Stressors that affect Cognition Perception Sensory Sleep

1. Stressors that affectCognition &PerceptionSensorySleep NUR101 FALL 2008 LECTURE # 18 K. BURGER PPP By Sharon Niggemeier RN MS

2. Sensory Needs Senses- needed for survival, growth & development and bodily pleasure Give meaning to events in the environment Alterations in senses- affect ability to function in the environment

3. Sensory Experience When we sense things: process of sensory reception (receive stimuli) and sensory perception (organization and transmission of stimuli into meaningful data�influenced by experiences, knowledge, attitudes) Sensory reception � stimuli can be visual, auditory, olfactory, tactile or gustatory. Also can be kinesthetic, stereognosis or visceral. RAS(reticular activating system)- responsible for stimulus arousal (monitors & regulates incoming stimuli) Visual- sight Auditory-Hearing-Olfactory is smell Tactile-Touch Gustatory-taste Kinesthetic-aware of location of body parts�walking aware which leg is forward Stereognosis- know an object thru touch by its size shape texture dime vs penny with eyes closed Visceral- organs within the body that may produce stimuli make you aware of them (full stomach)Visual- sight Auditory-Hearing-Olfactory is smell Tactile-Touch Gustatory-taste Kinesthetic-aware of location of body parts�walking aware which leg is forward Stereognosis- know an object thru touch by its size shape texture dime vs penny with eyes closed Visceral- organs within the body that may produce stimuli make you aware of them (full stomach)

4. Consider this�. Sensory Adaptation Stimulus must be variable to create a response, otherwise it is gradually ignored. Think about when you are in a client�s room on the clinical unit to which you are assigned:Do you hear all the overhead pages?Do you hear all the beeping IV pumps?Do you hear the rattling of garbage pails being emptied?Do you hear the roommate�s TV? Important! Nurses adapt to unit noises and may not realize stimuli affecting their clients.

5. Factors Affecting Sensory Functioning Developmental level Culture Stress Meds Illness & Therapies Personality

6. Think-Pair-Share Think about some of the unit noises we discussed on the Consider this� Slide Which noises bother YOU the most?What could you do to decrease this sensory overload? Share your experience with a classmate and discuss other interventions.

7. Sensory Alterations A change in environment can lead to MORE or LESS normal stimuli. When stimuli is different from what one is used to it leads to sensory alterations. Hospitalized patients will experience sensory alterations due to different stimuli loads. Can result in sensory overload or sensory deprivation

8. Sensory Overload Results from being unable to manage sensory stimuli: (too much stimuli) Pain, dyspnea, anxiety (internal) Noise, intrusive procedures, contact with many strangers (external) Inability to disregard stimuli: for example meds that stimulate the arousal mechanism, may prevent one from ignoring noise Loss of control�brain can�t respond meaningfully or ignore stimuli �ICU Psychosis� 24/7 nervous system disturbances�intrusive monitoring equipment Loss of control�brain can�t respond meaningfully or ignore stimuli �ICU Psychosis� 24/7 nervous system disturbances�intrusive monitoring equipment

9. Assessment: Sensory Overload Unrealistic perceptions, ineffective coping Acts bewildered,disoriented, difficulty concentrating, muscle tension Reduced problem-solving ability, scattered attention, racing thoughts

10. Interventions: Sensory Overload Prevent sensory alteration Reduce environmental stimuli, promote sleep Establish a routine for care Speak calmly and slowly with simple explanations Eliminate personal stimuli Environment- move away from nurses station Routine- bathing, treatment in afternoon, ambulation early evening spaced apart Stimuli- turn off phone, deny visitorsEnvironment- move away from nurses station Routine- bathing, treatment in afternoon, ambulation early evening spaced apart Stimuli- turn off phone, deny visitors

11. Sensory Deprivation Results from decreased sensory input or meaningless input: (too little stimuli) Isolation/non-stimulating monotonous environment Impaired ability to receive and/or send stimuli IE: vision, hearing deficits, speech deficits ( expressive or receptive aphasia) Inability to cognitively process stimuli-confused, brain injury, meds affecting CNS

12. Sensory Deficits Impaired reception, perception or both of the senses Blindness, deafness, loss of taste, smell, touch One sense may become more acute to compensate for deficit At risk for sensory overload in the compensated sense or deprivation overall

13. Assessing: Sensory Deprivation Drowsiness/sleeping/yawning Decreased attention span, difficulty concentrating, impaired memory Disorientation, confusion, hallucinations RAS needs stimulus; body may produce hallucinations to maintain optimal arousal Crying, annoyance over small matters, depression Apathy, daydreaming, boredom, anger

14. Assessment: Sensory Deficit Assess loss of one or more senses Note behaviors to compensate for deficit-always turns right ear toward person speaking to compensate for hearing loss Assess for diseases that can affect senses, inner ear infection causes loss of kinesthetic sense, neurological disease can effect tactile perception

15. NURSING DIAGNOSIS Disturbed sensory perception Social Isolation OTHERS in which decreased sensory perception may be an etiology? Situational low self-esteem Disturbed thought processes WHAT IS A PRIORITY NURSING DIAGNOSIS for the client with altered sensory perception?

16. PLANNING Client will:Demonstrate understanding by a verbal, written, or signed response (SENSORY DEFICIT) Client will:Demonstrate relaxed body movements and facial expressions (SENSORY OVERLOAD) Client will:Increase and maintain personal interactions(SENSORY DEVICIT) Client will:Remain free from injury

17. Interventions: Sensory Deprivation Prevent sensory alteration Teach self stimulation methods- reading, singing etc. Provide stimulation � visual, auditory, gustatory, tactile and cognitive Provide reality orientation Utilize interpreters for communication barriers Visual- TV, clocks, calendars, colorful PJ, open blinds Auditory- radio, TV, cd player, conversation Gustatory- foods from home, variety tastes textures and smells of food Tactile- backrub, rom, brushing hair, shaving Cognitive- puzzles, hobbies, provideVisual- TV, clocks, calendars, colorful PJ, open blinds Auditory- radio, TV, cd player, conversation Gustatory- foods from home, variety tastes textures and smells of food Tactile- backrub, rom, brushing hair, shaving Cognitive- puzzles, hobbies, provide

18. Interventions: Sensory Deficit Deficit may be new- determine ability to compensate Provide care to facilitate sense Provide glasses, hearing aids, adaptive equipment etc. to reduce sensory deficit Utilize all health care team members to assist with sensory deficit�dietary for loss of gustatory sense New deficit- take longer compensate then born with it Facilitate senses- speak in right ear, for auditory deficit Blind- use clock method to explain surrounding or items on plateNew deficit- take longer compensate then born with it Facilitate senses- speak in right ear, for auditory deficit Blind- use clock method to explain surrounding or items on plate

19. Which of the following are guidelines that should be followed when caring for visually impaired clients? (select ALL that apply) Wait for the person to sense your presence in the room before identifying yourself Speak in a normal tone of voice Explain the reason for touching the person after doing so Orient the person to the arrangement of the room and its furnishings Assist with ambulation by walking slightly behind the person Sit in the person�s field of vision if he or she has partial or reduced peripheral vision

20. Which of the following are guidelines to follow when caring for clients with hearing impairments (select ALL that apply) Increase the noise level in the room Clean ears on a daily basis Position yourself so that the light is on your face when you speak Talk to the person from a distance so that he/she may read your lips Demonstrate or pantomime ideas you wish to express Write any ideas that you cannot convey to the person in another manner.

21. Communication MethodsforClients with Special Needs Review Box 24-10 in Potter & PerryPage 357

22. Evaluation: Sensory alterations Were outcomes met ? Is patient compensating ? Sensory deprivation hasn�t become sensory overload? Does nursing care plan need modifying if goals not met?

23. Sleep/Rest Essential for health Illness requires increased need for sleep/rest Rest � calmness, free from stress/anxiety Sleep � altered state of consciousness in which reaction and perception is decreased Effects of sleep on the body not completely understood Physiological & psychological rhythms are high or most active than you are awake, when low you sleepPhysiological & psychological rhythms are high or most active than you are awake, when low you sleep

24. Sleep Circadian synchronization- sleep-wake pattern follows the body�s biologic clock RAS and Bulbar synchronizing region of Pons work together to control sleep/wake cycles Restores balance to nervous system Promotes physiological & psychological restoration Lack of sleep- irritable, poor concentration, difficulty making decisions

25. Sleep Stages NREM- non-rapid eye movement 75-80% of adult sleep Has 4 stagesI � sl. AwarenessII- easily arousedIII � less easily arousedIV � Delta sleep; arousal difficult REM(Stage V) - rapid eye movement 20-25% of adult sleep DreamingEyes dartingfacial muscles flacid Essential for emotional equilibrium

26. Sleep Requirements Individualized Less sleep required the older one is�newborns sleep 16-18 hr/day (with more Delta & REM sleep) whereas elders sleep 6 hr/day ( with less Delta & REM sleep)

27. Factors Affecting Sleep Health/illness (CAD pain, GI secretions increased in REM sleep, Environment Exercise and Fatigue Lifestyle Emotional stress Stimulants/Alcohol (decrease Delta & REM sleep) Diet Smoking Medication Motivation

28. Sleep Disorders Insomnia Narcolepsy Sleep apnea Parasomnias Insomnia- lack adequate amount or quality of sleep�.difficulty falling asleep, staying also, early waking, usually resulting from overstimulation due to anxiety�need to develop behavior patterns to induce sleep Narcolepsy- sudden wave of overwhelming sleepiness during the day�.sleep attacks�.onset 15-30 yr even though they sleep well at night Sleep apnea- cessation of breathing� periods last from 10sec �2 min�50-600 x a night lead to excessive daytime sleepiness Parasomnias sleep walking, sleep terrors, sleep talking, nightmares, bruxism ( grinding teeth) enuresisInsomnia- lack adequate amount or quality of sleep�.difficulty falling asleep, staying also, early waking, usually resulting from overstimulation due to anxiety�need to develop behavior patterns to induce sleep Narcolepsy- sudden wave of overwhelming sleepiness during the day�.sleep attacks�.onset 15-30 yr even though they sleep well at night Sleep apnea- cessation of breathing� periods last from 10sec �2 min�50-600 x a night lead to excessive daytime sleepiness Parasomnias sleep walking, sleep terrors, sleep talking, nightmares, bruxism ( grinding teeth) enuresis

29. Assessing: Sleep Pattern Quality Energy level Sleeping aids Sleep disturbances-nature-onset-causes-symptoms (Do you snore? Do you wake up with HA?) Pattern- usual number of hours� Quality- awake felling restedPattern- usual number of hours� Quality- awake felling rested

30. Assessing Sleep What are some objective signs of inadequate sleep the nurse should be observant to?

31. Nursing Dx Sleep pattern disturbance R/T physical discomfort AEB s/p L hip arthroplasty, positioning restrictions and client statement �I can�t sleep on my back; I like to sleep on my side� Sleep deficit R/T shift changes at work AEB � I�m tired going to work but when I get home I can�t fall asleep�

32. Nursing Diagnoses with Sleep Deprivation as etiology Anxiety r/t Activity intolerance r/t Ineffective coping r/t Risk for injury r/t

33. Outcome Criteria Client will: Wake up less frequently during the night Fall asleep without difficulty Verbalize plan that provides adequate time for sleep Identify actions that can be taken to improve quality of sleep Awaken refreshed and be less fatigued during the day

34. Implementing: Promote Sleep Restful environment Comfort/relaxation Bedtime rituals Sleep pattern Medications Environment- Sheet straightened,Temp room is good, lighting dimmed, noise decreased TV off/low, pj, Comfort/relaxation- reduce pain, back massage, low music,snacks Meds last resort Rituals - prayers, meditation, watching TV, showering, reading, Patterns -Night worker, expect them to sleep during the day and be awake at night Environment- Sheet straightened,Temp room is good, lighting dimmed, noise decreased TV off/low, pj, Comfort/relaxation- reduce pain, back massage, low music,snacks Meds last resort Rituals - prayers, meditation, watching TV, showering, reading, Patterns -Night worker, expect them to sleep during the day and be awake at night

35. Pharmacological Approaches Herbals: Melatonin, Chamomile Sedatives: Temazepam (Restoril) Triazolam ( Halcion ) Zolpidem ( Ambien) Alprazolam ( Xanax) Diazepam ( Valium )