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
Obj. 5: Sensory Deprivation
Persons at riskElderlyInfantsImmobilizedIsolation
Obj. 5: Sensory Deprivation
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
Types of Sensory Loss w/CVA
Types of Sensory Loss w/CVA
Cognitive deficits Short and long term memory loss Decreased attention span Impaired ability to concentrate Altered judgement
Types of Sensory Loss w/CVA
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
Glaucoma Medications
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
Glaucoma Medications
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
Glaucoma Medications
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
Glaucoma Medications
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