Sensory Alteration and the Nursing Process

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Week One Objectives

differentiate the processes of reception, perception and reaction to stimuli;

•

define sensory deficit, sensory deprivation and sensory overload and discuss

the factors affecting sensory alteration;

•

discuss assessment including sources and, methods of data collection and

identify signs, symptoms and clinical manifestations;

•

identify medical diagnoses, develop and prioritise nursing diagnoses and

discuss the relationships between them;

•

develop and write client centred goals, evidence based interventions and

evaluation statements;

•

apply the Nursing Process and critical thinking in order to plan and provide

patient care;

•

discuss the Nursing Process in relation to clients with sensory alterations;

•

perform Neurological observations.

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differentiate the processes of reception, perception and reaction to stimuli;

RECEPTION

Receive data or stimulation. External stimuli include the five senses Visual, Auditory, Olfactory, gustatory and tactile . Internal include kin-aesthetic (position sense) and visual awareness

PERCEPTION

Receiving, organisation and translation of data by cerebral cortex when the person receives the stimulation and becomes conscious of the stimuli

REACTION

Awareness and response to stimuli - controlled by the reticular activating system (RAS)

https://www.youtube.com/watch?v=unWnZvXJH2o (Enclavar)

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define sensory deficit, sensory deprivation and sensory overload and discuss the factors affecting sensory alteration;

Sensory Deficit

a deficit in the normal function of sensory reception

and perception.

Common Sensory Deficits:

Visula - presbyopia, cataract, dry eyes, diabetic retinopathy, senile

macular degeneration;

Hearing - cerumen accumulation;

Balance - dizziness and disequilibrium;

Taste - xerostomia;

Neurological - peripheral neuropathy, CVA (stroke).

Sensory Deprivation

…… an inadequate quality or quantity of stimulation

There are 3 types:

• Reduced sensory input e.g. visual or hearing loss;

•

Elimination of order or meaning from input e.g.

exposure to strange environments;

•

Restriction of the environment that produces monotony

or boredom e.g. bed rest.

COGNITIVE:

•  capacity to learn, think/problem solve

• poor task performance, disoriented, regression, bizarre thoughts, 

need: socialisation & attention

AFFECTIVE (mood):

• bored, restless,  anxiety, emotional lability, panic,  need

physical stimulation

PERCEPTUAL:

• altered visual & motor coordination, interpretation o

Sensory Overload

…a person receives multiple sensory stimuli and cannot

perceptually disregard or selectively ignore some stimuli.

Causative factors may include:  external stimuli,  internal stimuli

or an inability to disregard stimuli selectively.

EFFECTS OF SENSORY OVERLOAD:

• Behavioural changes (confusion)

• Disorientated (mood swings or simple disorientation)

• Racing thoughts

• Short attention span

• Restlessness

• Anxiety

Factors affecting sensory alternation

Age

• Elderly: senses - presbyopia >40 yrs, memory, hearing, gustatory

and olfactory , proprioception > 60 yrs.

Medications

• Narcotics, sedatives, antidepressants, aspirin and loop diuretics and

some antibiotics

Environment

• Excessive stimuli: busy ward, staff conversation etc. Constant

exposure to high noise levels  hearing

• Restricted stimuli: protective isolation, elderly living alone in

isolation.

Comfort Level

• Pain and fatigue

Pre existing Illness

• Peripheral vascular disease (PVD), chronic diabetes mellitis, CVA,

endotracheal tube (speech).

Culture

• Living with extended family, touching for comfort unacceptable.

Smoking

• Taste buds atrophy  taste.

https://video.byui.edu/media/Sensory+Deficits/0_fdoia0wu (Enclavar)

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discuss assessment including sources and, methods of data collection and identify signs, symptoms and clinical manifestations;

Assessment consists of:

Systematic collection of data from patient/client

(primary source), family/friends/health professionals

(secondary source)

Analysis of data as a basis for nursing diagnoses

Assessment provides a basis from which to develop nursing

diagnoses and plan individualised nursing care and is evaluated

and refined throughout the time the nurse cares for the

patient/client

Types of Data:

 Objective

 Subjective

Sources of Data:

 Client

 Family and Significant others

 Healthcare team members

 Medical records

 Other records

 Literature Review

 Nurses experience

Objective and subjective (some are observable and

measurable and some we only know about if the

patient/family/carer tell us) evidence of a medical or nursing

problem/diagnoses or how a problem manifests (shows)

itself.

E.g. Blood in the stool, loss of speech, loss of memory, skin

rash, hypertension, stomach ache, lower back pain, fever,

pain, elevated blood glucose level (BGL), elevated white

blood cell count etc.

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identify medical diagnoses, develop and prioritise nursing diagnoses and discuss the relationships between them; •

A medical diagnoses predominantly identifies the disease

state. It’s focus is on the diagnoses and treatment of

the disease

e.g. appendicitis, pneumonia, deep vein thrombosis,

fractured neck of femur, diabetes

The goals of a medical diagnoses are to identify and

design a treatment plan for curing/managing the

disease or the pathological process

Remember that nursing interventions cannot change

the medical diagnosis

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develop and write client centred goals, evidence based interventions and

evaluation statements;

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apply the Nursing Process and critical thinking in order to plan and provide

patient care

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• discuss the Nursing Process in relation to clients with sensory alterations;

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Perform a Full Neurological Assessment

General Information

There are 2 primary functions in neurological assessment:

 The assessment of impaired consciousness and coma for a

wide range of

conditions including strokes, brain trauma, metabolic

conditions and infections

 The score derived provides a baseline comparison with

future scores to determine

improving, deteriorating or static clinical states2

[Level IV]

A Full Neurological Observation (FNO) assessment

incorporates the following patient

assessments 3 [Level IV]:

 Glasgow Coma Scale

 Observation of vital signs

 Observation of the following neurological signs:

 Pupil size and reaction to light

 Upper limb motor function

 Lower limb motor function

The Glasgow Coma Scale (GCS) provides a framework for

describing the state of a

patient in terms of three aspects of responsiveness, each

stratified according to

increasing impairment:

 Eye opening

 Verbal response

 Best motor response

4 [Level IV]

GCS is used to stratify head injury into mild (GCS 13-15),

moderate (GCS 9-12) and

severe categories (GCS 3-8) 5

[Level I].

Pre Assessment Considerations

The Nurse may need to consider the following prior to

commencing a FNO

assessment:

 Ascertain if English is the primary language

 If the patient is under the influence of substances for

example, alcohol or a

medication thus altering FNO assessment score

 Alternative assessment techniques to be considered if the

patient has

communication issues such as aphasia, dysphasia, or if the

patient is hearing or

visually impaired

 Where possible the physical environment should have

limited background noise

and distractions to assist the patient focus on requests by

the assessor

Documentation

 All patient responses are to be documented in the

appropriate box on the Chart for

Patients with Impaired Consciousness (refer to Appendix I)

 Any change in patient condition and management plan is to

be documented in the

patient integrated notes

Nursing Practice

Patient Assessment Using the Glasgow Coma Scale (GCS)

The GCS is used at RPH to assist in neurological assessment

of patients.

The maximum score for a GCS is 15 and the minimum is 3 1,4,7

[Level IV].

 The relevant MO is to be informed when there is a decrease

by 2 points in the GCS

as per MET criteria

 Activate MET or resuscitation as clinically indicated.

Refer to Management of

Medical Emergencies and Cardiorespiratory Arrest CPS

1. Assessment of Eye Opening

Refer to Appendix I: Chart for Patients with Impaired

Consciousness.

Assess if the patient opens their eyes in one of the

following situations:

Spontaneously 1 [Level IV]

Assess if the patient is asleep and wake them

 If they are able to consistently keep their eyes open

without dozing off then a score

of 4 can be given

 If the patient is awake observe if the patient opens their

eyes without verbal, touch

or other stimuli

To speech

This observation is made without touching the patient.

 Instruct the patient to open their eyes in a firm, loud

voice. Allow for hearing

impairment 1 [Level IV]

Pain

 If no eye opening response to verbal

stimuli , gently touch the patient to

elicit a response (refer to Figure 1) 8

[Level IV]

 If still no eye opening response refer to

Refer to Painful Stimuli section1

[Level IV]

Figure 1: Applying stimuli flow chart

None

If the patients eyes have been open continuously (no

blinking observed), record as ‘no

eye-opening response’.

The patient may have flaccid ocular muscles and may lie with

their eyes open all the

time. This is not a true arousal response 9 [Level IV].

 Observe that the patient does not open their eyes to any

stimuli

 Observe for signs of swelling around eyes

 If eye swelling is present mark the box corresponding to

’none’ with a ‘C’

 ‘C’ indicates eyes closed

1 [Level IV]

Applying stimuli

Auditory (voice/other sounds) Tactile (touch)

Normal

Voice

Loud voice/

other loud

sounds

Light

touch

Painful

stimuli

Version 3 Compiled: July 2006

Title: Assessment of Full Neurological Observations NPS

Document Owner: Nursing Director Cancer and Neurosciences

9

Endorsed by NPC: 22nd November 2012

Authorised by: Acting DoN Robyn Kovac 3rd December 2012

Nursing Practice

Patient Assessment Using the Glasgow Coma Scale (GCS) cont’d

2. Assessment of Patient’s Best Verbal Response

Assess the patient’s ability to respond to questions posed

to them

 Only ask one question at a time and always allow adequate

time for the patient to

respond to your questions1 [Level IV]

 Speak in a voice loud enough for the patient to hear. To

allow for any hearing

impairment 1 [Level IV]

 Vary the questions. Answers to questions may be learned by

the patient

Assess if patient is: Orientated

Ask the patient one question related to each of the

following:

 Time

 Place

 Person

The patient should be able to answer the questions correctly

if they are to be deemed

orientated.

Examples of questions to ask the patient 10 [Level IV]:

 What year is it?

 What month is it?

 What time of day is it? (i.e. morning, afternoon, evening

– not a specific time)

 Where are you?

 What is your name?

 What is your date of birth?

Confused

Observe the patient being unable to accurately answer one or

more of the questions

asked to assess orientation

Correct wrongly answered questions, but change the order

each time to avoid the

patient from repeating them.

Inappropriate Words

Observe the patient using disorganised speech, giving

consideration to patient history.

Examples are using words at random, shouting or swearing

inappropriately.

Patient may be aphasic, dysphasic, have a previous acquired

brain injury affecting

speech pattern and/or a pre-existing speech and hearing

condition 11 [Level IV].

Incomprehensible Sounds

Observe the patient making unintelligible sounds.

Examples of unintelligible sounds include moaning or

mumbling 1

[Level IV].

Ascertain if English is the primary language. Refer to RPH

Policy: Language services

None

Observe the patient making no sounds or speech

If the patient is unable to respond due to the presence of a

tracheostomy or

endotracheal tube (ETT) insitu, aphasia or dysphasia

document in the appropriate box

on the chart as follows 1 [Level IV]:

 T = tracheostomy, ETT

 A = aphasia (aphasia is an inability to generate speech)

12 [Level IV].

Version 3 Compiled: July 2006

Title: Assessment of Full Neurological Observations NPS

Document Owner: Nursing Director Cancer and Neurosciences

10

Endorsed by NPC: 22nd November 2012

Authorised by: Acting DoN Robyn Kovac 3rd December 2012

Nursing Practice

Patient Assessment Using the Glasgow Coma Scale (GCS) cont’d

3. Assessment of the Best Motor Response of the Patient

This measures the overall awareness and the ability to

respond (by movement) to

external stimuli 1 [Level IV].

Motor responses can be affected by medications such as

muscle relaxants and/or

sedation and are to be recorded on the Chart for Patients

with Impaired Consciousness

using the following codes:

 M = muscle relaxant

 S = sedation

Obey commands

Ask the patient to follow a simple command.

 If the patient is observed to execute this task the Nurse

should attempt to test limb

strength

 The appropriate command is given to the patient, taking

into account any physical

impairment they may have i.e. paraplegia

 E.g. Stick out your tongue, hold up your arm, open your

eyes - to assess

cerebral function to obey commands 1 [Level IV]

NB: “Squeeze my fingers” is discouraged as this is a

primitive reflex and may

occur involuntarily unless followed by the request to

‘release my fingers’

Allow a short time for the patient to respond to your

command 1 [Level IV]. Patients with

an acquired brain injury may be slow to respond.

Localise

If no response to verbal command, apply central painful

stimuli.

Observe the patient attempting to remove or locate the

painful stimuli in a purposeful

way 1 [Level IV]. E.g. if the patient has a tracheostomy

tube insitu and is attempting to

touch the tube. Refer to Painful Stimuli- Central painful

stimuli section

Withdraw

Observe the patient attempting to withdraw the limb away

from the painful stimuli

 Patient does not attempt to remove the stimuli or locate

the source of the pain

Version 3 Compiled: July 2006

Title: Assessment of Full Neurological Observations NPS

Document Owner: Nursing Director Cancer and Neurosciences

11

Endorsed by NPC: 22nd November 2012

Authorised by: Acting DoN Robyn Kovac 3rd December 2012

Nursing Practice

Patient Assessment Using the Glasgow Coma Scale (GCS) cont’d

3. Assessment of the Best Motor Response of the Patient

cont’d

Abnormal flexion

Observe the patient performing non-purposeful flexion to

painful stimuli.

This presents as flexion of the elbows, wrists and fingers

with the arms held tightly to

the sides and extension of the legs (refer to Figure 1).

This may also be known as decorticate posturing 1 [Level

IV].

Figure 1: Decorticate Posturing 13 [Level IV].

Decorticate posturing correlates with damage to the cerebral

hemispheres interrupting

the cortico-spinal pathways of the diencephalon 14 [Level

IV].

Extension

Observe if the patient presents with adduction of the arms

and extension of the elbows,

pronation of the forearms with the wrists and fingers

flexed, to painful stimuli.

The legs are also extended (with the toes pointing

downwards) (refer to Figure 2).

This may also be known as decerebrate posturing 1 [Level

IV].

Figure 2: Decerabrate posturing 13 [Level IV].

Decerebrate posturing

corresponds with destruction of the midbrain and upper pons14

[Level IV].

None

Observe no response to painful stimuli

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