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53 a focus 11 neurosensory & protective needs


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53 a focus 11 neurosensory & protective needs

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