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Nursing 122 Fundamentals of Neuro-Sensory nursing --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---
Review major structures and functions of both central and peripheral nervous system. (Carolyn Jarvis, Physical Examination and Health Assessment, 3rd ed., pages 688-692
Structure and function of the CNS and PNS

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Potter and Perry, Fundamentals of nursing (8th), Chapter 16 p. 210-211

Types of Data
--There are two primary sources of data: subjective and objective. Subjective data are your patients’ verbal descriptions of their health problems. Only patients provide subjective data. For example, Mr. Jacobs's report of incision pain and his expression of concern about whether the pain means that he will not be able to go home as soon as he hoped are subjective findings. Subjective data usually include feelings, perceptions, and self-report of symptoms. Only patients provide subjective data relevant to their health condition. The data sometimes reflect physiological changes, which you further explore through objective data collection.
--Objective data are observations or measurements of a patient's health status. Inspecting the condition of a surgical incision or wound, describing an observed behavior, and measuring blood pressure are examples of objective data. The measurement of objective data is based on an accepted standard such as the Fahrenheit or Celsius measure on a thermometer, inches or centimeters on a measuring tape, or known characteristics of behaviors (e.g., anxiety or fear). When you collect objective data, apply critical thinking intellectual standards (e.g., clear, precise, and consistent) so you can correctly interpret your findings.

Sources of Data p. 210
--As a nurse you obtain data from a variety of sources that provide information about the patient's current level of wellness and functional status, anticipated prognosis, risk factors, health practices and goals, responses to previous treatment, and patterns of health and illness.

Patient: A patient is usually your best source of information. Patients who are conscious, alert, and able to answer questions correctly provide the most accurate information about their health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, responses to treatment, and changes in activities of daily living. Always consider the setting for your assessment and your patient's condition. A patient experiencing acute symptoms in an emergency department will not offer as much information as one who comes to an outpatient clinic for a routine checkup. An older adult requires more time than someone younger, and often multiple visits are required to gather a complete database. Always be attentive and show a caring presence with patients. Let a patient know you are interested in what he or she has to say. Patients are less likely to fully reveal the nature of their health care problems when nurses show little interest or are easily distracted by activities around them.

Family and Significant Others: Family members and significant others are primary sources of information for infants or children; critically ill adults; and patients who are mentally handicapped, disoriented, or unconscious. In cases of severe illness or emergency situations, families are often the only sources of information for nurses and other health care providers. The family and significant others are also important secondary sources of information. They confirm findings that a patient provides (e.g., whether he takes medications regularly at home or how well he sleeps or eats). Include the family when appropriate. Remember, a patient does not always want you to question or involve the family. You must obtain a patient's agreement to include family members or friends. Often spouses or close friends sit in during an assessment and provide their view of the patient's health problems or needs. Not only do they supply information about the patient's current health status, but they are also able to tell when changes in the patient's status occurred. Family members are often very well informed because of their experiences living with the patient and observing how health problems affect daily living activities. Family and friends make important observations about the patient's needs that can affect the way care is delivered (e.g., how a patient eats a meal or how he or she makes choices).

Health Care Team: You frequently communicate with other health care team members in gathering information about patients. In the acute care setting the change-of-shift report is how nurses from one shift communicate information to nurses on the next shift. During the report you have the chance to collect the first set of information about patients assigned to your care. Researchers found that bedside rounds, also called bedside handover, promote patient-centered care. During bedside rounds, the nurse who is completing care for a shift, the patient, and the nurse assuming care for a shift share information about the patient's condition, status of problems, and treatment plan for the next shift. In some settings other health care team members participate in the rounds. When nurses, physicians, physical therapists, social workers, or other staff consult on a patient's condition, they share information about how the patient is interacting within the health care environment, the patient's reactions to treatment, and the result of diagnostic procedures or therapies. Every member of the team is a source of information for identifying and verifying information about the patient.

Medical Records: The medical record is a source for the patient's medical history, laboratory and diagnostic test results, current physical findings, and the primary health care provider's treatment plan. The record is a valuable tool for checking the consistency and similarities of your personal observations. Data in the records offer a baseline and ongoing information about the patient's response to illness and progress to date. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 has a privacy rule that came into effect on April 14, 2003 to set standards for the protection of health information. Information in a patient's record is confidential. Each health care agency has policies governing how the patient's health information can be shared among health care providers. It is important to know organization policies for reviewing a patient's medical record for the purpose of assessment.

Other Records and the Scientific Literature: Educational, military, and employment records sometimes contain significant health care information (e.g., immunizations). If a patient received services at a community health center or different hospital, you need written permission from the patient or guardian to access the records. The HIPAA regulations protect access to patients’ health information. The privacy rule allows health care providers to share protected information as long as they use reasonable safeguards. Check the policy of your agency for HIPAA guidelines.
Reviewing nursing, medical, and pharmacological literature about a patient's illness completes your assessment database. This review increases your knowledge about the patient's diagnosed problems, expected symptoms, treatment, prognosis, and established standards of therapeutic practice. The scientific literature offers evidence to direct you on how and why to conduct assessments for particular patient conditions. A knowledgeable nurse obtains relevant, accurate, and complete information for the assessment database.

Nurse's Experience: Through clinical experience a nurse observes other patients; recognizes clinical changes; and learns the types of questions to ask, choosing only the questions that will give the most useful information. A nurse's expertise develops after testing and refining inferences, questions, and principle- or standard-based expectations. For example, while caring for Mr. Jacobs, Tonya has learned what a prostatectomy incision looks like and how a patient responds to the associated discomfort. In the future Tonya will more quickly recognize the behavior of a patient in acute pain and how it affects normal mobility. --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---

Chapter 30 Health Assessment and Physical examination, pgs 555-562

FIG. 30-71 p. 553
Range of motion of hand and wrist. A, Metacarpophalangeal flexion and hyperextension. B, Finger flexion: thumb to each fingertip and to the base of the little finger. C, Finger flexion, fist formation. D, Finger abduction. E, Wrist flexion and hyperextension. F, Wrist radial and ulnar movement.

FIG. 30-71 p. 553
Range of motion of hand and wrist. A, Metacarpophalangeal flexion and hyperextension. B, Finger flexion: thumb to each fingertip and to the base of the little finger. C, Finger flexion, fist formation. D, Finger abduction. E, Wrist flexion and hyperextension. F, Wrist radial and ulnar movement.

TABLE 30-33 Terminology for Normal Range-of-Motion Positions p. 553 TERM | RANGE OF MOTION | EXAMPLES OF JOINTS | Flexion | Movement decreasing angle between two adjoining bones; ending of limb | Elbow, fingers, knee | Extension | Movement increasing angle between two adjoining bones | Elbow, knee, fingers | Hyperextension | Movement of body part beyond its normal resting extended position | Head | Pronation | Movement of body part so front or ventral surface faces downward | Hand, forearm | Supination | Movement of body part so front or ventral surface faces upward | Hand, forearm | Abduction | Movement of extremity away from midline of body | Leg, arm, fingers | Adduction | Movement of extremity toward midline of body | Leg, arm, fingers | Internal rotation | Rotation of joint inward | Knee, hip | External rotation | Rotation of joint outward | Knee, hip | Eversion | Turning of body part away from midline | Foot | Inversion | Turning of body part toward midline | Foot | Dorsiflexion | Flexion of toes and foot upward | Foot | Plantar flexion | Bending of toes and foot downward | Foot |

Assessing muscle tone.
Assessing muscle tone.
The patient flexes the arm; the goniometer measures joint range of motion.

The patient flexes the arm; the goniometer measures joint range of motion.

Muscle Tone and Strength p. 554
--Assess muscle strength and tone during ROM (range of motion) measurement. Integrate these findings with those from the neurological assessment. Note muscle tone, the slight muscular resistance felt as you move the relaxed extremity passively through its ROM. --Ask the patient to allow an extremity to relax or hang limp. This is often difficult, particularly if the patient feels pain in it. Support the extremity and grasp each limb, moving it through the normal ROM. Normal tone causes a mild, even resistance to movement through the entire range.
If a muscle has increased tone, or hypertonicity, there is considerable resistance with any sudden passive movement of a joint. Continued movement eventually causes the muscle to relax. A muscle that has little tone (hypotonicity) feels flabby. The involved extremity hangs loosely in a position determined by gravity.

For assessment of muscle strength, have the patient assume a stable position. He or she performs maneuvers demonstrating strength of major muscle groups. Use a grading scale of “0 to 5” to compare symmetrical muscle pairs for strength. The arm on the dominant side normally is stronger than the arm on the nondominant side. In older adults a loss of muscle mass causes bilateral weakness, but muscle strength remains greater in the dominant arm or leg.

TABLE 30-35 Muscle Strength p. 554 MUSCLE FUNCTION LEVEL | GRADE | No evidence of contractility | 0 | Slight contractility, no movement | 1 | Full range of motion, gravity eliminated | 2 | Full range of motion with gravity | 3 | Full range of motion against gravity, some resistance | 4 | Full range of motion against gravity, full resistance | 5 |

TABLE 30-34 Maneuvers to Assess Muscle Strength p. 554 MUSCLE GROUP | MANEUVER | Neck (sternocleidomastoid) | Place hand firmly against patient's upper jaw. Ask patient to turn head laterally against resistance. | Shoulder (trapezius) | Place hand over midline of patient's shoulder, exerting firm pressure.Have patient raise shoulders against resistance. | Elbow Biceps Triceps | Pull down on forearm as patient attempts to flex arm.As you flex patient's arm, apply pressure against forearm. Ask patient to straighten arm. | Hip Quadriceps Gastrocnemius | When patient is sitting, apply downward pressure to thigh. Ask patient to raise leg up from table.Patient sits while examiner holds shin of flexed leg. Ask patient to straighten leg against resistance. |

Examine each muscle group. Ask the patient to first flex the muscle you are examining and then to resist when you apply an opposing force against that flexion. It is important to not allow the patient to move the joint. Gradually increase pressure to a muscle group (e.g., elbow extension). Have the patient resist the pressure you apply by attempting to move against resistance (e.g., elbow flexion) until instructed to stop. Vary the amount of pressure applied and observe the joint move. If you identify a weakness, compare the size of the muscle with its opposite counterpart by measuring the circumference of the muscle body with a tape measure. A muscle that has atrophied (reduced in size) feels soft and boggy when palpated.
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Potter and Perry, Fundamentals of nursing (8th), CH 14, p. 178-180

Cognitive Changes p. 178
--A common misconception about aging is that cognitive impairments are widespread among older adults. Because of this misconception, older adults often fear that they are, or soon will be, cognitively impaired. Younger adults often assume that older adults will become confused and no longer able to handle their affairs. Forgetfulness as an expected consequence of aging is a myth. Some structural and physiological changes within the brain are associated with cognitive impairment. Reduction in the number of brain cells, deposition of lipofuscin and amyloid in cells, and changes in neurotransmitter levels occur in older adults both with and without cognitive impairment. Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes. There are standard assessment forms for determining a patient's mental status, including the Mini-Mental State Exam (MMSE), the Confusion Assessment Method (CAM) and the NEECHAM Confusion Scale.
--The three common conditions affecting cognition are delirium, dementia, and depression. Distinguishing among these three conditions is challenging. Complete a careful and thorough assessment of older adults with cognitive changes to distinguish among them. Select appropriate nursing interventions that are specific to the cause of the cognitive impairment. TABLE 14-2 Comparison of Clinical Features of Delirium, Dementia, and Depression CLINICAL FEATURE | DELIRIUM | DEMENTIA | DEPRESSION | Onset | Sudden/abrupt; depends on cause | Insidious/slow and often unrecognized | Happens with major life changes; often abrupt but can be gradual | Course | Short, daily fluctuations in symptoms; worse at night, in darkness, and on awakening | Long, no diurnal effects; symptoms progressive yet relatively stable over time; some deficits with increased stress | Diurnal effects, typically worse in the morning; situational fluctuations but less than with delirium | Progression | Abrupt | Slow but uneven | Variable; rapid or slow but even | Duration | Hours to less than 1 month; longer if unrecognized and untreated | Months to years | At least 6 weeks; sometimes several months to years | Consciousness | Reduced/disturbed | Clear | Clear | Alertness | Fluctuates; lethargic or hypervigilant | Generally normal | Normal | Attention | Impaired; fluctuates; inattention; distractible | Generally normal | Minimal impairment but is easily distracted | Orientation | Generally impaired; severity varies | Generally normal to person but not to place or time | Selective disorientation | Memory | Recent and immediate impaired; forgetful; many need instructions for simple tasks one step at a time | Recent and remote impaired | Selective or “patchy” impairment; “islands” of intact memory; evaluation often difficult because of low motivation | Thinking | Disorganized, distorted, fragmented, illogical; incoherent speech, either slow or accelerated | Difficulty with abstraction; thoughts diminished; judgment impaired; words difficult to find | Intact but with themes of hopelessness, helplessness, or self-deprecation | Perception | Distorted, illusions, delusions, and hallucinations; difficulty distinguishing between reality and misperceptions | Misperceptions usually absent | Intact; delusions and hallucinations absent except in severe cases | Psychomotor behavior | Variable; hypokinetic, hyperkinetic, and mixed | Normal; some have apraxia | Variable; psychomotor retardation or agitation | Sleep/wake cycle | Disturbed; cycle reversed | Fragmented | Disturbed; usually early morning awakening | Associated features | Variable affective changes; symptoms of autonomic hyperarousal; exaggeration of personality type; associated with acute physical illness | Affect tends to be superficial, inappropriate, and labile (changing); attempts to hide deficits in intellect; personality changes, aphasia, agnosia sometimes present; lacks insight | Affect depressed; dysphoric mood; exaggerated and detailed complaints; preoccupied with personal thoughts; insight present; verbal elaboration; somatic complaints, poor hygiene, neglect of self | Assessment | Distracted from task; makes numerous errors | Failings highlighted by family, frequent “near miss” answers; struggles with test; great effort to find an appropriate reply; frequent requests for feedback on performance | Failings highlighted by individual, frequent “don't knows”; little effort; frequently gives up; indifferent toward test; does not care or attempt to find answer |

Delirium p. 179
--Delirium, or acute confusional state, is potentially a reversible cognitive impairment that often has a physiological cause. Physiological causes include electrolyte imbalances; cerebral anoxia; hypoglycemia; medication effects; tumors; subdural hematomas; and cerebrovascular infection, infarction, or hemorrhage. Delirium in older adults sometimes accompanies systemic infections and is often the presenting symptom for pneumonia or urinary tract infection. Sometimes it is also caused by environmental factors such as sensory deprivation or unfamiliar surroundings or psychosocial factors such as emotional distress or pain. Sleep deprivation is another possible reason for delirium. Although it occurs in any setting, an older adult in the acute care setting is especially at risk because of predisposing factors (physiological, psychosocial, and environmental) in combination with the underlying medical condition. Dementia is an additional risk factor that greatly increases the risk for delirium, and it is possible for delirium and dementia to occur in a patient at the same time. The presence of delirium is a medical emergency and requires prompt assessment and intervention. Nurses are at the bedside 24/7 and in a position to recognize delirium development and report it. The cognitive impairment usually reverses once health care providers identify and treat the cause of delirium.

Box 30-31 Clinical Criteria for Delirium p. 556 Definition: An acute disturbance of consciousness that is accompanied by a change in cognition. It is not caused by a preexisting or evolving dementia. Delirium develops over a short period of time, usually hours to days, and tends to fluctuate during the course of the day. It is usually a direct physiological consequence of a general medical condition. It is most common in older adults but occurs occasionally in younger patients.• There is reduced clarity of awareness of the environment.• Ability to focus, sustain, or shift attention is impaired (questions must be repeated).• Irrelevant stimuli easily distract the person.• There is an accompanying change in cognition (memory impairment, disorientation, or language disturbance).• Recent memory is commonly affected.• Disorientation usually occurs, with patient disoriented to time, place, or person.• Language disturbance involves impaired ability to name objects or ability to write; speech is sometimes rambling.• Perceptual disturbances include misinterpretations, delusions, or visual and auditory hallucinations. Neurological signs include tremor, unsteady gait, asterixis, or myoclonus. |

Dementia p. 179
--Dementia is a generalized impairment of intellectual functioning that interferes with social and occupational functioning. It is an umbrella term that includes Alzheimer's disease, Lewy body disease, frontal-temporal dementia, and vascular dementia. Cognitive function deterioration leads to a decline in the ability to perform basic ADLs. Unlike delirium, a gradual, progressive, irreversible cerebral dysfunction characterizes dementia. Because of the similarity between delirium and dementia, you need to assess carefully to rule out the presence of delirium whenever you suspect dementia.
--Nursing management of older adults with any form of dementia always considers the safety and physical and psychosocial needs of the older adult and the family. These needs change as the progressive nature of dementia leads to increased cognitive deterioration. To meet the needs of the older adult, individualize nursing care to enhance quality of life and maximize functional performance by improving cognition, mood, and behavior.

Depression p. 180
--Approximately one third of older adults experience depressive symptoms. Older adults sometimes experience late-life depression, but it is not a normal part of aging. Depression is the most common, yet most undetected and untreated, impairment in older adulthood. Co-occurring diseases may include stroke, dementia, Parkinson's disease, heart disease, cancer, and pain-provoking diseases such as arthritis. Loss of a significant loved one or a nursing center admission may precipitate depression. Clinical depression is treatable and includes medication, psychotherapy, or a combination of both. Of special note, suicide attempts in older adults are often successful. In fact, suicide in older adults comprises 20% of all suicides.

Box 14-6 Nursing Care Principles for Care of Cognitively Impaired Older Adults • Institute medical measures to correct underlying physiological alterations.• Maximize safe function. Keep a routine, limit choices (e.g., clothes for dressing, what to eat), allow for rest.• Provide unconditional positive regard. Be respectful. Nonverbal communication also should be positive.• Use behaviors to gauge activity and stimulation. Watch for facial signs of anxiety.• Teach caregivers to listen to the behaviors that show stress (e.g., verbalizations such as repetition).• Modify the environment.• Promote social interaction based on abilities. Make sure that the environment is safe for mobility and promote way-finding with pictures or cues. Try to identify patients who wander and remove the cause (e.g., pain, thirst, unfamiliar surroundings, new noises).• Compensate for any sensory deficits (e.g., hearing aids, glasses, dentures).• Encourage fluid intake (make sure that fluids are accessible) and avoid long periods of giving nothing orally.• Be vigilant for drug reactions or interactions; consider onset of new symptoms as an adverse reaction.• Activate bed and chair alarms.• Provide ongoing assistance to family caregivers; educate them in nursing care techniques and inform them about community resources. |

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Health Promotion and Maintenance: Psychosocial Health Concerns p. 186-188
--Interventions supporting the psychosocial health of older adults resemble those for other age-groups. However, some interventions are more crucial for older adults experiencing social isolation; cognitive impairment; or stresses related to retirement, relocation, or approaching death.

Therapeutic Communication: Therapeutic communication skills enable you to perceive and respect the older adult's uniqueness and health care expectations. Attentive nurses provide care in a timely fashion, meeting a patient's expressed or unexpressed needs. A caring nurse expresses attitudes of concern, kindness, and compassion. Knowledgeable nurses not only demonstrate procedural competence but recognize needs and relay information skillfully. Patients accept and respect nurses who meet these expectations and communicate effectively about concern for the older adult's welfare. However, you cannot simply enter an older adult's environment and immediately establish a therapeutic relationship. First you have to be knowledgeable and skilled in communication techniques.

Touch: Touch is a therapeutic tool that you use to help comfort older adults. A pilot study showed that agitation levels were significantly lower in demented older adults who received a healing touch intervention. Touch provides sensory stimulation, induces relaxation, provides physical and emotional comfort, orients the person to reality, shows warmth, and communicates interest. It is a powerful physical expression of a relationship.
--Older adults are often deprived of touching when separated from family or friends. An older adult who is isolated, dependent, or ill; who fears death; or who lacks self-esteem has a greater need for touch. You recognize touch deprivation by behaviors as simple as an older adult reaching for the nurse's hand or standing close to the nurse. Unfortunately older men are sometimes wrongly accused of sexual advances when they reach out to touch others. When you use touch, be aware of cultural variations and individual preferences. Touch should convey respect and sensitivity. Do not use it in a condescending way such as patting an older adult on the head. When you reach out to an older adult, do not be surprised if the older adult reciprocates.

Reality Orientation: Reality orientation is a communication technique that makes an older adult more aware of time, place, and person. The purposes of reality orientation include restoring a sense of reality; improving the level of awareness, promoting socialization; elevating independent functioning; and minimizing confusion, disorientation, and physical regression. Although you use reality orientation techniques in any health care setting, they are especially useful in the acute care setting. The older adult experiencing a change in environment, surgery, illness, or emotional stress is at risk for becoming disoriented. Environmental changes such as the bright lights, unfamiliar noises, and lack of windows in specialized units of a hospital often lead to disorientation and confusion. Absence of familiar caregivers is also disorienting. Using anesthesia, sedatives, tranquilizers, analgesics, and physical restraints with older patients increases disorientation. Anticipate and monitor for disorientation and confusion as possible consequences of hospitalization, relocation, surgery, loss, or illness and incorporate interventions based on reality orientation into the care plan.
The principles of reality orientation offer useful guidelines for communicating with acutely confused individuals. The key elements of reality orientation include frequent reminders of person, time, and place; the use of environmental aids such as clocks, calendars, and personal belongings; and stability of environment, routine, and staff. However, do not continue to reorient older adults with chronic cognitive impairment. Communication is always respectful, patient, and calm. Answer questions from the older adult simply and honestly with sensitivity and a caring attitude.

Validation Therapy: Validation therapy is an alternative approach to communication with a confused older adult. Whereas reality orientation insists that the confused older adult agree with our statements of time, place, and person, validation therapy accepts the description of time and place as stated by the confused older adult. Older adults with dementia are less likely to benefit and more likely to become agitated by a caregiver's insistence on the “correct” time, place, and person. In validation therapy you do not challenge or argue with statements and behaviors of the confused older adult. They represent an inner need or feeling. For example, the person might insist that the day is actually a different day because of high anxiety. The appropriate nursing intervention is to recognize and address that inner need or feeling. Validation does not involve reinforcing the confused older adult's misperceptions; it reflects sensitivity to hidden meanings in statements and behaviors. By listening with sensitivity and validating what the patient is expressing, you convey respect, reassurance, and understanding. Validating or respecting confused older adults’ feelings in the time and place that is real to them is more important than insisting on the literally correct time and place.

Reminiscence: Reminiscence is recalling the past. Many older adults enjoy sharing past experiences. As a therapy, reminiscence uses the recollection of the past to bring meaning and understanding to the present and resolve current conflicts. Looking back to positive resolutions of problems reminds the older adult of coping strategies used successfully in the past. Reminiscing is also a way to express personal identity. Reflection on past achievements supports self-esteem. For some older adults the process of looking back on past events uncovers new meanings for those events.
During the assessment process use reminiscence to assess self-esteem, cognitive function, emotional stability, unresolved conflicts, coping ability, and expectations for the future. For example, have a patient talk about a previous loss to assess coping. You can also reminisce during direct care activities. Taking time to ask questions about past experiences and listening attentively conveys to an older adult your attitudes of respect and concern.
Although many use reminiscence in a one-on-one situation, it is also used as a group therapy for cognitively impaired or depressed older adults. The nurse organizes the group and selects strategies to start a conversation. For example, the nurse asks the group to discuss family activities or childhood memories. He or she adapts the group's size, structure, process, goals, and activities to meet its members’ needs.

Body-Image Interventions: The way that older adults present themselves influences body image and feelings of isolation. Some physical characteristics of older adulthood such as distinguished-looking gray hair are socially desirable. Other features such as a lined face that displays character or wrinkled hands that show a lifetime of hard work are also impressive. However, too often society sees older people as incapacitated, deaf, obese, or shrunken in stature. Consequences of illness and aging that threaten the older adult's body image include invasive diagnostic procedures, pain, surgery, loss of sensation in a body part, skin changes, and incontinence. The use of devices such as dentures, hearing aids, artificial limbs, indwelling catheters, ostomy devices, and enteral feeding tubes also affects body image.
The nurse needs to consider the importance to the older adult of presenting a socially acceptable image. When older adults have acute or chronic illnesses, the related physical dependence makes it difficult for them to maintain body image. You influence the older adult's appearance by helping with grooming and hygiene. It takes little effort to help the older adult comb hair, clean dentures, shave, or change clothing. He or she does not choose to have an objectionable appearance. Be sensitive to odors in the environment. Odors created by urine and some illnesses are often present. By controlling odors you may prevent visitors from shortening their stay or not coming at all.

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Older Adults and the Acute Care Setting p. 187
--Older adults in the acute care setting need special attention to help them adjust to the acute care environment and meet their basic needs. The acute care setting poses increased risk for adverse events such as delirium, dehydration, malnutrition, health care–associated infections (HAIs), urinary incontinence, and falls. The risk for delirium increases when hospitalized older adults experience immobilization, sleep deprivation, infection, dehydration, pain, sensory impairment, drug interactions, anesthesia, and hypoxia. Nonmedical causes of delirium include placement in unfamiliar surroundings and staff, bed rest, separation from supportive family members, and stress. Impaired vision or hearing contributes to confusion and interferes with attempts to reorient the older adult. When the prevention of delirium fails, nursing management begins with identifying and treating the cause. Supportive interventions include encouraging family visits, providing memory cues (clocks, calendars, and name tags), and compensating for sensory deficits. Reality orientation techniques are also useful.
--Older adults are at greater risk for dehydration and malnutrition during hospitalization because of standard procedures such as limiting food and fluids in preparation for diagnostic tests and medications that decrease appetite. The risk for dehydration and malnutrition increases when older adults are unable to reach beverages or feed themselves while in bed or connected to medical equipment. Interventions include getting the patient out of bed, providing beverages and snacks frequently, and including favorite foods and beverages in the diet plan.
--The increased risk for HAIs in older adults is associated with age-related reductions in immune system responses. Urinary catheter–related bacteriuria in older adults is the most common type. Other HAIs in this population include infection at the surgical site, pneumonia, and bloodstream infections. Prevention begins with hand hygiene and measures to minimize the risk of infection from procedures.
--Older hospitalized adults in acute care are at risk for becoming incontinent of urine (transient incontinence). Causes of incontinence include delirium, untreated urinary tract infection, medications, restricted mobility or need for assistance to get to the bathroom, and constipation or stool impaction. Interventions to decrease incontinence include individualized care planning to provide voiding opportunities and modification of the environment to improve access to the toilet. Avoid indwelling urinary catheterization and promote measures to prevent skin breakdown. The increased risk for skin breakdown and the development of pressure ulcers is related to changes in aging skin and to situations that occur in the acute care setting such as immobility, incontinence, and malnutrition. The key points in the prevention of skin breakdown are avoiding pressure with proper positioning and use of a support surface based on risk status, reducing shear forces and friction, providing meticulous skin care and moisture management, and providing nutritional support.
--Older adults in the acute care setting are at risk for falling and sustaining injuries. The cause of a fall is typically multifactorial and composed of intrinsic or extrinsic factors. Sedative and hypnotic medications increase unsteadiness. Medications causing orthostatic hypotension also increase the risk for falls because of the blood pressure drop when the older adult gets out of a bed or chair. The increase in urine output from diuretics increases the risk for falling by increasing the number of attempts to get out of bed to void. Attempts to get out of bed when physically restrained sometimes lead to injury when the older adult becomes entangled in the restraint. Equipment such as wires from monitors, intravenous tubing, urinary catheters, and other medical devices become obstacles to safe ambulation. Impaired vision prevents the older adult from seeing tripping hazards such as trash cans.
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Neurological system p. 555

Data collected in the nursing history
TABLE 30-36 Nursing History for Neurological Assessment p. 555 ASSESSMENT | RATIONALE | Determine if patient uses analgesics, alcohol, sedatives, hypnotics, antipsychotics, antidepressants, nervous system stimulants, or recreational drugs. | These medications alter level of consciousness or cause behavioral changes. Abuse sometimes causes tremors, ataxia, and changes in peripheral nerve function. | Determine if patient has recent history of seizures/convulsions: clarify sequence of events (aura, fall to ground, motor activity, loss of consciousness); character of any symptoms; and relationship of seizure to time of day, fatigue, or emotional stress. | Seizure activity often originates from central nervous system alteration. Characteristics of seizure help determine its origin. | Screen patient for symptoms of headache, tremors, dizziness, vertigo, numbness or tingling of body part, visual changes, weakness, pain, or changes in speech. Presence of any symptom requires more detailed review (onset, severity, precipitating factors or sequence of events). | These symptoms frequently originate from alterations in central or peripheral nervous system function. Identification of specific patterns aids in diagnosis of pathological condition. | Discuss with patient's family any recent changes in patient's behavior (e.g., increased irritability, mood swings, memory loss, change in energy level). | Behavioral changes sometimes result from intracranial pathological states. | Assess patient for history of change in vision, hearing, smell, taste, or touch. | Major sensory nerves originate from brainstem. These symptoms help to localize nature of problem. | If an older patient displays sudden acute confusion (delirium), review history for drug toxicity (anticholinergics, diuretics, digoxin, cimetidine, sedatives, antihypertensives, antiarrhythmics), serious infections, metabolic disturbances, heart failure, and severe anemia. | Delirium is one of the most common mental disorders in older persons. Condition is always potentially reversible. | Review past history for head or spinal cord injury, meningitis, congenital anomalies, neurological disease, or psychiatric counseling. | Factors cause neurological symptoms or behavioral changes to develop, focusing assessment on possible cause. |

Neurological System p. 555
--The neurological system is responsible for many functions, including initiation and coordination of movement, reception and perception of sensory stimuli, organization of thought processes, control of speech, and storage of memory. A close integration exists between the neurological system and all other body systems. For example, urine production relies in part on the adequacy of blood flow to the kidneys, and the size of arterioles supplying the kidneys is under neural control.
--A full assessment of neurological function requires much time and attention to detail. For efficiency, integrate neurological measurements with other parts of the physical examination. For example, test cranial nerve function while assessing the head and neck. Observe mental and emotional status during the initial interview.
--Consider many variables when deciding the extent of the neurological examination. A patient's level of consciousness influences his or her ability to follow directions. General physical status influences tolerance to assessment. A patient's chief complaint also helps determine the need for a thorough neurological assessment. If a patient complains of headache or a recent loss of function in an extremity, he or she needs a complete neurological review. You will need the following items for a complete examination:
• Reading material
• Vials containing aromatic substances (e.g., vanilla extract and coffee)
• Opposite tip of cotton swab or tongue blade broken in half
• Snellen eye chart
• Penlight
• Vials containing sugar or salt
• Tongue blade
• Two test tubes, one filled with hot water and the other with cold water
• Cotton balls or cotton-tipped applicators
• Tuning fork
• Reflex hammer

• Reading material
• Vials containing aromatic substances (e.g., vanilla extract and coffee)
• Opposite tip of cotton swab or tongue blade broken in half
• Snellen eye chart
• Penlight
• Vials containing sugar or salt
• Tongue blade
• Two test tubes, one filled with hot water and the other with cold water
• Cotton balls or cotton-tipped applicators
• Tuning fork
• Reflex hammer

Mental and Emotional Status p. 555
--You learn a great deal about mental capacities and emotional state simply by interacting with a patient. Ask questions during an examination to gather data and observe the appropriateness of emotions and thoughts. Special assessment tools are designed to assess a patient's mental status. The Mini-Mental State Examination (MMSE) is an instrument that measures orientation and cognitive function. The maximum score on the MMSE is 30. Patients with scores of 21 or less generally reveal cognitive impairment requiring further evaluation.
--To ensure an objective assessment, consider a patient's cultural and educational background, values, beliefs, and previous experiences. Such factors influence response to questions. An alteration in mental or emotional status reflects a disturbance in cerebral functioning. The cerebral cortex controls and integrates intellectual and emotional functioning. Primary brain disorders, medication, and metabolic changes are examples of factors that change cerebral function.
Delirium is an acute mental disorder that occurs among hospitalized patients. Obtain a thorough history of a patient's behavior before delirium develops so as to recognize the condition early. Family members are usually a good resource. Among older adults delirium most often presents within the first 48 to 72 hours of hospital admission. It is an acute mental disorder characterized by confusion, disorientation, and restlessness. It is often a sign of an impending or underlying physical illness in older adults. The acute condition differs from dementia, a more progressive, organic mental disorder such as Alzheimer's disease. You need to recognize the difference so you can try to learn the underlying cause of delirium. Fortunately the condition often reverses when it is correctly assessed and the underlying cause is treated (i.e., central nervous system [CNS], metabolic, and cardiopulmonary disorders; systemic illnesses; and sensory deprivation or overload). To avoid misdiagnosis you need to adequately assess mental status. Frequently patients who develop delirium are labeled with “sundown syndrome” because the delirium frequently worsens at night. Many practitioners mistake this as being common with old age. Be aware that children are vulnerable to delirium from causes such as infection, drugs, serious trauma, autoimmune disorders, general anesthesia, and after transplant.

Box 30-30 Mini-Mental State Examination Sample Questions p. 556 • Orientation to time“What is the date?”Watch the you-tube video on the Mini-Mental Status exam Watch the you-tube video on the Mini-Mental Status exam • Registration“Listen carefully. I am going to say three words. Say them back after I stop.Ready? Here they are …HOUSE (pause), CAR (pause), LAKE (pause). Now repeat these words back to me.”(Repeat up to 5 times but score only the first trial.)• Naming“What is this?” (Point to a pencil or pen.)• Reading“Please read this and do what it says.” (Show examinee the words on the stimulus form.)CLOSE YOUR EYES |

Level of Consciousness p. 556
--A person's level of consciousness exists along a continuum from full awakening, alertness, and cooperation to unresponsiveness to any form of external stimuli. Talk with the patient, asking questions about events involving his or her concerns about any health problems. A fully conscious patient responds to questions quickly and expresses ideas logically. With a lowering of a patient's consciousness, use the Glasgow Coma Scale (GCS) for an objective measurement of consciousness on a numerical scale. The patient needs to be as alert as possible before testing. Take care when using the scale if the patient has sensory losses (e.g., vision or hearing). The GCS allows evaluation of a patient's neurological status over time. The higher the score, the better the patient's neurological function. Ask short, simple questions such as “What is your name?” “Where are you?” and “What day is this?” Also ask the patient to follow simple commands such as “Move your toes.”
--If the patient is not conscious enough to follow commands, try to elicit the pain response. Apply firm pressure with the thumb over the root of the patient's fingernail. The normal response to the painful stimuli is withdrawal of the body part from the stimulus. A patient with serious neurological impairment exhibits abnormal posturing in response to pain. A flaccid response indicates the absence of muscle tone in the extremities and severe injury to brain tissue.

Watch the you-tube video on the Glasgow Coma Scale Watch the you-tube video on the Glasgow Coma Scale TABLE 30-37 Glasgow Coma Scale (The total score is the sum of the scores in the three categories) | ACTION | RESPONSE | SCORE | Eyes open | SpontaneouslyTo speechTo painNone | 4321 | Best verbal response | OrientedConfusedInappropriate wordsIncomprehensible soundsNone | 54321 | Best motor response | Obeys commandsLocalized painFlexion withdrawalAbnormal flexionAbnormal extensionFlaccid | 654321 | | TOTAL SCORE | 3 to 15 |

Behavior and Appearance p. 556
--Behavior, moods, hygiene, grooming, and choice of dress reveal pertinent information about mental status. Remain perceptive of a patient's mannerisms and actions during the entire physical assessment. Note nonverbal and verbal behaviors. Does the patient respond appropriately to directions? Does his or her mood vary with no apparent cause? Does he or she show concern about appearance? Is his or her hair clean and neatly groomed, and are the nails trim and clean? The patient should behave in a manner expressing concern and interest in the examination. He or she should make eye contact with you and express appropriate feelings that correspond to the situation. Normally the patient shows some degree of personal hygiene.
--Choice and fit of clothing reflect socioeconomic background or personal taste rather than deficiency in self-concept or self-care. Avoid being judgmental and focus assessment on the appropriateness of clothing for the weather. Older adults sometimes neglect their appearance because of a lack of energy, finances, or reduced vision.

--Normal cerebral function allows a person to understand spoken or written words and express the self through written words or gestures. Assess the patient's voice inflection, tone, and manner of speech. Normally a patient's voice has inflections, is clear and strong, and increases in volume appropriately. Speech is fluent. When communication is clearly ineffective (e.g., omission or addition of letters and words, misuse of words, or hesitations), assess for aphasia. Injury to the cerebral cortex results in aphasia.
--The two types of aphasia are sensory (or receptive) and motor (or expressive). With receptive aphasia a person cannot understand written or verbal speech. With expressive aphasia a person understands written and verbal speech but cannot write or speak appropriately when attempting to communicate. A patient sometimes suffers a combination of receptive and expressive aphasia. Assess language capabilities when it is clear that a patient is communicating ineffectively. Some simple assessment techniques include the following:
• Point to a familiar object, and ask the patient to name it.
• Ask the patient to respond to simple verbal and written commands such as “Stand up” or “Sit down.”
• Ask the patient to read simple sentences out loud.
Normally a patient names objects correctly, follows commands, and reads sentences correctly.

Watch the you-tube videos on aphasia

example of expressive aphasia same person at 3 years recovery

(Wernicke’s area – receptive aphasia)

Watch the you-tube videos on aphasia

example of expressive aphasia same person at 3 years recovery

(Wernicke’s area – receptive aphasia)

Intellectual Function p.557
--Intellectual function includes memory (recent, immediate, and past), knowledge, abstract thinking, association, and judgment. Testing each aspect of function involves a specific technique. However, because cultural and educational background influences the ability to respond to test questions, do not ask questions related to concepts or ideas with which a patient is unfamiliar.

Assess immediate recall and recent and remote memory. Patients demonstrate immediate recall by repeating a series of numbers (e.g., 7, 4, 1) in the order they are presented or in reverse order. Patients normally recall a series of five to eight digits forward and four to six digits backward.
--First ask to test the patient's memory. Then state clearly and slowly the name of three unrelated objects. After mentioning all three, ask the patient to repeat each. Continue until he or she is successful. Later in the assessment, ask the patient to repeat the three words again. He or she should be able to identify them. Another test for recent memory involves asking the patient to recall events occurring during the same day (e.g., what was eaten for breakfast). Validate information with a family member.
--To assess past memory, ask the patient to recall his or her mother's maiden name, a birthday, or a special date in history. It is best to ask open-ended rather than simple yes/no questions. A patient usually has immediate recall of such information. With older adults do not interpret hearing loss as confusion. Good communication techniques are essential throughout the examination to ensure that a patient clearly understands all directions and testing.

Assess knowledge by asking how much the patient knows about his or her illness or the reason for seeking health care. A knowledge assessment allows you to determine a patient's ability to learn or understand. If there is an opportunity to teach, test a patient's mental status by asking for feedback during a follow-up visit.

Abstract Thinking
Interpreting abstract ideas or concepts reflects the capacity for abstract thinking. For an individual to explain common phrases such as “A stitch in time saves nine” or “Don't count your chickens before they're hatched” requires a higher level of intellectual function. Note whether a patient's explanations are relevant and concrete. A patient with altered mental status probably interprets the phrase literally or merely rephrases the words. Other examples: ‘don’t cry over spilt milk.’ ‘It all comes out in the wash.’

Another higher level of intellectual functioning involves finding similarities or associations between concepts: a dog is to a beagle as a cat is to a Siamese. Name related concepts and ask the patient to identify their associations. Ask questions that are appropriate to the patient's level of intelligence, using simple concepts.

Judgment requires a comparison and evaluation of facts and ideas to understand their relationships and form appropriate conclusions. Attempt to measure the patient's ability to make logical decisions with questions such as “Why did you seek health care?” or “What would you do if you became ill at home?” Normally a patient makes logical decisions.

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Cranial Nerve Function p. 557

--To assess cranial nerve function, you may test all 12 cranial nerves, a single nerve, or related group of nerves. A dysfunction in one nerve reflects an alteration at some point along the distribution of the cranial nerve. Measurements used to assess the integrity of organs within the head and neck also assess cranial nerve function. A complete assessment involves testing the 12 cranial nerves in their numerical order. To remember the order of the nerves, use this simple phrase, “On old Olympus’ towering tops, a Finn and German viewed some hops.” (Oh Oh Oh To Touch And Feel Very Good Velvet, Such Heaven). The first letter of each word in the phrase is the same as the first letter of the names of the cranial nerves listed in order.

Watch the you-tube videos on the cranial nerves and basic neuro assessment. You will need to know these.

The fun way to learn the CN:

Watch the you-tube videos on the cranial nerves and basic neuro assessment. You will need to know these.

The fun way to learn the CN:

TABLE 30-38 Cranial Nerve Function and Assessment p. 558 NUMBER | NAME | TYPE | FUNCTION | METHOD | I | Olfactory | Sensory | Sense of smell | Ask patient to identify different nonirritating aromas such as coffee and vanilla. | II | Optic | Sensory | Visual acuity | Use Snellen chart or ask patient to read printed material while wearing glasses. | III | Oculomotor | Motor | -Extraocular eye movements: inward, up and inward, up and outward, down and outward-Pupil constriction and dilation-Opening the eye | -Assess six directions of gaze.-Measure pupillary reaction to light reflex and accommodation. | IV | Trochlear | Motor | Downward, inward eye movements | Assess six directions of gaze. | V | Trigeminal | Sensory and motor | -Sensory nerve to skin of face-Motor nerve to muscles of jaw | -Lightly touch cornea with wisp of cotton. Assess corneal reflex. Measure sensation of light pain and touch across skin of face.-Palpate temples as patient clenches teeth. | VI | Abducens | Motor | Lateral movement of eyeballs | Assess six directions of gaze. | VII | Facial | Sensory and motor | -Facial expression-Taste | -As patient smiles, frowns, puffs out cheeks, and raises and lowers eyebrows, look for asymmetry.-Have patient identify salty or sweet taste on front of tongue. | VIII | Auditory | Sensory | Hearing | Assess ability to hear spoken word. | IX | Glossopharyngeal | Sensory and motor | -Taste-Ability to swallow | -Ask patient to identify sour or sweet taste on back of tongue.-Use tongue blade to elicit gag reflex. | X | Vagus | Sensory and motor | -Sensation of pharynx-Movement of vocal cords | -Ask patient to say “ah.” Observe movement of palate and pharynx.-Assess speech for hoarseness. | XI | Spinal accessory | Motor | Movement of head and shoulders | Ask patient to shrug shoulders and turn head against passive resistance. | XII | Hypoglossal | Motor | Position of tongue | Ask patient to stick out tongue to midline and move it from side to side. |

Sensory Function p. 557
--The sensory pathways of the CNS conduct sensations of pain, temperature, position, vibration, and crude and finely localized touch. Different nerve pathways relay the sensations. Most patients require only a quick screening of sensory function unless there are symptoms of reduced sensation, motor impairment, or paralysis. The risk of skin breakdown is greater in a patient with impaired sensation. When assessing decreased sensation, complete a skin and tissue assessment of the area affected by the sensory loss. In addition, teach the patient to avoid pressure, thermal, and/or chemical trauma to the area.
--Normally a patient has sensory responses to all stimuli that are tested. He or she feels sensations equally on both sides of the body in all areas. Assess the major sensory nerves by knowing the sensory dermatome zones. Some areas of the skin are innervated by specific dorsal root cutaneous nerves. For example, if assessment reveals reduced sensation when checking for light touch along an area of the skin (e.g., the lower neck), this determines in general where a neurological lesion exists (e.g., fourth cervical spinal cord segment).
--Perform all sensory testing with the patient's eyes closed so he or she is unable to see when or where a stimulus touches the skin. Then touch the patient's skin in a random, unpredictable order to maintain his or her attention and prevent detection of a predictable pattern. Ask the patient to describe when, what, and where he or she feels each stimulus. Compare symmetrical areas of the body while applying stimuli to the patient's arms, trunk, and legs.

Dermatomes of body (body surface areas innervated by particular spinal nerves); C1 usually has no cutaneous distribution. A, Anterior view. B, Posterior view. It appears that there is a distinct separation of surface area controlled by each dermatome, but there is almost always overlap between spinal nerves. Dermatomes of body (body surface areas innervated by particular spinal nerves); C1 usually has no cutaneous distribution. A, Anterior view. B, Posterior view. It appears that there is a distinct separation of surface area controlled by each dermatome, but there is almost always overlap between spinal nerves.

TABLE 30-39 Assessment of Sensory Nerve Function p. 560 FUNCTION | EQUIPMENT | METHOD | PRECAUTIONS | Pain | Broken tongue blade or wooden end of cotton applicator | Ask patients to voice when they feel dull or sharp sensation. Alternately apply sharp and blunt ends of tongue blade to surface of skin. Note areas of numbness or increased sensitivity. | Remember that areas where skin is thick such as heel or sole of foot are less sensitive to pain. | Temperature | Two test tubes, one filled with hot water and another with cold | Touch skin with tube. Ask patient to identify hot or cold sensation. | Omit test if pain sensation is normal. | Light touch | Cotton ball or cotton-tip applicator | Apply light wisp of cotton to different points along surface of skin. Ask patients to voice when they feel a sensation. | Apply at areas where skin is thin or more sensitive (e.g., face, neck, inner aspect of arms, top of feet and hands). | Vibration | Tuning fork | Apply stem of vibrating fork to distal interphalangeal joint of fingers and interphalangeal joint of great toe, elbow, and wrist. Have patients voice when and where they feel vibration. | Be sure that patient feels vibration and not merely pressure. | Position | | Grasp finger or toe, holding it by its sides with thumb and index finger. Alternate moving finger or toe up and down. Ask patient to state when finger is up or down. Repeat with toes. | Avoid rubbing adjacent appendages as you move finger or toe. Do not move joint laterally; return to neutral position before moving again. | Two-point discrimination | Two broken tongue blades | Lightly apply one or both tongue blade tips simultaneously to the surface of the skin. Ask patients whether they feel one or two pricks. Find the distance at which patient can no longer distinguish two points. | Apply blade tips to same anatomical site (e.g., fingertips, palm of hand, or upper arms). Minimum distance at which patient discriminates two points varies (2 to 8 mm on fingertips). |
Motor Function p. 558
--An examination of motor function includes assessments made during the musculoskeletal examination. In addition, the nurse assesses cerebellar function. The cerebellum coordinates muscular activity, maintains balance and equilibrium, and controls posture.

--To avoid confusion, demonstrate each maneuver and then have the patient repeat it, observing for smoothness and balance in his or her movements. In older adults normally slow reaction time causes movements to be less rhythmical.
To assess fine-motor function, have the patient extend the arms out to the sides and touch each forefinger alternately to the nose (first with eyes open, then with eyes closed). Normally a patient alternately touches the nose smoothly. Performing rapid, rhythmical, alternating movements demonstrates coordination in the upper extremities. While sitting, the patient begins by patting the knees with both hands. Then he or she alternately turns up the palm and back of the hands while continuously patting the knees. Normally patients perform the maneuver smoothly and regularly with increasing speed.
An additional maneuver for upper-extremity coordination involves touching each finger with the thumb of the same hand in rapid sequence. A patient moves from the index finger to the little finger and back, with one hand tested at a time. The dominant hand is slightly less awkward when performing this movement. Movement is smooth and in succession.
Test lower-extremity coordination with the patient lying supine, legs extended. Place a hand at the ball of the patient's foot. The patient taps the hand with the foot as quickly as possible. Test each foot for speed and smoothness. The feet do not move as rapidly or evenly as the hands.

Use one or two of the following tests to assess balance and gross-motor function. When examining the older adult for balance and equilibrium, be aware of the risk for falls. Some older adults need help with this portion of the examination.
Have the patient perform a Romberg's test by standing with feet together, arms at the sides, both with eyes open and eyes closed. Protect the patient's safety by standing at the side, observe for swaying. Expect slight swaying of the body in the Romberg's test. A loss of balance (positive Romberg) causes a patient to fall to the side. Normally he or she does not break the stance.
Have the patient close the eyes, with arms held straight at the sides, and stand on one foot and then the other. Normally patients are able to maintain balance for 5 seconds with slight swaying. Another test involves asking the patient to walk a straight line by placing the heel of one foot directly in front of the toes of the other foot. Reflexes
Eliciting reflex reactions provides data about the integrity of sensory and motor pathways of the reflex arc and specific spinal cord segments. Assessment of reflexes does not determine higher neural center functioning. Each muscle contains a small sensory unit called a muscle spindle, which controls muscle tone and detects changes in the length of muscle fibers. Tapping a tendon with a reflex hammer stretches the muscle and tendon, lengthening the spindle. The spindle sends nerve impulses along afferent nerve pathways to the dorsal horn of the spinal cord segment. Within milliseconds the impulses reach the spinal cord and synapse to travel to the efferent motor neuron in the spinal cord. A motor nerve sends the impulses back to the muscle, causing the reflex response.

Pathway of the reflex arc.

Pathway of the reflex arc.

--The two categories of normal reflexes are deep tendon reflexes, elicited by mildly stretching a muscle and tapping a tendon, and cutaneous reflexes, elicited by stimulating the skin superficially.

Grade reflexes as follows:0: No response1+: Sluggish or diminished2+: Active or expected response3+: More brisk than expected, slightly hyperactive4+: Brisk and hyperactive with intermittent or transient clonus |

--When assessing reflexes have the patient relax as much as possible to avoid voluntary movement or tensing of muscles. Position the limbs to slightly stretch the muscle being tested. Hold the reflex hammer loosely between the thumb and fingers so it is able to swing freely and tap the tendon briskly. Compare the responses on corresponding sides. Normally the older adult presents with diminished reflexes. Reflexes are hyperactive in patients with alcohol, cocaine, or opioid intoxication.

TABLE 30-40 Assessment of Common Reflexes p. 561 TYPE | PROCEDURE | NORMAL REFLEX | Deep Tendon Reflexes | Biceps | Flex patient's arm up to 45 degrees at elbow with palms down. Place your thumb in antecubital fossa at base of biceps tendon and your fingers over biceps muscle. Strike biceps tendon with reflex hammer. | Flexion of arm at elbow | Triceps | Flex patient's arm at elbow, holding arm across chest, or hold upper arm horizontally and allow lower arm to go limp. Strike triceps tendon just above elbow. | Extension at elbow | Patellar | Have patient sit with legs hanging freely over side of table or chair or have him or her lie supine and support knee in a flexed 90-degree position. Briskly tap patellar tendon just below patella. | Extension of lower leg | Achilles | Have patient assume same position as for patellar reflex. Slightly dorsiflex patient's ankle by grasping toes in palm of your hand. Strike Achilles tendon just above heel at ankle malleolus. | Plantar flexion of foot | Cutaneous Reflexes | Plantar | Have patient lie supine with legs straight and feet relaxed. Take handle end of reflex hammer and stroke lateral aspect of sole from heel to ball of foot, curving across ball of foot toward big toe. | Plantar flexion of all toes | Abdominal | Have patient stand or lie supine. Stroke abdominal skin with base of cotton applicator over lateral borders of rectus abdominis muscle toward midline. Repeat test in each abdominal quadrant. | Contraction of rectus abdominis muscle with pulling of umbilicus toward stimulated side |

Fanning of the toes (Babinski’s) is normal in an infant; It is not normal in an adult.
Fanning of the toes (Babinski’s) is normal in an infant; It is not normal in an adult. --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---
Sensory Alterations CH 49 pages 1233-1251
--Sensory stimulation comes from many sources in and outside the body, particularly through the senses of sight (visual), hearing (auditory), touch (tactile), smell (olfactory), and taste (gustatory). The body also has a kinesthetic sense that enables a person to be aware of the position and movement of body parts without seeing them. Stereognosis is a sense that allows a person to recognize the size, shape, and texture of an object. The ability to speak is not a sense but it is similar in that some patients lose the ability to interact meaningfully with other human beings. Meaningful stimuli allow a person to learn about the environment and are necessary for healthy functioning and normal development. When sensory function is altered, a person's ability to relate to and function within the environment changes drastically.
Many patients seeking health care have preexisting sensory alterations. Others develop them as a result of medical treatment (e.g., hearing loss from antibiotic use or hearing or visual loss from brain tumor removal) or hospitalization. The health care environment is a place of unfamiliar sights, sounds, and smells and minimal contact with family and friends. If patients feel depersonalized and are unable to receive meaningful stimuli, serious sensory alterations sometimes develop. As a nurse, you meet the needs of patients with existing sensory alterations and recognize patients most at risk for developing sensory problems. You also help patients who have partial or complete loss of a major sense to find alternate ways to function safely within their environment.

Scientific Knowledge Base
Normal Sensation
The nervous system must be intact for sensory stimuli to reach appropriate brain centers and for an individual to perceive the sensation. After interpreting the significance of a sensation, the person is then able to react to the stimulus.
--Reception, perception, and reaction are the three components of any sensory experience. Reception begins with stimulation of a nerve cell called a receptor, which is usually for only one type of stimulus such as light, touch, or sound. In the case of special senses, the receptors are grouped close together or located in specialized organs such as the taste buds of the tongue or the retina of the eye. When a nerve impulse is created, it travels along pathways to the spinal cord or directly to the brain. For example, sound waves stimulate hair cell receptors within the organ of Corti in the ear, which causes impulses to travel along the eighth cranial nerve to the acoustic area of the temporal lobe. Sensory nerve pathways usually cross over to send stimuli to opposite sides of the brain.
--The actual perception or awareness of unique sensations depends on the receiving region of the cerebral cortex, where specialized brain cells interpret the quality and nature of sensory stimuli. When a person becomes conscious of a stimulus and receives the information, perception takes place. Perception includes integration and interpretation of stimuli based on the person's experiences. A person's level of consciousness influences perception and interpretation of stimuli. Any factors lowering consciousness impair sensory perception. If sensation is incomplete such as blurred vision or if past experience is inadequate for understanding stimuli such as pain, the person can react inappropriately to the sensory stimulus.
--It is impossible to react to all stimuli entering the nervous system. The brain prevents sensory bombardment by discarding or storing sensory information. A person usually reacts to stimuli that are most meaningful or significant at the time. However, after continued reception of the same stimulus, a person stops responding, and the sensory experience goes unnoticed. For example, a person concentrating on reading a good book is not aware of background music. This adaptability phenomenon occurs with most sensory stimuli except for those of pain.
--The balance between sensory stimuli entering the brain and those actually reaching a person's conscious awareness maintains a person's well-being. If an individual attempts to react to every stimulus within the environment or if the variety and quality of stimuli are insufficient, sensory alterations occur.

Sensory Alterations p. 1234
--The most common types of sensory alterations are sensory deficits, sensory deprivation, and sensory overload. When a patient suffers from more than one sensory alteration, the ability to function and relate effectively within the environment is seriously impaired.

Sensory Deficits
A deficit in the normal function of sensory reception and perception is a sensory deficit. A person loses a sense of self with impaired senses. Initially he or she withdraws by avoiding communication or socialization with others in an attempt to cope with the sensory loss. It becomes difficult for the person to interact safely with the environment until he or she learns new skills. When a deficit develops gradually or when considerable time has passed since the onset of an acute sensory loss, a person learns to rely on unaffected senses. Some senses may even become more acute to compensate for an alteration. For example, a blind patient develops an acute sense of hearing to compensate for visual loss.
Patients with sensory deficits often change behavior in adaptive or maladaptive ways. For example, a patient with a hearing impairment turns the unaffected ear toward the speaker to hear better, whereas another patient avoids people because he or she is embarrassed about not being able to understand what other people say.

Box 49-1 Common Sensory Deficits p. 1235 Visual DeficitsPresbyopia: A gradual decline in the ability of the lens to accommodate or focus on close objects. Individual is unable to see near objects clearly.Cataract: Cloudy or opaque areas in part of the lens or the entire lens that interfere with passage of light through the lens, causing problems with glare and blurred vision. Cataracts usually develop gradually, without pain, redness, or tearing in the eye.Dry eyes: Result when tear glands produce too few tears, resulting in itching, burning, or even reduced vision.Glaucoma: A slowly progressive increase in intraocular pressure that, if left untreated, causes progressive pressure against the optic nerve, resulting in peripheral visual loss, decreased visual acuity with difficulty adapting to darkness, and a halo effect around lights.Diabetic retinopathy: Pathological changes occur in the blood vessels of the retina, resulting in decreased vision or vision loss caused by hemorrhage and macular edema.Macular degeneration: Condition in which the macula (specialized portion of the retina responsible for central vision) loses its ability to function efficiently. First signs include blurring of reading matter, distortion or loss of central vision, and distortion of vertical lines. | Hearing DeficitsPresbycusis: A common progressive hearing disorder in older adults.Cerumen accumulation: Buildup of earwax in the external auditory canal. Cerumen becomes hard and collects in the canal and causes conduction deafness. | Balance DeficitDizziness and disequilibrium: Common condition in older adulthood, usually resulting from vestibular dysfunction. Frequently a change in position of the head precipitates an episode of vertigo or disequilibrium. | Taste DeficitXerostomia: Decrease in salivary production that leads to thicker mucus and a dry mouth. Often interferes with the ability to eat and leads to appetite and nutritional problems. | Neurological DeficitsPeripheral neuropathy: Disorder of the peripheral nervous system, characterized by symptoms that include numbness and tingling of the affected area and stumbling gait.Stroke: Cerebrovascular accident caused by clot, hemorrhage, or emboli disrupting blood flow to the brain. Creates altered proprioception with marked incoordination and imbalance. Loss of sensation and motor function in extremities controlled by the affected area of the brain also occurs. A stroke affecting the left hemisphere of the brain results in symptoms on the right side such as difficulty with speech. A stroke on the right hemisphere has symptoms on the left side, which includes visual spatial alterations such as loss of half of a visual field or inattention and neglect, especially to the left side. |

Sensory Deprivation
The reticular activating system in the brainstem mediates all sensory stimuli to the cerebral cortex; thus patients are able to receive stimuli even while sleeping deeply. Sensory stimulation must be of sufficient quality and quantity to maintain a person's awareness. Three types of sensory deprivation are reduced sensory input (sensory deficit from visual or hearing loss), the elimination of patterns or meaning from input (e.g., exposure to strange environments), and restrictive environments (e.g., bed rest) that produce monotony and boredom.
--In adults the symptoms are similar to psychological illness, confusion, symptoms of severe electrolyte imbalance, or the influence of psychotropic drugs. Therefore always be aware of a patient's existing sensory function and the quality of stimuli within the environment.

Box 49-2 Effects of Sensory Deprivation p. 1235 Cognitive• Reduced capacity to learn• Inability to think or problem solve• Poor task performance• Disorientation• Bizarre thinking• Increased need for socialization, altered mechanisms of attentionAffective• Boredom

• Restlessness• Increased anxiety• Emotional lability• Panic• Increased need for physical stimulationPerceptual• Changes in visual/motor coordination• Reduced color perception• Less tactile accuracy• Changes in ability to perceive size and shape• Changes in spatial and time judgment |

Sensory Overload p. 1235
--When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation prevents the brain from responding appropriately to or ignoring certain stimuli. Because of the multitude of stimuli leading to overload, a person no longer perceives the environment in a way that makes sense. Overload prevents meaningful response by the brain; the patient's thoughts race, attention scatters in many directions, and anxiety and restlessness occur. As a result, overload causes a state similar to that produced by sensory deprivation. However, in contrast to deprivation, overload is individualized. The amount of stimuli necessary for healthy function varies with each individual. People are often subject to environmental overload more at one time than another. A person's tolerance to sensory overload varies with level of fatigue, attitude, and emotional and physical well-being.
--The acutely ill patient easily experiences sensory overload. The patient in constant pain or who undergoes frequent monitoring of vital signs is at risk. Multiple stimuli combine to cause overload even if the nurse offers a comforting word or provides a gentle back rub. Some patients do not benefit from nursing intervention because their attention and energy are focused on more stressful stimuli. Another example is a patient who is hospitalized in an intensive care unit (ICU), where the activity is constant. Lights are always on. Patients can hear sounds from monitoring equipment, staff conversations, equipment alarms, and the activities of people entering the unit. Even at night an ICU is very noisy.
It is easy to confuse the behavioral changes associated with sensory overload with mood swings or simple disorientation. Look for symptoms such as racing thoughts, scattered attention, restlessness, and anxiety. Patients in ICUs sometimes resort to constantly fingering tubes and dressings. Constant reorientation and control of excessive stimuli become an important part of a patient's care.

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Nursing Knowledge Base p. 1236
Factors Influencing Sensory Function
Many factors influence the capacity to receive or perceive stimuli.

--Infants and children are at risk for visual and hearing impairment because of a number of genetic, prenatal, and postnatal conditions. A concern with high-risk neonates is that early, intense visual and auditory stimulation can adversely affect visual and auditory pathways and alter the developmental course of other sensory organs. Visual changes during adulthood include presbyopia and the need for glasses for reading. These changes usually occur from ages 40 to 50. In addition, the cornea, which assists with light refraction to the retina, becomes flatter and thicker. These aging changes lead to astigmatism. Pigment is lost from the iris, and collagen fibers build up in the anterior chamber, which increases the risk of glaucoma by decreasing the resorption of intraocular fluid. Other normal visual changes associated with aging include reduced visual fields, increased glare sensitivity, impaired night vision, reduced depth perception, and reduced color discrimination.
--Hearing changes begin at the age of 30. Changes associated with aging include decreased hearing acuity, speech intelligibility, and pitch discrimination. Low-pitched sounds are easiest to hear, but it is difficult to hear conversation over background noise. It is also difficult to discriminate the consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k). Vowels that have a low pitch are easiest to hear. Speech sounds are distorted, and there is a delayed reception and reaction to speech. A concern with normal age-related sensory changes is that older adults with a deficit are sometimes inappropriately diagnosed with dementia.
--Gustatory and olfactory changes begin around age 50 and include a decrease in the number of taste buds and sensory cells in the nasal lining. Reduced taste discrimination and sensitivity to odors are common.
Proprioceptive changes common after age 60 include increased difficulty with balance, spatial orientation, and coordination. Older adults cannot avoid obstacles as quickly, and the automatic response to protect and brace oneself when falling is slower. Older adults experience tactile changes, including declining sensitivity to pain, pressure, and temperature secondary to peripheral vascular disease and neuropathies.

Meaningful Stimuli
--Meaningful stimuli reduce the incidence of sensory deprivation. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock. The same stimuli need to be present in health care settings. Note whether patients have roommates or visitors. The presence of others offers positive stimulation. However, a roommate who constantly watches television, persistently tries to talk, or continuously keeps lights on contributes to sensory overload. The presence or absence of meaningful stimuli influences alertness and the ability to participate in care.

Amount of Stimuli
--Excessive stimuli in an environment causes sensory overload. The frequency of observations and procedures performed in an acute health care setting are often stressful. If a patient is in pain or restricted by a cast or traction, overstimulation frequently is a problem. In addition, a room that is near repetitive or loud noises (e.g., an elevator, stairwell, or nurses’ station) contributes to sensory overload.

Social Interaction
--The amount and quality of social contact with supportive family members and significant others influence sensory function. The absence of visitors during hospitalization or residency in an extended care facility influences the degree of isolation a patient feels. This is a common problem in hospital intensive care settings, where visitation is often restricted. The ability to discuss concerns with loved ones is an important coping mechanism for most people. Therefore the absence of meaningful conversation results in feelings of isolation, loneliness, anxiety, and depression for a patient. Often this is not apparent until behavioral changes occur.

Environmental Factors
--A person's occupation places him or her at risk for hearing, visual, and peripheral nerve alterations. Individuals who have occupations involving exposure to high noise levels (e.g., factory or airport workers) are at risk for noise-induced hearing loss and need to be screened for hearing impairments. Hazardous noise is common in work settings and recreational activities. Noisy recreational activities that weaken hearing ability include target shooting and hunting, woodworking, and listening to loud music. Individuals who have occupations involving risk of exposure to chemicals or flying objects (e.g., welders) are at risk for eye injuries and need to be screened for visual impairments. Sports activities and consumer fireworks also place individuals at risk for visual alterations. Occupations that involve repetitive wrist or finger movements (e.g., heavy assembly line work) cause pressure on the median nerve, resulting in carpal tunnel syndrome. Carpal tunnel syndrome alters tactile sensation and is one of the most common industrial or work-related injuries. Patients at risk for carpal tunnel need to be carefully assessed for numbness, tingling, weakness, and pain.
--A hospitalized patient is sometimes at risk for sensory alterations as a result of exposure to environmental stimuli or a change in sensory input. Patients who are immobilized by bed rest or who have a chronic disability are unable to experience all of the normal sensations of free movement. Another group at risk includes patients isolated in a health care setting or at home because of conditions such as active tuberculosis. These patients stay in private rooms and are often unable to enjoy normal interactions with visitors.

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Nursing Process p. 1237
The nursing process provides a clinical decision-making approach for you to develop and implement an individualized plan of care for your patients.

During the assessment process, thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care.

Through the Patient's Eyes
--When conducting an assessment, value the patient as a full partner in planning, implementing, and evaluating care. Patients are often hesitant to admit sensory losses. Therefore start gathering information by establishing a therapeutic rapport with the patient. Elicit his or her values, preferences, and expectations with regard to his or her sensory impairment. Many patients have a definite plan as to how they want their care delivered. Some patients expect caregivers to recognize and appropriately manage and adjust their environment to meet their sensory needs. This includes helping the patient learn and adapt to a changed lifestyle based on the specific sensory impairment. Determine from the patient which interventions have been helpful in the past in the management of limitations. Assess the patient's expertise with his or her own health and symptoms. Always remember that patients with sensory alterations have strengthened their other senses and expect caregivers to anticipate their needs (e.g., for safety and security).
--When assessing a patient with or at risk for sensory alteration, first consider the pathophysiology of existing deficits and the factors influencing sensory function to anticipate how to approach his or her assessment. For example, if a patient has a hearing disorder, adjust your communication style and focus the assessment on relevant criteria related to hearing deficits. Collect a history that also assesses the patient's current sensory status and the degree to which a sensory deficit affects the patient's lifestyle, psychosocial adjustment, developmental status, self-care ability, health promotion habits, and safety. Also focus the assessment on the quality and quantity of stimuli within the patient's environment.

Persons at Risk
--Older adults are a high-risk group because of normal physiological changes involving sensory organs. However, be careful not to automatically assume that a patient's sensory problem is related to advancing age. For example, adult sensorineural hearing loss is often caused by exposure to excess and prolonged noise or metabolic, vascular, and other systemic alterations. Some patients benefit from a referral to an audiologist or otolaryngologist if assessment reveals serious hearing problems.
--Other individuals at risk for sensory alterations include those living in a confined environment such as a nursing home. Although most quality nursing homes or centers offer meaningful stimulation through group activities, environmental design, and mealtime gatherings, there are exceptions. The individual who is confined to a wheelchair, suffers from poor hearing and/or vision, has decreased energy, and avoids contact with others is at significant risk for sensory deprivation. If the environment creates monotony, the individual is less able to learn and think. Patients who are acutely ill are also at risk because of an unfamiliar and unresponsive environment. This does not mean that all hospitalized patients have sensory alterations. However, you need to carefully assess patients subjected to continued sensory stimulation (e.g., ICU settings, long-term hospitalization, or multiple therapies). Assess the patient's environment within both the health care setting and the home, looking for factors that pose risks or need adjustment to provide safety and more stimulation.

Box 49-5 Nursing Assessment Questions Nature of the Problem• What type of problem are you having with your vision/hearing?• What have you tried to correct the vision/hearing difficulty?• Do you use any devices to improve your vision/hearing?Signs and Symptoms• Ask a patient with visual alterations: Do you require books with large print or on audiotape? Are you able to prepare a meal or write a check?• Ask a patient with hearing alterations: What types of sounds or tones do you have difficulty hearing? Do people tell you that they have to “shout” for you to hear them? Do you have a ringing, crackling, or buzzing in your ears?• Is there pain: sharp, dull, burning, itching?• Have you noticed any redness, swelling, or drainage? Any signs of infection?Onset and Duration• When did you notice the problem? How long has this problem lasted?• Does it come and go, or is it constant?Predisposing Factors• Do you work or participate in any activities that have the potential for vision/hearing injury? If so, how do you protect your hearing and vision?• Do you have a family history of cataracts, glaucoma, macular degeneration, or hearing loss?• When was your last vision/hearing examination?Effect on Patient• What effect has your vision/hearing problem had on your work, family, or social life?• Have changes in your vision/hearing affected your feelings of independence?• How does your vision/hearing problem make you feel about yourself?• Do you have problems with routine care of glasses, contact lenses, or hearing aids? |

Sensory Alterations History
The nursing history includes assessment of the nature and characteristics of sensory alterations or any problem related to an alteration. When taking the history, consider the ethnic or cultural background of the patient because certain alterations are higher in some cultural groups.
During the history it is useful to assess the patient's self-rating for a sensory deficit by asking, “Rate your hearing as excellent, good, fair, poor, or bad.” Then, based on the patient's self-rating, explore his or her perception of a sensory loss more fully. This provides an in-depth look at how the sensory loss influences the patient's quality of life. In the case of hearing problems, a screening tool such as the Hearing Handicap Inventory for the Elderly (HHIE-S) effectively identifies patients needing audiological intervention. The HHIE-S is a 5-minute, 10-item questionnaire that assesses how the individual perceives the social and emotional effects of hearing loss. The higher the HHIE-S score, the greater the handicapping effect of a hearing impairment.
--A nursing history also reveals any recent changes in a patient's behavior. Frequently friends or family are the best resources for this information. Ask the family the following questions:
• Has your family member shown any recent mood swings (e.g., outbursts of anger, nervousness, fear, or irritability)?
• Have you noticed the family member avoiding social activities?

TABLE 49-2 Assessment of Sensory Function p. 1239 ASSESSMENT ACTIVITIES | BEHAVIOR INDICATING DEFICIT (CHILDREN) | BEHAVIOR INDICATING DEFICIT (ADULTS) | Vision Ask patient to read newspaper, magazine, or lettering on menu.Ask patient to identify colors on color chart or crayons.Observe patients performing ADLs. | Self-stimulation, including eye rubbing, body rocking, sniffing or smelling, arm twirling; hitching (using legs to propel while in sitting position) instead of crawling | Poor coordination, squinting, underreaching or overreaching for objects, persistent repositioning of objects, impaired night vision, accidental falls | Hearing Assess patient's hearing acuity using spoken word and tuning fork tests.Assess for history of tinnitus.Observe patient conversing with others.Inspect ear canal for hardened cerumen.Observe patient behaviors in a group. | Frightened when unfamiliar people approach, no reflex or purposeful response to sounds, failure to be awakened by loud noise, slow or absent development of speech, greater response to movement than to sound, avoidance of social interaction with other children | Blank looks, decreased attention span, lack of reaction to loud noises, increased volume of speech, positioning of head toward sound, smiling and nodding of head in approval when someone speaks, use of other means of communication such as lip-reading or writing, complaints of ringing in ears | Touch Check patient's ability to discriminate between sharp and dull stimuli.Assess whether patient is able to distinguish objects (coin or safety pin) in the hand with eyes closed.Ask whether patient feels unusual sensations. | Inability to perform developmental tasks related to grasping objects or drawing, repeated injury from handling of harmful objects (e.g., hot stove, sharp knife) | Clumsiness, overreaction or underreaction to painful stimulus, failure to respond when touched, avoidance of touch, sensation of pins and needles, numbnessUnable to identify object placed in hand | Smell Have patient close eyes and identify several nonirritating odors (e.g., coffee, vanilla). | Difficult to assess until child is 6 or 7 years old, difficulty discriminating noxious odors | Failure to react to noxious or strong odor, increased body odor, decreased sensitivity to odors | TasteAsk patient to sample and distinguish different tastes (e.g., lemon, sugar, salt). (Have patient drink or sip water and wait 1 minute between each taste.) | Inability to tell whether food is salty or sweet, possible ingestion of strange-tasting things | Change in appetite, excessive use of seasoning and sugar, complaints about taste of food, weight change |
ADLs, Activities of daily living.

Mental Status p. 1239
--Assessment of mental status is valuable when you suspect sensory deprivation or overload. Observation of a patient during history taking, during the physical examination, and while providing nursing care offers valuable data about key patient behaviors and his or her mental status. Observe the patient's physical appearance and behavior, measure cognitive ability, and assess his or her emotional status. The Mini-Mental State Examination (MMSE) is a tool you can use to measure disorientation, change in problem-solving abilities, and altered conceptualization and abstract thinking. For example, a patient with severe sensory deprivation is not always able to carry on a conversation, remain attentive, or display recent or past memory. An important step toward preventing cognition-related disability is education by nurses about disease process, available services, and assistive devices.

Physical Assessment
--To identify sensory deficits and their severity, use physical assessment techniques to assess vision, hearing, olfaction, taste, and the ability to discriminate light touch, temperature, pain, and position. You gather more accurate data if the examination room is private, quiet, and comfortable for the patient. In addition, rely on personal observation to detect sensory alterations. Patients with a hearing impairment may seem inattentive to others, respond with inappropriate anger when spoken to, believe people are talking about them, answer questions inappropriately, have trouble following clear directions, and have monotonous voice quality and speak unusually loud or soft.
Ability to Perform Self-Care
--Assess patients’ functional abilities in their home environment or health care setting, including the ability to perform feeding, dressing, grooming, and toileting activities. For example, assess whether a patient with altered vision is able to find items on a meal tray and read directions on a prescription. Also determine a patient's ability to perform instrumental activities of daily living (IADLs), such as reading bills and writing checks, differentiating money denominations, and driving a vehicle at night. If a patient seems to have a sensory deficit, does he or she show concern for grooming? Does a patient's loss of balance prevent rising from a toilet seat safely? Can a patient recovering from a stroke manipulate buttons or zippers for dressing? If a sensory alteration impairs a patient's functional ability, providing resources within the home is a necessary part of discharge planning. Your findings may indicate the need for an occupational therapy consult.

Health Promotion Habits
--Assess the daily routines that patients follow to maintain sensory function. What type of eye and ear care is a part of the patient's daily hygiene? For individuals who participate in sports (e.g., racquetball) or recreational activities (e.g., motorcycle riding) or who work in a setting where ear or eye injury is a possibility (e.g., chemical exposure, welding, glass or stone polishing, or constant exposure to loud noise), determine if they wear safety glasses or hearing protective devices (HPDs). Do patients who use assistive devices such as eyeglasses, contact lenses, or hearing aids know how to provide daily care? Do patients use the devices, and are they in proper working order?
--It is also important to assess a patient's adherence with routine health screening. When was the last time the patient had an eye examination or hearing evaluation? For adults routine screening of visual and hearing function is imperative to detect problems early. This is especially true in the case of glaucoma, which, if undetected, leads to permanent visual loss. Recommended screening guidelines usually occur on the basis of age. When a patient begins to show a hearing deficit, incorporate routine screening in regular examinations.

Environmental Hazards
--Patients with sensory alterations are at risk for injury if their living environments are unsafe. For example, a patient with reduced vision cannot see potential hazards clearly. A patient with proprioceptive problems loses balance easily. A patient with reduced sensation cannot perceive hot versus cold temperatures. The condition of the home, the rooms, and the front and back entrances are often problematic to the patient with sensory alterations. Assess the patient's home for common hazards, including the following:
• Uneven, cracked walkways leading to front/back door
• Extension and phone cords in the main route of walking traffic
• Loose area rugs and runners placed over carpeting
• Bathrooms without shower or tub grab bars
• Water faucets unmarked to designate hot and cold
• Unlit stairways, lack of handrails
In the hospital environment caregivers often forget to rearrange furniture and equipment to keep paths from the bed and chair to the bathroom and entrance clear. It is helpful to walk into a patient's room and look for safety hazards:
• Is the call light within easy, safe reach?
• Are intravenous (IV) poles on wheels and easy to move?
• Are suction machines, IV pumps, or drainage bags positioned so a patient can rise from a bed or chair easily?
An additional problem faced by patients who are visually impaired is the inability to read medication labels and syringe markings. Ask the patient to read a label to determine if he or she is able to read the dosage and frequency. If a patient has a hearing impairment, check to see whether the sounds of a doorbell, telephone, smoke alarm, and alarm clock are easy to discriminate.

Communication Methods
--To understand the nature of a communication problem, you need to know whether a patient has trouble speaking, understanding, naming, reading, or writing. Patients with existing sensory deficits often develop alternate ways of communicating. To interact with the patient and promote interaction with others, understand his or her method of communication. Vision becomes almost a primary sense for people with hearing impairments.
--Patients with visual impairments are unable to observe facial expressions and other nonverbal behaviors to clarify the content of spoken communication. Instead they rely on voice tones and inflections to detect the emotional tone of communication. Some patients with visual deficits learn to read Braille. Patients with aphasia have varied degrees of inability to speak, interpret, or understand language. Expressive aphasia, a motor type of aphasia, is the inability to name common objects or express simple ideas in words or writing. For example, a patient understands a question but is unable to express an answer. Sensory or receptive aphasia is the inability to understand written or spoken language. A patient is able to express words but is unable to understand questions or comments of others. Global aphasia is the inability to understand language or communicate orally.
--The temporary or permanent loss of the ability to speak is extremely traumatic to an individual. Assess a patient's alternate communication method and whether it causes anxiety. Patients who have undergone laryngectomies often write notes, use communication boards or laptop computers, speak with mechanical vibrators, or use esophageal speech. Patients with endotracheal or tracheostomy tubes have a temporary loss of speech. Most use a notepad to write their questions and requests. However, some patients become incapacitated and unable to write messages. Determine whether the patient has developed a sign-language system or symbols to communicate needs.

FIG. 49-2 Nurse sits at eye level so patient with hearing impairment can communicate
FIG. 49-2 Nurse sits at eye level so patient with hearing impairment can communicate

Social Support
--Assess if a patient lives alone and whether family or friends frequently visit. It is important to assess the patient's social skills and level of satisfaction with the support given by family and friends. Is the patient satisfied with the support available? Is he or she able to solve problems with family members? Is there a family caregiver who offers support when the patient requires assistance as a result of a sensory loss? The long-term effects of sensory alterations influence family dynamics and a patient's willingness to remain active in society.

Use of Assistive Devices
--Assess the use of assistive devices (e.g., use of a hearing aid or glasses) and the sensory effects for the patient. This includes learning how often the patient uses the devices daily, the patient's or family caregiver's method of cleaning, and the patient's knowledge of what to do when a problem develops. When you identify that the patient has an assistive device, it is important to remember that, just because the individual has the assistive device, it does not mean that it works or that the patient uses it or benefits from it.

Other Factors Affecting Perception
--Factors other than sensory deprivation or overload cause impaired perception (e.g., medications or pain). Assess the patient's medication history, which includes prescribed and over-the-counter medications and herbal products. Also gather information regarding the frequency, dose, method of administration, and last time these medications were taken. Some antibiotics (e.g., streptomycin, gentamicin, and tobramycin) are ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Opioid analgesics, sedatives, and antidepressant medications often alter the perception of stimuli. Conduct a thorough pain assessment when you suspect that pain is causing perceptual problems.

Nursing Diagnosis p. 1241
--After assessment review all available data and look critically for patterns and trends suggestive of a health problem relating to sensory alterations. Validate findings to ensure accuracy of the diagnosis. Determine the factor that likely causes the patient's health problem. The etiology or related factor of a nursing diagnosis is a condition that nursing interventions can affect. The etiology needs to be accurate; otherwise nursing therapies are ineffective.
--Some patients have health care problems for which sensory alteration is the etiology, such as with the diagnosis of risk for injury. You select nursing diagnoses by recognizing the way that sensory alterations affect a patient's ability to function (e.g., self-care deficit). In addition, most patients present themselves to health care professionals with multiple diagnoses. In the example of the concept map, a patient with a cataract has the nursing diagnoses of risk for injury, anxiety, fear, and risk for falls. The sensory alteration caused by the cataract is an etiology for both risk for injury and risk for falls. Furthermore, fear occurs as a response to a perceived risk of falling. You need to recognize patterns of data that reveal health problems created by the patient's sensory alteration. Examples of nursing diagnoses that apply to patients with sensory alterations include the following:
• Risk-prone health behavior
• Impaired verbal communication
• Risk for injury
• Impaired physical mobility
• Bathing self-care deficit
• Dressing self-care deficit
• Toileting self-care deficit
• Situational low self-esteem
• Risk for falls
• Social isolation

-During planning synthesize information from multiple resources.
FIG. 49-4 Critical thinking model for sensory alterations planning.

FIG. 49-4 Critical thinking model for sensory alterations planning.

Goals and Outcomes
-During planning develop an individualized plan of care for each nursing diagnosis. Partner with the patient to develop a realistic plan that incorporates what you know about his or her sensory problems and the extent to which he or she can maintain or improve sensory function. Goals and outcomes need to be realistic and measurable. An example of a goal of care for a patient with an actual or potential sensory alteration is “The patient will achieve improvement in hearing acuity within 2 weeks.” Associated outcomes for this goal include the following:
• The patient and family will report using communication techniques to send and receive messages within 2 days.
• The patient will successfully demonstrate correct technique for cleaning a hearing aid within 1 week.
• The patient will self-report improved hearing acuity.

Setting Priorities
--You consider the type and extent of sensory alteration affecting a patient when determining priorities of care. For example, a patient who enters the emergency department after experiencing eye trauma has priorities of reducing anxiety and preventing further injury to the eye. In contrast, a patient who is being discharged from an outpatient surgery department following cataract removal has the priority of learning about self-care restrictions. Safety is always a top priority. The patient also helps prioritize aspects of care. For example, a patient wishes to learn ways to communicate more effectively or participate in favorite hobbies given his or her limitation.
--Some sensory alterations are short term (e.g., a patient experiencing sensory overload in an ICU). Thus appropriate interventions are likely to be temporary (e.g., frequent reorientation or introduction of pleasant stimuli such as a back rub). Some sensory alterations such as permanent visual loss require long-term goals of care for patients to adapt. Patients who have sensory alterations at the time of entering a health care setting are usually most informed about how to adapt interventions to their lifestyles. For example, allow patients who are blind to control whatever parts of their care they can. Sometimes it becomes necessary for the patient to make major changes in self-care activities, communication, and socialization to ensure safe and effective nursing care.

Teamwork and Collaboration
--When developing a plan of care, consider all resources available to patients. (occupational or speech therapists, home care ,community-based resources )

Nursing Care Plan example p. 1244 Risk for injury AssessmentMs. Judy Long is a 70-year-old retired widow who resides in a two-story home with her son. She tells the community health nurse that she is having increased difficulty with night driving and blurry vision. She enjoys reading and sewing; however, her reduced vision limits her ability to participate in these activities. Assessment Activities-Ask Ms. Long to describe her vision changes.-Ask Ms. Long to describe life changes that have occurred since the change in vision.-Assess Ms. Long's visual acuity.-Ask Ms. Long the results of the visit to the ophthalmologist.-Conduct a home hazard assessment. | Ms. Long reports that her vision is blurred even with glasses and she is afraid that she will fall. Ms. Long visited an ophthalmologist 1 year ago, but didn't follow up with the recommended treatment.Findings/Defining Characteristics-Ms. Long states, “My left eye seems to have a film over it that makes my vision blurred. I am having difficulty reading. I also have difficulty with night driving.”-Ms. Long states, “I've lost my independence because I can no longer drive at night. I'm hesitant to use the stairs at home because I can't judge steps clearly.”-Ms. Long can't read the Snellen chart with the left eye.-Ms. Long states, “I was told I had a cataract of the left eye, and surgery was recommended.”-There is clutter in the home, dim lighting, and stairs without handrails. | Nursing Diagnosis: Risk for injury | | Planning- GoalMs. Long will maintain independence in a safe home environment. | Expected OutcomesSafe Home EnvironmentMs. Long and her son will make recommended changes to home environment within 4 weeks.Ms. Long will report an increased sense of home safety and independence within 4 weeks. | Interventions - RationaleEnvironmental Management-Teach Ms. Long and her son methods to improve environmental safety such as installing handrails along stairs, securing carpeting, removing throw rugs, and painting stairs. -Teach Ms. Long to use a light over the shoulder for reading and sewing.-Explain use of a pocket magnifier and offer list of locations where Ms. Long can purchase one.-Have Ms. Long make appointment with ophthalmologist within the next 4 weeks.-Emotional SupportEncourage Ms. Long to express feelings regarding loss of vision and lifestyle changes. | - A decrease in visual acuity and depth perception places a patient at risk for falls in the presence of environmental hazards (Ebersole et al., 2008). Environmental safety modifications reduce injury.-Good lighting and an adjustable lamp reduce glare (Rosenberg and Sperazza, 2008).-Magnifier enlarges visual images when reading or doing close work (Ebersole et al., 2008).-Older adults need a routine eye examination annually or as recommended (Ebersole et al., 2008).-Visual impairment often leads to functional disabilities that have adverse effects on quality of life (Hodge et al., 2007). | Evaluation - Nursing Actions -Ask Ms. Long to describe the changes made in the home to reduce environmental hazards.- As Ms. Long uses a magnifier, have her read a medication label.- Ask Ms. Long if she is able to maintain a degree of independence with the environmental and lifestyle modifications | Patient Response/Finding -Ms. Long responds that she has removed the clutter and placed handrails at the entryway. She has also placed lighting behind her chair, and there are 100-watt lights in the living room.- Ms. Long is able to read name of medication and dosage correctly- Ms. Long states, “I'm more independent at home, and until surgery I don't mind having someone drive for me.” | Achievement of Outcome-Ms. Long reports feeling safer walking the stairs and moving about in her home. The home hazards have been reduced.- Visual acuity has not been further compromised.- Ms. Long has attained some degree of independence. |

FIG. 49-3
Concept map for Ms. Long

FIG. 49-3
Concept map for Ms. Long

Implementation p. 1242
--Nursing interventions involve the patient and family so the patient is able to maintain a safe, pleasant, and stimulating sensory environment. The most effective interventions enable a patient with sensory alterations to function safely with existing deficits and continue a normal lifestyle. Patients can learn to adjust to sensory impairments at any age with the proper support and resources. Use measures to maintain a patient's sensory function at the highest level possible.

Health Promotion
--Good sensory function begins with prevention.

--Preventable blindness is a worldwide health issue that begins with children and requires appropriate screening. Four recommended interventions are (1) screening for rubella, syphilis, chlamydia, and gonorrhea in women who are considering pregnancy; (2) advocating adequate prenatal care to prevent premature birth (with the danger of exposure of the infant to excessive oxygen); (3) administering eye prophylaxis in the form of erythromycin ointment approximately 1 hour after an infant's birth; and (4) periodic screening of all children, especially newborns through preschoolers, for congenital blindness and visual impairment caused by refractive errors and strabismus.
--Visual impairments are common during childhood. The most common visual problem is a refractive error such as nearsightedness. The nurse's role is one of detection, education, and referral. Parents need to know the signs of visual impairment (e.g., failure to react to light and reduced eye contact from the infant). Instruct parents to report these signs to their health care provider immediately. Vision screening of school-age children and adolescents helps detect problems early. The school nurse is usually responsible for vision testing.
--In the United States glaucoma is the second leading cause of blindness in the general population and the primary cause of blindness in African Americans. If left undetected and untreated, it leads to permanent visual loss.
--Hearing impairment is one of the most common disabilities in the United States. Children at risk include those with a family history of childhood hearing impairment, perinatal infection (rubella, herpes, or cytomegalovirus), low birth weight, chronic ear infection, and Down syndrome. Advise pregnant women of the importance of early prenatal care, avoidance of ototoxic drugs, and testing for syphilis or rubella.
--Children with chronic middle ear infections, a common cause of impaired hearing, need to receive periodic auditory testing. Warn parents of the risks and to seek medical care when the child has symptoms of earache or respiratory infection.
--Aging is associated with degenerative changes in the ear, Once a patient reports a hearing loss, regular testing also becomes necessary. In addition, a patient who works or lives in a high–noise level environment requires an annual screening. Occupational health nurses play a key role in the assessment of the auditory system and the initiation of prompt referrals. The early identification and treatment of problems help older adults be more active and healthy.

Preventive Safety
--Trauma is a common cause of blindness in children. Penetrating injury from propulsive objects such as firecrackers or slingshots or from penetrating wounds from sticks, scissors, or toy weapons are just a few examples. Parents and children require counseling on ways to avoid eye trauma such as avoiding use of toys with long, pointed projections and instructing children not to walk or run while carrying pointed objects. Instruct patients that they can find safety equipment in most sports shops and large department stores.
--Adults are at risk for eye injury while playing sports and working in jobs involving exposure to chemicals or flying objects. The Occupational Safety and Health Administration (OSHA, 2010) has guidelines for workplace safety. Employers are required to have eye wash stations and to have employees wear eye goggles and/or use equipment such as HPDs to reduce the risk of injury. Healthy People 2020 (USDHHS, 2009) identifies goals that include reducing new cases of work-related, noise-induced hearing loss. Occupational health nurses reinforce the use of protective devices. In addition, nurses need to routinely assess patients for noise exposure and participate in providing hearing conservation classes for teachers, students, and patients.
--Another means of prevention involves regular immunization of children against diseases capable of causing hearing loss (e.g., rubella, mumps, and measles). Nurses who work in health care providers’ offices, schools, and community clinics instruct patients about the importance of early and timely immunization. In all populations use caution when administering ototoxic drugs.

Use of Assistive Devices
--Patients who wear corrective contact lenses, eyeglasses, or hearing aids need to make sure that they are clean, accessible, and functional.
--Older adults are often reluctant to use hearing aids. Reasons cited most often include cost, appearance, insufficient knowledge about hearing aids, amplification of competing noise, and unrealistic expectations. Neuromuscular changes in the older adult such as stiff fingers, enlarged joints, and decreased sensory perception also make the handling and care of a hearing aid difficult.
--Acknowledging a need to improve hearing is a person's first step. Give patients useful information on the benefits of hearing aid use. A person who understands the need for good hearing will likely be influenced to wear hearing aids. It is also important to have a significant other available to assist with hearing aid adjustment. Federal regulations require medical clearance from a health care provider before an individual can purchase a hearing aid. Hearing aids are contraindicated for the following conditions: visible congenital or traumatic deformity of the ear, active drainage in the last 90 days, sudden or progressive hearing loss within the last 90 days, acute or chronic dizziness, unilateral sudden hearing loss within the last 90 days, visible cerumen accumulation or a foreign body in the ear canal, pain or discomfort in the ear, or an audiometric air-bone gap of 15 decibels or greater. A nursing assessment detects the first seven of these conditions during a physical examination. Refer the patient to an otolaryngologist for further counseling.

Promoting Meaningful Stimulation
--Life becomes more enriching and satisfying when meaningful and pleasant stimuli exist within the environment. You can help patients adjust to their environment in many ways so it becomes more stimulating. You do this best by considering the normal physiological changes that accompany sensory deficits.
--Vision - As a result of the normal changes of aging, the pupil's ability to adjust to light diminishes; thus older adults are often very sensitive to glare. Suggest the use of yellow or amber lenses and shades or blinds on windows to minimize glare. Wearing sunglasses outside obviously reduces the glare of direct sunlight. Other interventions to enhance vision for patients with visual impairment include warm incandescent lighting and colors with sharp contrast and intensity.
The ability to read is important. Therefore allow patients to use their glasses whenever possible (e.g., during procedures and instruction). Some patients with reduced visual acuity need more than corrective lenses. A pocket magnifier helps a patient read most printed material. Telescopic lens eyeglasses are smaller, easier to focus, and have a greater range. Books and other publications are also available in larger print. If a patient has a legal or other important document that he or she wishes to read, standard copying machines have enlarging capabilities. Closed-circuit television magnifying units enlarge written characters up to 45 times.
With aging a person experiences a change in color perception. Perception of the colors blue, violet, and green usually declines. Brighter colors such as red, orange, and yellow are easier to see. Offer suggestions of ways to decorate a room and paint hallways or stairwells so the patient is able to differentiate surfaces and objects in a room.
--Hearing - To maximize residual hearing function, work closely with the patient to suggest ways to modify the environment. Patients can amplify the sound of telephones and televisions. An innovative way to enrich the lives of the hearing impaired is recorded music. Some patients with severe hearing loss are able to hear music recorded in the low-frequency sound cycles.
One way to help an individual with a hearing loss is to ensure that the problem is not impacted cerumen. With aging, cerumen thickens and builds up in the ear canal. Excessive cerumen occluding the ear canal causes conductive hearing loss. Instilling a softening agent such as 0.5 to 1 mL of warm mineral oil into the ear canal followed by irrigation of a solution of 3% hydrogen peroxide in a quart of warmed water removes cerumen and significantly improves the patient's hearing ability.
--Taste and Smell - Promote the sense of taste by using measures to enhance remaining taste perception. Good oral hygiene keeps the taste buds well hydrated. Well seasoned, differently textured food eaten separately heightens taste perception. Flavored vinegar or lemon juice adds tartness to food. Always ask the patient which foods are most appealing. Improving taste perception improves food intake and appetite as well.
Stimulation of the sense of smell with aromas such as brewed coffee, cooked garlic, and baked bread heightens taste sensation. The patient needs to avoid blending or mixing foods because these actions make it difficult to identify tastes. Older persons need to chew food thoroughly to allow more food to contact remaining taste buds.
Improve smell by strengthening pleasant olfactory stimulation. Make a patient's environment more pleasant with smells such as cologne, mild room deodorizers, fragrant flowers, and sachets. Consult with patients to find out which scents they can tolerate. The removal of unpleasant odors (e.g., bedpans or soiled dressings) also improves the quality of a patient's environment.
Touch - Patients with reduced tactile sensation usually have the impairment over a limited portion of their bodies. Providing touch therapy stimulates existing function. If a patient is willing to be touched, hair brushing and combing, a back rub, and touching the arms or shoulders are ways of increasing tactile contact. When sensation is reduced, a firm pressure is often necessary for a patient to feel a nurse's hand. Turning and repositioning also improves the quality of tactile sensation.
If a patient is overly sensitive to tactile stimuli (hyperesthesia), minimize irritating stimuli. Keeping bed linens loose to minimize direct contact with a patient and protecting the skin from exposure to irritants are helpful measures. Physical therapists can recommend special wrist splints for patients to wear to dorsiflex their wrists and relieve nerve pressure when they have numbness and tingling or pain in the hands, as with carpal tunnel syndrome. For patients who use computers, special keyboards and wrist pads are available to decrease the pressure on the median nerve, aid in pain relief, and promote healing.

Establishing Safe Environments
When sensory function becomes impaired, individuals become less secure within their home and workplace. Security is necessary for a person to feel independent. Make recommendations for improving safety within a patient's living environment without restricting independence. During a home visit or while completing an examination in the clinic, offer several useful suggestions for home safety. The nature of the actual or potential sensory loss determines the safety precautions taken.
--Adaptations for Visual Loss
- When a patient experiences a decrease in visual acuity, peripheral vision, adaptation to the dark, or depth perception, safety is a concern. With reduced peripheral vision a patient cannot see panoramically because the outer visual field is less discrete. With reduced depth perception a person is unable to judge how far away objects are located. This is a special danger when he or she walks down stairs or over uneven surfaces.
-Driving is a particular safety hazard for older adults with visual alterations. Reduced peripheral vision prevents a driver from seeing a car in an adjacent lane. A sensitivity to glare creates a problem for driving at night with headlights. Vision is a primary consideration for safety, but there are other factors as well. In the case of older adults, decreased reaction time, reduced hearing, and decreased strength in the legs and arms further compromise driving skills. Some safety tips to share with those who continue to drive include the following: drive in familiar areas, do not drive during rush hour, avoid interstate highways for local drives, drive defensively, use rear-view and side-view mirrors when changing lanes, avoid driving at dusk or night, go slow but not too slow, keep the car in good working condition, and carry a preprogrammed cellular phone.
-The presence of visual alterations makes it difficult for a person to conduct normal activities of living within the home. Because of reduced depth perception, patients can trip on throw rugs, runners, or the edge of stairs. Teach patients and family members to keep all flooring in good repair and advise them to use low-pile carpeting. Thresholds between rooms need to be level with the floor. Recommend the removal of clutter to ensure clear pathways for walking and arrangement of furniture so a patient can move about easily without fear of tripping or running into objects. Suggest that stairwells have a securely fastened banister or handrail extending the full length of the stairs.
Front and back entrances to the home, work areas, and stairwells need to be properly lighted. Light fixtures need high-wattage bulbs with wider illumination. A light switch should be located at the top and bottom of stairwells. It is also important to be sure that lighting on the stairs does not cast shadows. Have a family member paint the edge of steps so the patient can clearly see each step, especially the first and last. When possible have patients replace steps inside and outside the home with ramps.
-An added consideration is to administer eye medications safely. Patients need to closely adhere to regular medication schedules for conditions such as glaucoma. Labels on medication containers need to be in large print. Make sure that a friend or spouse is familiar with dosage schedules in case a patient is unable to self-administer a medication. Patients with visual impairments often have difficulty manipulating eyedroppers.
--Adaptations for Reduced Hearing
-Patients hear important environmental sounds (e.g., doorbells and alarm clocks) best if they are amplified or changed to a lower-pitched, buzzerlike sound. Lamps designed to turn on in response to sounds such as doorbells, burglar alarms, smoke detectors, and babies crying are also available. Family members and anyone who calls the patient regularly need to learn to let the phone ring for a longer period. Amplified receivers for telephones and telephone communications devices (TCDs) are available that use a computer and printer to transfer words over the telephone for the hearing impaired. Both sender and receiver need to have the special device to complete a call.
--Adaptations for Reduced Olfaction
-The patient with a reduced sensitivity to odors is often unable to smell leaking gas, a smoldering cigarette, fire, or spoiled food. Advise patients to use smoke detectors and take precautions such as checking ashtrays or placing cigarette butts in water. In addition, teach patients to check food package dates, inspect the appearance of food, and keep leftovers in labeled containers with the preparation date. Pilot gas flames need to be checked visually.
--Adaptations for Reduced Tactile Sensation
When patients have reduced sensation in their extremities, they are at risk for injury from exposure to temperature extremes. Always caution these patients on the use of water bottles or heating pads. The temperature setting on the home water heater should be no higher than 48.8° C (120° F). If a patient also has a visual impairment, it is important to be sure that water faucets are clearly marked “hot” and “cold,” or use color codes (i.e., red for hot and blue for cold).
Communication p. 1246
--A sensory deficit often causes a person to feel isolated because of an inability to communicate with others. It is important for individuals to be able to interact with people around them. The nature of the sensory loss influences the methods and styles of communication that nurses use during interactions with patients. You also teach communication methods to family members and significant others. For patients with visual deficits or blindness, speak normally, not from a distance, and be sure to have sufficient lighting.
--The patient with a hearing impairment is often able to speak normally. To more clearly hear what a person communicates, family and friends need to learn to move away from background noise, rephrase rather than repeat sentences, be positive, and have patience. In a group setting it is better to form a semicircle in front of the patient so he or she can see who is speaking next; this helps foster group involvement. On the other hand, some patients who are deaf have serious speech alterations. Some use sign language or lip reading, wear special hearing aids, write with a pad and pencil, or learn to use a computer for communication. Special communication boards that contain common terms (e.g., pain, bathroom, dizzy, or walk) help patients express their needs. Patient education is one aspect of communication. Teaching booklets are available in large print for patients with visual loss. The patient who is blind often requires more frequent and detailed verbal descriptions of information. This is particularly true if there are no instructional booklets written in Braille. Patients with visual impairments can also learn by listening to audiotapes or the sound portion of a televised teaching session. Patients with hearing impairments often benefit from written instructional materials and visual teaching aids (e.g., posters and graphs). Demonstrations by the nurse are very useful. Hospitals are required to make professional interpreters available to read sign language for patients who are deaf.

Box 49-8 Communication Methods Patients with Aphasia• Listen to the patient and wait for him or her to communicate.• Do not shout or speak loudly (hearing loss is not the problem).• If the patient has problems with comprehension, use simple, short questions and facial gestures to give additional clues.• Speak of things familiar and of interest to the patient.• If the patient has problems speaking, ask questions that require simple yes or no answers or blinking of the eyes. Offer pictures or a communication board so the patient can point.• Give the patient time to understand; be calm and patient; do not pressure or tire him or her.• Avoid patronizing and childish phrases.Patients with an Artificial Airway• Use pictures, objects, or word cards so the patient can point.• Offer a pad and pencil or Magic Slate for the patient to write messages.• Do not shout or speak loudly.• Give the patient time to write messages because patients fatigue easily.• Provide an artificial voice box (vibrator) for the patient with a laryngectomy to use to speak.Patients with Hearing Impairment• Get the patient's attention. Do not startle him or her when entering the room. Do not approach a patient from behind. Be sure that he or she knows that you wish to speak.• Face the patient and stand or sit on the same level. Be sure that your face and lips are illuminated to promote lip-reading. Keep hands away from mouth.• Be sure that patients keep eyeglasses clean so they are able to see your gestures and face.• If the patient wears a hearing aid, make sure that it is in place and working.• Speak slowly and articulate clearly. Older adults often take longer to process verbal messages.• Use a normal tone of voice and inflections of speech. Do not speak with something in your mouth.• When you are not understood, rephrase rather than repeat the conversation.• Use visible expressions. Speak with your hands, your face, and your eyes.• Do not shout. Loud sounds are usually higher pitched and often impede hearing by accentuating vowel sounds and concealing consonants. If you need to raise your voice, speak in lower tones.• Talk toward the patient's best or normal ear.• Use written information to enhance the spoken word.• Do not restrict the hands of a patient who is deaf. Never have intravenous lines in both of the patient's hands if the preferred method of communication is sign language.• Avoid eating, chewing, or smoking while speaking.• Avoid speaking from another room or while walking away. |
Acute Care p. 1247
--When patients enter acute care settings for therapeutic management of sensory deficits or as a result of traumatic injury, use different approaches to maximize sensory function existing at the time. Safety is an obvious priority until the patient's sensory status is either stabilized or improved. For example, patients with sensory deficits have a high risk for falls in the acute care environment. It is very important to know the extent of any existing sensory impairment before the acute episode of illness so you are able to reinforce what the patient already knows about self-care or plan for more instruction before and following discharge.

--Orientation to the Environment
The patient with recent sensory impairment requires a complete orientation to the immediate environment. Provide reorientation to the institutional environment by ensuring that name tags on uniforms are visible, addressing the patient by name, explaining where the patient is (especially if patients are transported to different areas for treatment), and using conversational cues to time or location. Reduce the tendency for patients to become confused by offering short and simple, repeated explanations and reassurance. Encourage family members and visitors to help orient patients to the hospital surroundings.
--Patients with serious visual impairment need to feel comfortable in knowing the boundaries of the immediate environment. Normally we see physical boundaries within a room. Patients who are blind or severely visually impaired often touch the boundaries or objects to gain a sense of their surroundings. The patient needs to walk through a room and feel the walls to establish a sense of direction. Help patients by explaining objects within the hospital room, such as furniture or equipment. It takes time for a patient to absorb room arrangement. He or she often needs to reorient again as you explain the location of key items (e.g., call light, telephone, and chair). Remember to approach the patient from the front to avoid startling him or her.
--It is important to keep all objects in the same position and place. After an object is moved even a short distance, it no longer exists for a person who is blind. Simply moving a chair creates a safety hazard. Ask the patient if any item needs to be rearranged to make ambulation easier. Clear traffic patterns to the bathroom. Give the patient extra time to perform tasks. He or she needs a detailed description of how to perform an activity and moves slowly to remain safe.
Patients confined to bed are at risk for sensory deprivation. Normally movement gives an awareness of self through vestibular and tactile stimulation. Movement patterns influence sensory perception. The limited movement of bed rest changes how a person interprets the environment; surroundings seem different, and objects seem to assume shapes different from normal. A person who is on bed rest requires routine stimulation through range-of-motion exercises, positioning, and participation in self-care activities (as appropriate). Comfort measures such as washing the face and hands and providing back rubs improve the quality of stimulation and lessen the chance of sensory deprivation. Planning time to talk with patients is also essential. Explain unfamiliar environmental noises and sensations. A calm, unhurried approach gives you quality time to help reorient and familiarize the patient with care activities. The patient who is well enough to read will benefit from a variety of reading material.

The most common language disorder following a stroke is aphasia. Depending on the type of aphasia, the inability to communicate is often frustrating and frightening. Initially you need to establish very basic communication and recognize that it does not indicate intellectual impairment or degeneration of personality. Explain situations and treatments that are pertinent to the patient because he or she is able to understand the speaker's words. Because a stroke often causes partial or complete paralysis of one side of a patient's body, the patient needs special assistive devices. A variety of communication boards for different levels of disability are available. Sensitive pressure switches activated by the touch of an ear, nose, or chin control electronic communication boards. Make referrals to speech therapists to develop appropriate rehabilitation plans.
--In acute care hospitals or long-term care facilities, nurses often care for patients with artificial airways (such as an endotracheal tube). The placement of an endotracheal tube prevents a patient from speaking. In this case the nurse uses special communication methods to facilitate his or her ability to express needs. The patient is sometimes completely alert and able to hear and see the nurse normally. Giving patients time to convey any needs or requests is very important. Use creative communication techniques (e.g., a communication board or laptop computer) to foster and strengthen a patient's interactions with health care personnel, family, and friends.
--Controlling Sensory Stimuli
Patients need time for rest and freedom from stress caused by frequent monitoring and repeated tests. Reduce sensory overload by organizing the patient's plan of care. Combining activities such as dressing changes, bathing, and vital sign measurement in one visit prevents him or her from becoming overly fatigued. The patient also needs scheduled time for rest and quiet. Planning for rest periods often requires cooperation from family, visitors, and health care colleagues. Coordination with laboratory and radiology departments minimizes the number of interruptions for procedures. A creative solution to decrease excessive environmental stimuli that prevents restful, healing sleep is to institute “quiet time” in ICUs. Quiet time means dimming the lights throughout the unit, closing the shades, and shutting the doors.
When patients experience sensory overload or deprivation, their behavior is often difficult for family or friends to accept. Encourage the family not to argue with or contradict the patient but to calmly explain location, identity, and time of day. Engaging the patient in a normal discussion about familiar topics assists in reorientation. Anticipating patient needs such as voiding helps reduce uncomfortable stimuli.
--Try to control extraneous noise in and around a patient's room. It is often necessary to ask a roommate to lower the volume on a television or to move the patient to a quieter room. Keep equipment noise to a minimum. Turn off bedside equipment not in use such as suction and oxygen equipment. Avoid making abrupt loud noises such as dropping objects or causing the over-bed table to suddenly adjust to the lowest level. Nursing staff also need to control laughter or conversation at the nurses’ station. Allow patients to close their room doors.

Nurse assists in ambulation of patient with visual impairment.
Nurse assists in ambulation of patient with visual impairment.

Restorative and Continuing Care
FIG. 49-6 Location of food using clock as frame of reference.

FIG. 49-6 Location of food using clock as frame of reference.

Promoting Self-Care
--The ability to perform self-care is essential for self-esteem.

Through the Patient's Eyes
--It is important to evaluate whether care measures maintain or improve a patient's ability to interact and function within the environment. The patient is the source for evaluating outcomes. Notice that subtle behaviors often indicate the level of his or her satisfaction (the patient responds appropriately, such as by smiling). However, it is important for you to ask the patient if his or her sensory needs have been met. For example, ask, “Have we done all we can do to help improve your ability to hear?” If the patient's expectations have not been met, ask the patient, “How can the health care team better meet your needs?” Working closely with the patient and family enables you to redefine expectations that can be realistically met within the limits of the patient's condition and therapies. You have been effective when the patient's goals and expectations have been met.

Patient Outcomes
--To evaluate the effectiveness of specific nursing interventions, use critical thinking and make comparisons with baseline sensory assessment data to evaluate if sensory alterations have changed. It is your responsibility to determine if expected outcomes have been met. For example, use evaluative data to determine whether care measures improve or at least maintain a patient's ability to interact and function within the environment. The nature of a patient's sensory alterations influences how you evaluate the outcome of care. When caring for a patient with a hearing deficit, use proper communication techniques and then evaluate whether he or she has gained the ability to hear or interact more effectively. When expected outcomes have not been achieved, there is a need to change interventions or alter the patient's environment. If outcomes are not met, it is important to ask questions such as “How are you feeling emotionally?” “Do you feel that you are at risk for injury?”
If you have directed nursing care at improving or maintaining sensory acuity, evaluate the integrity of the sensory organs and the

patient's ability to perceive stimuli. Evaluate interventions designed to relieve problems associated with sensory alterations on the basis of the patient's ability to function normally without injury. When you directly or indirectly (through education) alter a patient's environment, evaluate by observing whether the patient makes environmental changes. When designing patient teaching to improve sensory function, it is important to determine whether the patient is following recommended therapies and meeting mutually set goals. Asking the patient to explain or demonstrate self-care skills is an effective evaluative measure. It is often necessary to reinforce previous instruction if learning has not taken place. If outcomes are not met, these are examples of questions to ask:
• “How often do you wear your hearing aids/corrective lenses?”
• “Are you able to participate in a small group discussion?”
• “Are you able to read the newspaper without squinting?”
The results of your evaluation will determine whether to continue the existing plan of care, make modifications, or end the use of select interventions.

--- --- --- --- --- --- --- --- --- ---- --- --- --- --- --- --- --- --- --- --- ---- --- --- --- --- --- --- --- --- --- --- ---- ---

Common diagnostic studies to evaluate neuro-sensory systems

--- --- --- --- --- --- --- --- --- ---- --- --- --- --- --- --- --- --- --- --- ---- --- --- --- --- --- --- --- --- --- --- ---- --- Are You Ready to Test Your Nursing Knowledge? P. 1251

1 A patient has been on contact isolation for 4 days because of a gastrointestinal infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Nursing measures to reduce sensory deprivation include: (Select all that apply.)
1 Arranging for him to have a roommate.
2 Turning off the lights and closing the room drapes.
3 Arranging for peacefulness and frequent rest periods.
4 Helping him to a chair or bringing a flower into the room.
5 Sitting down, speaking, touching, and listening to his feelings and perceptions.

2 The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which strategy is not effective in enhancing a patient's impaired vision?
1 Use of fluorescent lighting
2 Use of warm incandescent lighting
3 Use of colors with sharp contrast and intensity
4 Use of yellow or amber lenses to decrease glare

3 A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitate communication with her?
1 Speak directly into the patient's left ear.
2 Approach the patient from behind and speak frequently.
3 Face the patient when speaking; speak slower and in a normal volume.
4 Face the patient when speaking; use a louder than normal tone of voice.

4 The nurse is caring for an older patient with glaucoma. When developing a discharge plan, which of the priority interventions enables the patient to function safely with existing deficits and continue a normal lifestyle?
1 Encourage the patient's family to visit him or her once a month.
2 Suggest to the patient that he or she consider moving to a long-term care facility.
3 Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration.
4 Work closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources.

5 A 74-year-old patient who has returned to the nursing home following surgical removal of bilateral cataracts reports feeling a little uncertain about walking by herself. Which of the following approaches do you use to assist her with ambulation?
1 Walk one-half step behind and slightly to her side.
2 Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles.
3 Allow her to stand alone in unfamiliar areas to encourage confidence building.
4 If she requires assistance, place your hand around her waist.

6 Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to:
1 Avoid activities in which there may be crowds.
2 Delay childhood immunizations until hearing can be verified.
3 Prophylactically administer antibiotics to reduce the incidence of infections.
4 Take precautions when involved in activities associated with high-intensity noises.

7 The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements by the patient would indicate that additional teaching is needed?
1 “I am at risk for injury from temperature extremes.”
2 “I may be able to dress more easily with zippers or pullover sweaters.”
3 “A home care referral may help me achieve a maximum degree of independence.”
4 “I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first.”

8 The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. During the examination the patient's temperature is 99.6° F (37.6° C), heart rate 80 beats/min, respiratory rate 18 breaths/min, and blood pressure 142/84 mm Hg. She is not attentive as the nurse asks questions. At one point, she shouts answers to questions about her diet. However, as the nurse speaks, the patient consistently smiles and nods in agreement. The nurse's assessment indicates:
1 A visual deficit.
2 Patient is normal.
3 A hearing deficit.
4 Sensory overload.

9 When communicating with a patient who has expressive aphasia, the highest priority for the nurse is:
1 To ask open-ended questions.
2 To understand that the patient will be uncooperative.
3 To coach the patient to respond.
4 To offer pictures or a communication board so the patient can point.

10 A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. Interventions the nurse uses to reduce loneliness include: (Select all that apply.)
1 Reassuring the patient that loneliness is a normal part of aging.
2 Providing information about local social groups in the patient's neighborhood.
3 Maintaining distance while talking to avoid overstimulating the patient.
4 Recommending that the patient consider making living arrangements that will put him closer to family or friends.

11 A nurse is performing an assessment on a patient admitted to the emergency department with eye trauma. The nurse's priority interventions include which of the following? (Select all that apply.)
1 Conducting a home safety assessment and identifying hazards in the patient's living environment
2 Reinforcing eye safety at work and in activities that place the patient at risk for eye injury
3 Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching
4 Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye

12 Which patient is most likely to experience sensory deprivation?
1 A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities
2 A 14-year-old girl isolated in the hospital because of severe immune system suppression
3 A hearing-impaired 66-year-old woman who lives in an assisted-living facility
4 A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

13 The medical record of an older adult reveals a stroke affecting the right hemisphere of the brain. Which of these assessment findings should the nurse expect to find? (Select all that apply.)
1 Visual spatial alterations such as loss of half of a visual field
2 Loss of sensation and motor function on the right side of the body
3 Inattention and neglect, especially to the left side
4 Cloudy or opaque areas in part of the lens or the entire lens

14 A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, “I think my hearing aid is broken. I can't hear anything.” Which of the following teaching strategies should not be implemented?
1 Demonstrating hearing aid battery replacement
2 Reviewing method to check volume on hearing aid
3 Discussing measures for cleaning battery
4 Turning dial to minimum setting and, in a louder-than-normal voice, asking the patient, “Is this voice clear?”

15 When assessing a 45-year-old patient's sensory status, which of the following assessment findings does the nurse consider a normal part of aging?
1 Presbyopia and the need for glasses for reading
2 Reduced sensitivity to odors
3 Impaired balance and coordination
4 Reduced taste discrimination

Answers: 1. 4, 5; 2. 1; 3. 3; 4. 4; 5. 2; 6. 4; 7. 4; 8. 3; 9. 4; 10. 2, 4; 11. 3, 4; 12. 2; 13. 1, 3; 14. 4; 15. 1. (Potter 1233-1252)

The end…...

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