2. • Describe the normal sensory regulation process.
• Explain the importance for daily survival.
• Describe conditions and situation responsible for the
development of sensory deprivation and sensory overload.
• List the ways of assisting the client at risk for these problems.
• Discuss the significance of neurosensory findings.
• Identify the 4 major body functions responsible for meeting
one’s protection need.
• Describe conditions responsible for the development of
disruptions in the protection need.
• Discuss the related nursing interventions.
3.
4. • 4 aspects
must be
present:
• Stimulus
• Receptor
• Impulse
conduction
• Perception
• Arousal
mechanism
5. • Reception:
• stimulus is received through the receptors of the nervous system
• becomes a sensation
• Perception:
• conscious mental recognition or registration of the sensory stimulus
• input received and interpreted in a meaningful way
• Reaction:
• the action or response a person takes after identifying the sensation
6. • Inadequate reception or perception of
environmental stimuli
• Physical or environmental causes
8. • Excessive yawning, drowsiness, and sleeping
• Decreased attention span, difficulty concentrating,
and decreased problem solving
• Impaired memory; periodic disorientation, general
confusion, or nocturnal confusion
• Preoccupation with somatic complaints, such as
palpitations
• Hallucinations or delusions
• Crying, annoyance over small matters and
depression
• Apathy and emotional liability
9. • Increased in modern society.
• Excessive stimuli
• Unfamiliar routine
• Altered sleep rest pattern
• Effects:
• interferes with ability to focus:
• mood swings
• exaggerated emotional responses
10. • Complaints of fatigue, sleeplessness
• Irritability, anxiety, and restlessness
• Periodic or general disorientation
• Reduced problem-solving ability and task
performance
• Increased muscle tension
• Scattered attention and racing thoughts
11.
12. • Impaired reception / perception or both
• one or more of the senses
• Blindness
• Deafness
• Change tactile perception
13. • Nursing history
• Mental status examination
• Physical examination
• Identification of clients at risk
• Environment
• Social support network
14. Effects of sensory deprivation and sensory overload:
• CNS changes:
• Impaired judgment • Subtle changes for hearing
loss (speech delay)
• Inability to problem solve
• Other senses sharpen to
• Confusion
overcome loss
• Disorientation
• Can impair relationships,
• Hallucinations withdraws socially
• Delusions
15. • Nonstimulating or monotonous
environment
• Impaired vision or hearing
• Mobility restrictions
• Inability to process stimuli
• Emotional disorders
• Limited social contact
16. Therapeutic nursing actions to prevent sensory deprivation:
• Encourage family to bring in personal items
• Position bed for maximal visualization of the environment
• Encourage the use of glasses, hearing aids, to reduce
sensory deprivation
17. • Pain or discomfort
• Admission to an acute care facility
• Monitoring in intensive care units
• Invasive tubes
• Decreased cognitive ability
18. Therapeutic nursing actions to prevent sensory overload:
• Minimize unnecessary stimuli
• Pain control
• Privacy
• Periods of rest and sleep
• Low tones of voice
• Remove odors
• Give information gradually
19. Therapeutic nursing actions for managing sensory deficits:
• Encourage client to use sensory aids
• One sense is lost supplement with other senses
• Communicate effectively with clients sensory deficits
- visually impaired
- hearing impaired
20. • Levels of consciousness
• Glasgow Coma Score = scoring eye movement
+ verbal response
+ motor response
• Pupillary response
• Upper and lower body strength
22. • Prevent injury
• Maintain the function of existing senses
• Develop an effective communication
mechanism
• Prevent sensory overload or deprivation
• Reduce social isolation
• Perform ADLs independently and safely
23. • Promote healthy sensory function
• Appropriate sensory stimulation
• Prevention of sensory disturbances
• Adjust environmental stimuli
• Prevent sensory overload
• Prevent sensory deprivation
• Manage acute sensory deficits
• Use of sensory aids
• Use of other senses
• Effective communication
24. • Wear a readable name tag
• Address the person by name
• Introduce yourself frequently
• Identify time and place as indicated
• Ask the client “Where are you?”
• Orient the client to place if indicated
• Place a calendar and clock in the client’s room
• Mark holidays with ribbons, pins or other means
25. • Speak clearly and calmly, allowing time for words to be
processed and for a response
• Encourage family to visit frequently
• Provide clear, concise explanations of each treatment,
procedure or task
• Eliminate unnecessary noise
• Provide adequate sleep
• Keep glasses and hearing aids within reach
• Ensure adequate pain management
• Keep room well lit during waking hours
26.
27. • Auditory
• Introduce yourself to the client
• Orient the client to time, month, year, location
• Inform client beforehand the care to be provided
• Read literature to client
• Play a tape recording of familiar voice
• Converse directly to client
28. • Visual • Tactile
• Sit client upright in a • Incorporate during bath
chair or bed activities
• Olfactory • Kinesthetic
• Provide aromatic stimuli • Perform range-of-
that may include client’s motion exercises
favorites • Change client’s position
• Gustatory
• Provide mouth care
• Place different tastes on
tongue
32. • Disruption in skin • Wound. . .
integrity: • a type of lesion
• from abrasions • a disruption of normal
• tape blisters anatomical structure
• pressure ulcers and function
• major abdominal • results from bodily
injury or pathological
wounds
process
33. • Inflammatory Phase
• Immediate to 2-5 days
• Hemostasis
• Vasoconstriction
• Platelet aggregation
• Thromboplastin makes clot
• Inflammation
• Vasodilation
• Phagocytosis
•
34. • Proliferative regeneration phase
• 2 days to 3 weeks
• Granulation
• Fibroblasts lay bed of collagen
• Fills defect and produces new capillaries
• Contraction
• Wound edges pull together to reduce defect
• Epithelialization
• Crosses moist surface
• Cell travel about 3 cm from point of origin in all directions
35. • Remodeling phase 3, weeks to 2 years
• New collagen forms which increases tensile strength to
wounds
• Scar tissue is only 80 percent as strong as original
tissue
36. • Acute surgical wound
• heal by primary intention
• wound edges approximated
• secured using sutures, staples, tape.
• Wound bed fills in with granulation tissue and the scar is
thin and flat
37. • Extensive tissue loss
• Edges cannot be closed
• Repair time longer
• Scarring greater
• Susceptibility to infection greater
38. • Usually deep
• Extensive damage and drainage
• High risk of infection
• Initially left open
• Edema, infection, or exudate resolves
• Then closed
40. • Material such as fluid and cells that have
escaped from blood vessels during
inflammatory process
• Deposited in tissue or on tissue surface
• 3 major types
• Serous
• Purulent
• Sanguineous (hemorrhagic)
41. • Mostly serum
• Watery, clear of cells
• E.g., fluid in a blister
52. • Wound bed must be free of infection and clean
• Cleansing solution
• Irrigate with NS 30 ml syringe and 19 angiocath
• Keep wound be moist
• Clean to dirty from incision outward in a circular motion
changing swabs
54. • Stage I
Non-blanchable erythema of intact skin heralding lesion of
skin ulceration.
• Stage II
Partial thickness skin loss involving epidermis, dermis, or
both.
• Stage III
Full thickness skin loss involving damage to or necrosis of
subQ tissue that may extend down to, but not through
underlying fascia.
• Stage IV
Full thickness skin loss with extensive destruction, tissue
55. Stage related treatments
Stage I Relieve pressure
Stage II Maintain moist healing environment
Stage III Debridement
Stage IV Wound Coverage
56. Prevention
• Braden skin risk assessment- photograph wounds
• Clean and dry skin
• Promote nutrition
• Manage tissue loads
• Repositioning schedule
• HOB low as possible to decrease shearing forces
