevents meaningful response by the brain; the patient's thoughts race, attention scatters in many directions, and anxiety and restlessness occur. As a result, overload causes a state similar to that produced by sensory deprivation

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Factors that influence sensory function

Age,meaningful stimuli, amount of stimuli,social interaction,environmental factors,cultural factors

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Critical thinking model for sensory alterations

card image
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Assesment

When conducting an assessment, value the patient as a full partner in planning, implementing, and evaluating care. Patients are often hesitant to admit sensory losses. Therefore start gathering information by establishing a therapeutic rapport with the patient. Elicit his or her values, preferences, and expectations with regard to his or her sensory impairment. Many patients have a definite plan as to how they want their care delivered. Some patients expect caregivers to recognize and appropriately manage and adjust their environment to meet their sensory needs. This includes helping the patient learn and adapt to a changed lifestyle based on the specific sensory impairment. Determine from the patient which interventions have been helpful in the past in the management of limitations. Assess the patient's expertise with his or her own health and symptoms. Always remember that patients with sensory alterations have strengthened their other senses and expect caregivers to anticipate their needs (e.g., for safety and security).

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Onset and Duration

• When did you notice the problem? How long has this problem lasted?
• Does it come and go, or is it constant?

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Nursing Assessment Questions

• What type of problem are you having with your vision/hearing?
• What have you tried to correct the vision/hearing difficulty?
• Do you use any devices to improve your vision/hearing

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Signs and Symptoms

• Ask a patient with visual alterations: Do you require books with large print or on audiotape? Are you able to prepare a meal or write a check?
• Ask a patient with hearing alterations: What types of sounds or tones do you have difficulty hearing? Do people tell you that they have to “shout” for you to hear them? Do you have a ringing, crackling, or buzzing in your ears?
• Is there pain: sharp, dull, burning, itching?
• Have you noticed any redness, swelling, or drainage? Any signs of infection?

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Predisposing Factors

• Do you work or participate in any activities that have the potential for vision/hearing injury? If so, how do you protect your hearing and vision?
• Do you have a family history of cataracts, glaucoma, macular degeneration, or hearing loss?
• When was your last vision/hearing examination?

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Effect on Patient

• What effect has your vision/hearing problem had on your work, family, or social life?
• Have changes in your vision/hearing affected your feelings of independence?
• How does your vision/hearing problem make you feel about yourself?
• Do you have problems with routine care of glasses, contact lenses, or hearing aids?

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examples of nursing diagnosis due too sensory alterations

•Risk-prone health behavior
•Impaired verbal communication
•Risk for injury
•Impaired physical mobility
•Bathing self-care deficit
•Dressing self-care deficit
•Toileting self-care deficit
•Situational low self-esteem
•Risk for falls
•Social isolation

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examples of goals and outcomes

•The patient and family will report using communication techniques to send and receive messages within 2 days.
•The patient will successfully demonstrate correct technique for cleaning a hearing aid within 1 week.
•The patient will self-report improved hearing acuity.