Chapter 48

Sensory Alterations

Mosby items and derived items © 2005 by Mosby, Inc.

 Normal Sensation

• Reception
– Perception
– Reaction

Mosby items and derived items © 2005 by Mosby, Inc.

 Sensory Alterations

• Sensory deficits
• Sensory deprivation
• Sensory overload

Mosby items and derived items © 2005 by Mosby, Inc.

 Common Sensory Deficits

• Visual
– Presbyopia
– Cataract
– Dry eyes
– Open-angle glaucoma
– Diabetic retinopathy
– Macular degeneration

Mosby items and derived items © 2005 by Mosby, Inc.

 Common Sensory Deficits
(cont'd)
• Auditory
– Presbycusis
– Cerumen accumulation
• Balance
– Dizziness and disequilibrium
• Taste
– Xerostomia

Mosby items and derived items © 2005 by Mosby, Inc.

 Common Sensory Deficits
(cont'd)
• Neurological
– Peripheral neuropathy
– Stroke (CVA)

Mosby items and derived items © 2005 by Mosby, Inc.

 Factors Affecting Sensory
Function
• Age
• Persons at risk—older adults
• Meaningful stimuli
• Amount of stimuli
• Family factors

Mosby items and derived items © 2005 by Mosby, Inc.

 Factors Influencing Sensory
Function

• Social interaction
• Environmental factors
• Cultural factors

Mosby items and derived items © 2005 by Mosby, Inc.

 Assessment

• Sensory alterations history

• Mental status
• Physical assessment
• Ability to perform self-care
• Health promotion habits
• Presence of hazards

Mosby items and derived items © 2005 by Mosby, Inc.

 Assessment (cont'd)

• Communication methods
• Social support
• Use of assistive devices
• Other factors: pathology, medications
• Client expectations

Mosby items and derived items © 2005 by Mosby, Inc.

 Nursing Diagnoses

• Impaired communication
• Risk for injury
• Situational low self-esteem
• Disturbed sensory perception
• Social isolation

Mosby items and derived items © 2005 by Mosby, Inc.

 Planning
• Goals and outcomes
– Client will demonstrate technique for
cleaning hearing aid within 1 week
– Client will use appropriate
communication skills within 2 weeks
• Setting priorities
• Continuity of care

Mosby items and derived items © 2005 by Mosby, Inc.

 Implementation:
Health Promotion

• Screenings: prenatal, hearing, vision

• Preventive safety at home, school,
recreational activities, and work
• Use of eyeglasses, contact lenses,
and hearing aids
• Promoting meaningful stimulation

Mosby items and derived items © 2005 by Mosby, Inc.

 Vision

• Minimize glare
• Encourage use of eyeglasses,
contact lenses, magnifiers
• Obtain large-print reading materials
• Use brighter colors (red, yellow,
orange)

Mosby items and derived items © 2005 by Mosby, Inc.

 Hearing

• Amplify telephones, televisions, and

radios
• Reduce extraneous noise
• Check for impacted cerumen
• Encourage use of hearing aid
• Speak directly at the client

Mosby items and derived items © 2005 by Mosby, Inc.

 Taste and Smell
• Provide oral hygiene
• Prepare well-seasoned foods of
different textures
• Avoid mixing or blending foods
• Provide aromas of coffee, bread,
flowers
• Remove unpleasant odors

Mosby items and derived items © 2005 by Mosby, Inc.

 Touch

• Provide touch therapy

• Turn and reposition client
• Avoid excessive stimuli for
hyperesthetic client

Mosby items and derived items © 2005 by Mosby, Inc.

 Visual Alterations
• Providing a safe environment
– Adequate lighting
– Promotion of safe driving principles
– Removal of clutter and loose items
– Use of color contrasts
– Removal of or caution with flammable
items
– Administration of eye medications

Mosby items and derived items © 2005 by Mosby, Inc.

 Hearing Alterations

• Providing a safe environment

– Amplification of important environmental
sounds
– Use of lights for alert
– Special telephone communication
system (TTD or TTY)

Mosby items and derived items © 2005 by Mosby, Inc.

 Olfaction Alterations

• Providing a safe environment

– Use of smoke and carbon monoxide
detectors
– Visually check gas stove
– Check appearance and dates of foods

Mosby items and derived items © 2005 by Mosby, Inc.

 Tactile Alterations

• Providing a safe environment

– Reduce the temperature of the water
heater
– Clearly mark faucets as “hot” and “cold”

Mosby items and derived items © 2005 by Mosby, Inc.

 Promoting Communication

• Approaching clients
• Use of alternative methods (sign
language)
• Client education

Mosby items and derived items © 2005 by Mosby, Inc.

 Implementation: Acute Care

• Orientation to the environment

• Comfort measures—stimulation
• Communication
• Control sensory stimuli: noise, light,
smells
• Safety measures

Mosby items and derived items © 2005 by Mosby, Inc.

Implementation: Restorative Care

• Maintaining a healthy lifestyle

• Understanding sensory loss
• Socialization
• Self-care

Mosby items and derived items © 2005 by Mosby, Inc.

 Evaluation

• Client care
• Client expectations

Mosby items and derived items © 2005 by Mosby, Inc.