Alterations in Sensory Stimulation Unit XI

1. Alterations in Sensory StimulationUnit XI Keith Rischer, RN Nursing 1120 Spring, 2011

2. 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 Summary of Unit

3. Obj. 1: Sensory Stimulation • A human need • Maslow’s Hierarchy • Senses are necessary for growth, development and survival • Any disruption of incoming stimuli can have an effect • The human body is adaptable over time

4. 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

5. Obj. 3: Types of Stimulation • External stimuli • Visual • Auditory • Olfactory • Tactile • Gustatory

6. Factors that affect stimulation needs • Growth and development • Culture • Stress

7. Factors that affect stimulation needs • Medications • Lifestyle • Environment

8. 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.”

9. 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

10. Obj. 5: Sensory Deprivation • Contributing factors • Non-stimulating environment • Inability to process environmental stimuli • Affective disorders • Brain damage • Medications

11. Obj. 5: Sensory Deprivation • Persons at risk Elderly Infants Immobilized Isolation

12. 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

13. Sensory Deprivation • Nursing actions: • Provide books, newspapers • Provide objects that are pleasant to touch • Encourage visitors • Adjust the environment • Use eyeglasses/hearing aids • Communicate frequently

14. Sensory Overload • Contributing factors Increased internal stimuli Increased external stimuli Inability to disregard stimuli Changes in daily living

15. Sensory Overload • Symptoms Fatigue Restlessness Anxiety sleeplessness Irritability Disorientation Reduced problem solving ability Hallucinations Illusions

16. Nursing Interventions Reduce environmental stimuli Dark glasses Decrease odors Provide rest intervals Decrease visitors Explain new sounds Relaxation Control pain Private room Reorient as necessary

17. 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

18. 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

19. Unconscious: Nursing Interventions • Often can hear, even if they can’t respond • Talk to the patient as if you are understood • Address the patient by name

20. 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

21. Obj. 14: Causes of CVA • 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

22. Stroke 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.

23. Stroke 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

24. Stroke Recognition Ischemic Stroke is more likely to present with: Hemiparesis/paralysis Facial Droop Altered speech Dysarthria – slurred speech usually associated with face or tongue weakness Aphasia – altered speech pattern Hemisensory loss Numbness most common Loss of coordination/difficulty walking Visual changes Loss of recognition/neglect

25. Stroke Recognition ~80% of ischemic strokes will have one or more of these symptoms

26. Stroke Recognition If stroke is suspected: Outside of the hospital CALL 911 For 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

27. Obj. 15: Types of Sensory Loss • Visual field deficits • Homonymous hemianopsia • Loss of peripheral vision • Diplopia

28. Types of Sensory Loss w/CVA • Motor/sensory deficits • Hemiparesis • Hemiplegia • Dysphagia

29. Types of Sensory Loss w/CVA • Verbal deficits • Aphasia • Expressive aphasia • Receptive aphasia • Global aphasia • Dysarthria

30. Types of Sensory Loss w/CVA Cognitive deficits Short and long term memory loss Decreased attention span Impaired ability to concentrate Altered judgement

31. 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

32. Obj. 7: Visual Problems • Clarity of vision-depends on: Intact eye structure Functioning vision center in the brain to transmit visual impulses

33. A&P Review • picture

34. Obj. 7: Eye Trauma • Common cause of unilateral visual loss • Foreign body • Penetrating injuries • Chemical burns • Corneal abrasions

35. Cataracts • Patho • Clouding of lens of eye • Cause • Primary cause of visual defects on elderly • Symptoms • Treatment

37. Treatment • Surgery-out patient • Medications • Lower IOP (mannitol/carbonic anhydrase) • To dilate eye (Mydriatic, cycloplegics) • Prevent infection (antibiotic drops) • Local anesthetic • Lens Replacement

38. Cataract Extraction • Nursing diagnosis • Sensory/perceptual alteration • Risk for Injury • Knowledge deficit/fear • Risk for poor home management

39. Nursing Interventions • Post op - teaching • Observe pt instilling medications • Avoid activities that Increase IOP • Dressings/patch/drainage • Pain/itching/redness

40. 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

41. Glaucoma: Classes • Two classes 1. Open angle glaucoma 2. Angle closure glaucoma • Diagnosis • tonometry, slit lamp, visual field exam

42. Glaucoma: Symptoms • PACG: • Sudden severe eye pain • N/V • Colored halos @ light • Blurred vision • Ocular redness • Brow pain • POAG: • Slow & asymptomatic • “tunnel vision” • No pain/pressure

43. 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

44. 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

45. 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

46. Glaucoma Medications • Beta Adrenergic Blockers • Timolol (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

47. Glaucoma Medications • Prostaglandins • Xalatan • Mech of action • Reduces IOP by increasing outflow of aqueous humor • Nursing responsibilities • Administer at bedtime to decrease SE of irritation/stinging of eyes

48. Glaucoma Medications • Alpha 2 Adrenergic Agonists • Brimonidine (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

49. Glaucoma Medications • Carbonic Anhydrase Inhibitors • Acetazolamide (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

50. Infections of Eye • Keratitis • inflammation or infection of the cornea • Bacterial • Viral • Fungi • Exposure • Treatment • anti-infective drops or systemic med, corneal transplant; if exposure-tape eye, lubrication