10-04-2017, 09:10 PM
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Stressors that Affect Cognition &Perception Sensory Sleep
Sensory Needs
Senses- needed for survival, growth & development and bodily pleasure
Give meaning to events in the environment
Alterations in senses- affect ability to function in the environment
Sensory Experience
When we sense things: process of sensory reception (receive stimuli) and sensory perception (organization and transmission of stimuli into meaningful data influenced by experiences, knowledge, attitudes)
Sensory reception stimuli can be visual, auditory, olfactory, tactile or gustatory. Also can be kinesthetic, stereognosis or visceral.
RAS(reticular activating system)- responsible for stimulus arousal (monitors & regulates incoming stimuli)
Factors Affecting Sensory Functioning
Developmental level
Culture
Stress
Meds
Illness & Therapies
Personality
Sensory Alterations
A change in environment can lead to MORE or LESS normal stimuli.
When stimuli is different from what one is used to it leads to sensory alterations.
Hospitalized patients will experience sensory alterations due to different stimuli loads.
Can result in sensory overload or sensory deprivation
Sensory Overload
Results from being unable to manage sensory stimuli: (too much stimuli)
Pain, dyspnea, anxiety (internal)
Noise, intrusive procedures, contact with many strangers (external)
Inability to disregard stimuli: for example meds that stimulate the arousal mechanism, may prevent one from ignoring noise
Assessment: Sensory Overload
Unrealistic perceptions, ineffective coping
Acts bewildered,disoriented, difficulty concentrating, muscle tension
Reduced problem-solving ability, scattered attention, racing thoughts
Interventions: Sensory Overload
Prevent sensory alteration
Reduce environmental stimuli, promote sleep
Establish a routine for care
Speak calmly and slowly with simple explanations
Eliminate personal stimuli
Sensory Deprivation
Results from decreased sensory input or meaningless input: (too little stimuli)
Isolation/non-stimulating monotonous environment
Impaired ability to receive and/or send stimuli IE: vision, hearing deficits, speech deficits ( expressive or receptive aphasia)
Inability to cognitively process stimuli-confused, brain injury, meds affecting CNS
Sensory Deficits
Impaired reception, perception or both of the senses
Blindness, deafness, loss of taste, smell, touch
One sense may become more acute to compensate for deficit
At risk for sensory overload in the compensated sense or deprivation overall
Assessing: Sensory Deprivation
Drowsiness/sleeping/yawning
Decreased attention span, difficulty concentrating, impaired memory
Disorientation, confusion, hallucinations RAS needs stimulus; body may produce hallucinations to maintain optimal arousal
Crying, annoyance over small matters, depression
Apathy, daydreaming, boredom, anger
Assessment: Sensory Deficit
Assess loss of one or more senses
Note behaviors to compensate for deficit-always turns right ear toward person speaking to compensate for hearing loss
Assess for diseases that can affect senses, inner ear infection causes loss of kinesthetic sense, neurological disease can effect tactile perception
NURSING DIAGNOSIS
Disturbed sensory perception
Social Isolation
OTHERS in which decreased sensory perception may be an etiology? Situational low self-esteem Disturbed thought processes
WHAT IS A PRIORITY NURSING DIAGNOSIS for the client with altered sensory perception?
PLANNING
Client will: Demonstrate understanding by a verbal, written, or signed response (SENSORY DEFICIT)
Client will: Demonstrate relaxed body movements and facial expressions (SENSORY OVERLOAD)
Client will: Increase and maintain personal interactions (SENSORY DEVICIT)
Client will: Remain free from injury
Interventions: Sensory Deprivation
Prevent sensory alteration
Teach self stimulation methods- reading, singing etc.
Provide stimulation visual, auditory, gustatory, tactile and cognitive
Provide reality orientation
Utilize interpreters for communication barriers
Interventions: Sensory Deficit
Deficit may be new- determine ability to compensate
Provide care to facilitate sense
Provide glasses, hearing aids, adaptive equipment etc. to reduce sensory deficit
Utilize all health care team members to assist with sensory deficit dietary for loss of gustatory sense
Communication Methods for Clients with Special Needs
Review Box 24-10 in Potter & Perry Page 357
Evaluation: Sensory alterations
Were outcomes met ?
Is patient compensating ?
Sensory deprivation hasn t become sensory overload?
Does nursing care plan need modifying if goals not met?
Sleep/Rest
Sleep
Sleep Stages
Sleep Requirements
Individualized
Less sleep required the older one is newborns sleep 16-18 hr/day (with more Delta & REM sleep) whereas elders sleep 6 hr/day ( with less Delta & REM sleep)
Factors Affecting Sleep
Health/illness (CAD pain, GI secretions increased in REM sleep,
Environment
Exercise and Fatigue
Lifestyle
Emotional stress
Stimulants/Alcohol (decrease Delta & REM sleep)
Diet
Smoking
Medication
Motivation
Sleep Disorders
Insomnia
Narcolepsy
Sleep apnea
Parasomnias
Assessing: Sleep
Pattern
Quality
Energy level
Sleeping aids
Sleep disturbances -nature -onset -causes -symptoms (Do you snore? Do you wake up with HA?)
Assessing Sleep
What are some objective signs of inadequate sleep the nurse should be observant to?
Nursing Dx
Sleep pattern disturbance R/T physical discomfort AEB s/p L hip arthroplasty, positioning restrictions and client statement I can t sleep on my back; I like to sleep on my side
Sleep deficit R/T shift changes at work AEB I m tired going to work but when I get home I can t fall asleep
Nursing Diagnoses with Sleep Deprivation as etiology
Anxiety r/t
Activity intolerance r/t
Ineffective coping r/t
Risk for injury r/t
Outcome Criteria
Client will:
Wake up less frequently during the night
Fall asleep without difficulty
Verbalize plan that provides adequate time for sleep
Identify actions that can be taken to improve quality of sleep
Awaken refreshed and be less fatigued during the day
Implementing: Promote Sleep
Restful environment
Comfort/relaxation
Bedtime rituals
Sleep pattern
Medications