The document discusses sensory perception and coordination. It defines key terms like sensory reception, kinesthetics, stereognosis, and visceral sensation. It describes the four aspects of the sensory process - stimulus, receptor, impulse conduction, and perception. It discusses factors that can affect sensory perception like environment, previous experience, and illness. It also outlines nursing interventions to promote normal sensory perception like stimulation, sensory aids, positioning, joint mobility exercises, ambulation assistance, and assistive devices.

1. PERCEPTION AND COORDINATION

2. Sensory Perception

3. Sensory perception- involves the conscious organization and translation of the data or stimuli into meaningful information Sensory reception- process of receiving stimuli or data Kinesthetics- awareness of the position and movement of body parts Stereognosis- ability to perceive and understand an object through its size, shape and texture Visceral - any large organ within the body

4. Four aspects of sensory process Stimulus – an agent or act that stimulates a nerve receptor Receptor- a nerve cell that concerts stimulus to a nerve impulse Impulse conduction- the impulse travels along nerve pathways to the spinal cord or directly to the brain Perception- perception, or awareness and interpretation of stimuli happens in the brain where specialized brain cells interpret the nature and quality of the sensory stimuli. The LOC affects the perception of stimuli

5. PROMOTING NORMAL SENSORY PERCEPTION STRUCTURE and FUNCTION of SENSORY PERCEPTION Sensory Awareness -Reticular activating system-responsible for bringing together information from the cerebellum and other parts of the brain with that obtained from the sense organs Input by senses -Special senses-vision, hearing, smell and taste -Somatic senses-touch, kinesthetics (or proprioceptive) sensation, and visceral sensation

6. PROMOTING NORMAL SENSORY PERCEPTION SENSORISTASIS state of optimum arousal-not too much not too little ADAPTATION beyond the point of sensoristasis AWARENESS ability to perceive environmental stimuli and body reactions and to respond appropriately through thought and action.

7. PROMOTING NORMAL SENSORY PERCEPTION LIFESPAN CONSIDERATION Newborn and Infant Toddler and Preschooler Child and adolescent Adult and Older Adult

8. FACTORS AFFECTING SENSORY PERCEPTION Environment Previous Experience Lifestyle and Habits Illness Medications Variations in Stimulation Sensory deprivation

9. SENSORY ALTERATIONS SENSORY DEPRIVATION- decrease in or lack of meaningful stimuli SENSORY DEFICIT- impaired reception, perception, or both, of one or more of the senses. SENSORY OVERLOAD- occurs when a person unable to process or manage the amount or intensity of the sensory stimuli Factors: Increased quality and quantity of internal stimuli Increased quality and quantity of external stimuli Inability to disregard stimuli selectively

10. ALTERED SENSORY PERCEPTION FUNCTION Manifestations of Altered Sensory Perception function Anxiety Cognitive Dysfunction Hallucinations and delusions Sensory deficits Depression and withdrawal

11. NURSING PROCESS ASSESSMENT Normal pattern identification Risk identification Sensory overload- Lengthy verbal explanations before the procedure Room close to the nurses station Bright lights Use of ECG monitor, mechanical ventilators, Oxygen ,IV tubes other equipment Frequent treatments Sensory deprivation Private room, eyes bandaged, bedrest, sensory aid not available isolation precautions, few visitors

12. ASSESSMENT CHARACTERISTICS OF NORMAL SENSORY PERCEPTION Normal vision-visual acuity at or near 20/20, full field of vision and tricolor vision (red, green and blue) Normal hearing-auditory acuity of sounds at an intensity of 0 to 25 dB, at frequencies of 125 to 8000 cycles per second Normal taste- ability to discriminate sour, salty, sweet and bitter Normal smell-discrimination of primary odours such as musky, floral, pepperminty, pungent Somatic senses-discrimination of touch, pressure, vibration, position, tickling, temperature and pain

13. State of Awareness State Description Full consciousness Alert; oriented to time, place, person; understands verbal and written words Disoriented Not oriented to time, place, or person Confused Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment Somnolent Extreme drowsiness but will respond to stimuli Semicomatose Can be aroused by extreme or repeated stimuli Coma Will not respond to verbal stimuli

14. NURSING PROCESS PHYSICAL ASSESSMENT Vision- use of snellen chart to measure visual acuity (or have the client read newspaper, menu or whatever) Smell- with eyes closed, have client identify 3 odors, such as coffee, tobacco and cloves, one nostril at a time, while occluding the other nostril

15. Hearing- whisper numbers in each ear, while occluding the other; ask the client to repeat; perform Weber and Rinne tuning fork test WEBER’S TEST- assesses bone conduction by testing the lateralization ( sideward transmission) of sounds. RINNE TEST- test compares air conduction to bone conduction Sound conducted by air is heard more readily than sound conducted by bone.

16. NURSING PROCESS PHYSICAL ASSESSMENT Taste-with eyes closed, have client identify 3 tastes such as lemon, salt, and sugar, waiting 1 minute and giving sips of water in between. Somatic sensations-Test light touch of extremities with a wisp of cotton; test sharp and dull sensation using the point and blunt end of a pin; test two-point discrimination using two pins held close together; test hot and cold sensation using test tube filled with warm and cold water; test position sense by moving the client’s fingers or toes

17. Diagnosing Disturbed sensory perception Risk for injury Impaired home maintenance Risk for impaired skin integrity Impaired verbal communication Self care deficit Social isolation

18. Planning The overall outcome criteria for clients with sensory-perception alterations are to: Maintain the function of existing senses Develop an effective communication mechanism Prevent injury Prevent sensory overload or deprivation Reduce social isolation Perform ADLs independently and safely

19. IMPLEMENTATION HEALTH PROMOTION Client Teaching Procedure preparation Nurse-client Interaction

20. NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION Stimulation Provision Stimulation Reduction Sensory Aids

21. SENSORY AIDS VISION Eyeglasses with proper prescription, clean and in good repair Adequate room lighting, drapes open Sunglasses or window shades to reduce glare Literature with large print Uncluttered environment, no furniture arrangement Clock with large numbers Telephone dial with large numbers Magnifying glass Bright, contrasting colors in environment NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION

22. SENSORY AIDS Hearing Hearing aid in good repair with working battery Speaking slowly and distinctly in client’s full view, no mouth covering or gum chewing Avoidance of background noise Amplified phone ringer, doorbell, smoke alarm Headset for telephone communication Closed-caption television NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION

23. SENSORY AIDS Smell Fresh food served for meals Fresh flower or fragrance in the room Others wearing light perfume or fragrance Notice of environmental smells NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION

24. SENSORY AIDS TASTE Fresh food, seasoned, appropriately, not overcooked or overprocessed to preserve texture Foods served at appropriate temperature and time of a day Note smell and taste of food Sips of water between foods No mixing of foods NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION

25. SENSORY AIDS Touch Therapeutic touch Massage (self or Nurse) Turning and repositioning Hairbrushing and grooming (self or nurse) Activity around the environment Amount of pressure individualized to client’s comfort level Clothing of various texture NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION

26. NURSING INTERVENTIONS for ALTERED SENSORY PERCEPTION FUNCTION Promoting the use of other Senses Communicating effectively Conscious and unconscious client Ensuring client safety

27. Evaluation

28. Coordination Activity, Mobility and Exercise

29. Definition: Body Mechanism Activity Exercise

30. Body mechanics – is the safe use of muscles of the body to accomplish mechanical task

31. Principles of Body Mechanism Bend knees to lift objects form the floor Use a wide base of support by placing the feet 12-18 inches apart when moving objects Pulling is easier than pushing Work is best accomplished at the center of gravity. Working at the waist level is most efficient.

32. APPLIED PRINCIPLES OF BODY MECHANICS Hold objects close to the body when lifting Use rhythmic, smooth, and coordinated motions at a reasonable speed Use elbows, hips and knees as levers when lifting Use mechanical devices when appropriate Holding the breath during a physical activity is an indication of muscle strain and inefficient use of body mechanics

33. APPLIED PRINCIPLES OF BODY MECHANICS Adjust the height of the work area when possible Assume a starting position that will permit freedom of movement in range, direction and position Keep body balanced over the base of support with knees relaxed and trunk erect (in relation to the pelvis) Bend hips and knees to alter position of body, widening the base of support as needed, for effective leverage and use of energy Face the direction of motion, using the muscles of the lower extremities and shifting body weight for lifting, pushing and pulling actions

34. PRINCIPLES OF BODY MECHANICS Reducing friction between the object moved and the surface on which it moved requires less energy Holding an object close to the body requires less energy than holding it farther away Muscle strain can be avoided by using the strong leg muscles when lifting, pushing and pulling Smooth continuous movements are easier and safer than sudden, sharp or uncontrolled movements Using rhythmic movements at normal speed requires less energy

35. Diet – a balance diet is important in maintaining the bones or muscles for optimum activity should be contain adequate sources of calcium, phosphorus and vitamin D for bone growth and prevention of osteoporosis. The diet should contain adequate sources of the following;

36. Calcium – for bone and teeth formation, blood clotting, muscle activity and nerve function. High Calcium – dried and fresh dilis, dried and fresh alamang, fried fish, shell fish, certain fresh fishes such as silinyasi, tunsoy, milk, cheese, ice cream, soy beans, monggo and other dried beans, leafy vegetables. Low Calcium – cereal and cereal products without milk, fruit and fruit juices, vegetables, lean meat. Poultry sugar starchy roots and tubers, young coconut.

37. Phosphorus – for bone and teeth formation, important in energy transfer, component of nucleic acid. High Phosphorus – Meat, fish, poultry, egg yolk, milk, cheese, beans and bean products, nuts and seeds, dried banana and flowers, cocoa, chocolate, undermilled rice, pinipig, whole grain cereal, cookies and sweet made with nuts. Low Phosphorus – Egg white, sugar, fats and oil, fruits, kaong, gabi stem, sayote, bihon, sotanghon, kusinta and nata de coco

39. EXERCISE CLASSIFICATION Source of Energy - Aerobic Exercise -Anaerobic Exercise Type of Muscle Tension -Isotonic Exercise -Isometric Exercise

40. Effects of Exercise on: Cardiovascular System Respiratory System Endocrine System Immune System Muscular System Metabolic Rate

41. FACTORS AFFECTING MOBILITY Lifestyle and habits Intact musculoskeletal system Nervous system control Circulation and Oxygenation Energy Congenital problems Therapeutic modalities

42. Manifestations of Altered Mobility Decreased muscle tone and strength Lack of coordination Altered gait Falls Decreased joint flexibility Pain on movement Activity intolerance

43. Impact of Immobility on Function Activity and Exercise -muscle atrophy and weakness -contractures and joint pains -increased cardiac workload -orthostatic hypotension -thrombus formation and embolism -decreased lung expansion

44. Impact of Immobility on Function Nutrition and Metabolism Decreased metabolic rate Negative nitrogen balance Anorexia Disuse osteoporosis Impaired immunity Pressure ulcers

45. Impact of Immobility on Function ELIMINATION -Urinary stasis -urinary tract infection -renal calculi -constipation

46. Impact of Immobility on Function SLEEP and REST COGNITION and PERCEPTION SELF-PERCEPTION and SELF-CONCEPT ROLES and RELATIONSHIP COPING and STRESS TOLERANCE SEXUALITY

47. Nursing Assessment Health History Physical Exam – Inspection and Palpation The muscles are inspected for bulk, palpated for tenderness, consistency and contractures. Tone Muscle tone is assessed by putting selected muscle groups through passive range of motion. The most commonly used maneuvers for the upper extremities are flexion and extension at the elbow and wrist. The most commonly used maneuvers for the lower extremities are flexion and extension at the knee and ankle.

48. PHYSICAL ASSESSMENT Muscle Strength Grading 0 – No contraction 1 – Slight contraction, no movement 2 – Full range of motion without gravity 3 – Full range of motion with gravity 4 – Full range of motion , some resistance 5 – Full range of motion, full resistance

49. PHYSICAL ASSESSMENT Stretch or Deep Tendon Reflexes A brisk tap to the muscle tendon using a reflex hammer produces a stretch to the muscle that results in a reflex contraction of the muscle. The muscles tested, segmental level, and grading of DTR's is listed below. Grading DTR's 0 – Absent 1 – Decreased but present 2 – Normal 3 – Brisk and excessive 4 – With clonus

51. Nursing Assessment Laboratory findings

52. Nursing Assessment Laboratory findings

54. IMPLEMENTATION Health Promotion Physical Fitness Program Osteoporosis Prevention Injury Prevention

55. NURSING INTERVENTIONS for ALTERED MOBILITY POSITIONING Think through the task before beginning Ensure that all needed equipment is within reach Explain to the client exactly what will happen before the beginning of position change Enlist the client’s assistance whenever possible, giving instructions and encouragement as necessary When the position change has been completed, ask if the client is comfortable. Reposition as necessary Tell the client how long he or she will remain in the position. Provide a call device within reach. Document position changes and the client’s tolerance.

56. NURSING INTERVENTIONS for ALTERED MOBILITY JOINT MOBILITY MAINTENANCE Types of ROM General Principles of ROM Exercises Guidelines for moving clients Assess the client’s abilities and limitations Medicate client to provide optimal pain relief Organize environment and request needed help to ensure safety Explain what you are going to do and how you expect your client to help

57. NURSING INTERVENTIONS for ALTERED MOBILITY General Principles of ROM Exercises Permit client to do as much as his or her capabilities allow Consider safety precautions Follow the principles of body mechanics Keep movements smooth and rhythmic Prevent trauma (e.g. Friction against skin, pulling joints) Check client for proper body alignment and comf ort, and provide client with call bell before leaving

58. NURSING INTERVENTIONS for ALTERED MOBILITY AMBULATION Dangling of the legs Assisting the client with ambulation Transfer belts Mechanical aids Muscle strengthening to facilitate ambulation

59. NURSING INTERVENTIONS for ALTERED MOBILITY ASSISTIVE DEVICE for WALKING CANES Types- single, tripod cane, quadripod cane Patient must hold the cane in hand opposite affected extremity. Advance cane as the affected leg is moved forward

60. NURSING INTERVENTIONS for ALTERED MOBILITY ASSISTIVE DEVICE for WALKING WALKER Hip level Lift and walk Positioned at the back when going up the stairs Positioned in front when going down stairs

61. NURSING INTERVENTIONS for ALTERED MOBILITY ASSISTIVE DEVICE for WALKING CRUTCHES Assure proper length With patient standing: top of the crutch is 2 inches below the axilla and the tip of each crutch is 6 inches in front and to the side of the feet ( 2 inches forward, then 4 inches to the side) Patients elbows should be slightly flexed when hand is on bar (30 degrees) Weight must be borne by axillae, but on palms of the hand to prevent crutch palsy

62. NURSING INTERVENTIONS for ALTERED MOBILITY ASSISTIVE DEVICE for WALKING CRUTCHES CRUTCH GAIT Four point gait. Advance right crutch followed by the left foot, then left crutch followed by right foot Two point Gait- Advance right crutch and left foot together, then the left crutch and the right foot together Three point Gait- Advance both crutches and the affected leg together, followed by the unaffected leg. None or little weight-bearing is allowed. Swing to gait-Advance both crutches, swing the body so that the feet will be at the level of crutches Swing through gait-Advance both crutches, swing the body so that the feet will be past the level of crutches

63. NURSING INTERVENTIONS for ALTERED MOBILITY ASSISTIVE DEVICE for WALKING CRUTCHES Going up and down the stairs Up with the good (good leg first, then the bad leg and crutches) Down with the bad ( bad leg and crutches first, then good leg)

64. NURSING INTERVENTIONS for ALTERED MOBILITY TRANSFERS Two or three persons lift Hydraulic lifts Stand-up assists lifts Safety alert: The under-axilla lift techniques, where care providers pull the client by grasping the arms and under the axilla should never be employed. This technique exerts pressure on the brachial plexus that can affect the nerve function to the neck, shoulder, arms and hands. It can also subluxate the shoulder. Also this technique is the cause of poor body mechanics for the nurse and has been associated with L5-S1 back injuries.

65. Transport of Clients Guidelines for Safe Lifting 1 . Consider the weight of the patient together with the weight of the stretcher or other equipment being carried and determine if additional help is needed. 2. Know your physical ability and limitations. Know your combined ability with your partner. If absolutely necessary, you can ask bystanders to help. You or your partner must be in charge and give the orders, not the bystander. 3. Lift without twisting. Avoid any kind of swinging motion when lifting as well. 4. Position your feet shoulder width apart with one foot slightly in front of the other. Wear proper boots that go above the ankle to protect your feet and help keep a firm footing. Boots should have nonskid soles. 5. Communicate clearly and frequently with your partner. Decide ahead of time how you will move the patient and what verbal commands will be used. Also, tell the patient what you will be doing ahead of time. A startled patient may reach out or grab something and cause a loss of balance.

66. Position the stretcher at a right angle to the patient's bed with the head end of the stretcher at the foot of the bed. Prepare the stretcher by unbuckling the straps, removing other items, and lowering the closest railing. Both EMTs stand between the stretcher and the bed, facing the patient. The EMT at the head end of the stretcher slides one arm under the patient's neck and shoulders, cupping the far shoulder with his or her hand and cradling the head. The second EMT slides one arm under the small of the patient's back, slides the arm under the buttocks and lifts slightly to allow the first EMT to slide an arm under the waist. The second EMT reaches under the patient's lower legs. The patient is pulled to the edge of the bed, then lifted and curled toward the EMT's chest. The EMTs rotate to be in line with the stretcher, then place the patient gently on to it.

67. Draw Sheet Method

68. Nursing Intervention to Promote Activity and Exercise