 SENSORY ALTERATIONS

 TERMINOLOGY
MODULE 16 

SCIENTIFIC KNOWLEDGE BASE
SENSORY ALTERATIONS
: NURSING INTERVENTION TO PROMOTE  FACTORS AFFECTING SENSORY FUNCTION
 CRITICAL THINKING
HEALTHY PSYCHOSOCIAL RESPONSES  NURSING PROCESS: ASSESSMENT
 NURSING DIAGNOSIS FOR SENSORY ALTERATIONS
 IMPLEMENTATION FOR SENSORY ALTERATIONS
 SEXUALITY AND NURSING CARE
 CONTRACEPTION AND STI PREVENTION
 SEXUALLY TRANSMITTED INFECTIONS (STIS)
 FACTORS INFLUENCING SEXUALITY
 NURSING KNOWLEDGE AND PRACTICE
 SPIRITUAL HEALTH
 CURRENT CONCEPTS IN SPIRITUAL HEALTH
 RELIGIOUS VS. SPIRITUAL CARE
 SPIRITUAL HEALTH
 CRITICAL THINKING
SENSORY ALTERATIONS
 Sensory Function: People perceive their environment through five senses: sight, hearing, smell, taste, and touch. These
sensory experiences help individuals interpret and respond to their surroundings.
 Altered Sensory Function: When a person's sensory function is impaired, their ability to interact with and understand the
environment can be significantly affected. As a nurse, it's essential to assess and manage sensory alterations in patients, as
well as provide strategies for those with partial or complete sensory loss.

TERMINOLOGY
 Senses:
o Sight (Visual): The ability to perceive the environment through light and color.
o Hearing (Auditory): The ability to detect sound waves and interpret them.
o Touch (Tactile): Perception through skin, including sensations of pressure, pain, and temperature.
o Smell (Olfactory): The ability to perceive airborne molecules, giving information about the environment.
o Taste (Gustatory): The ability to recognize flavors via taste buds on the tongue.
o Position and Motion (Kinesthetic): The sense of body movement and spatial orientation.
 Stereognosis: The sense that allows a person to identify the size, shape, and texture of an object by touch.

SCIENTIFIC KNOWLEDGE BASE

 Sensory Reception: Involves the stimulation of sensory nerve fibers and transmission of impulses to the brain.
o Reception: The initial stimulation of a receptor (e.g., light, touch, sound).
o Perception: The brain's integration and interpretation of sensory stimuli.
o Reaction: Only the most important stimuli trigger a response, allowing individuals to focus on relevant
information.

SENSORY ALTERATIONS
1. Sensory Deficits:
o Impaired function in the reception and perception of sensory stimuli.
2. Sensory Deprivation:
o Occurs when there is an insufficient amount or quality of sensory input. This may lead to confusion, hallucinations,
or disorientation.
3. Sensory Overload:
o When multiple sensory stimuli are received at once, overwhelming the individual's ability to process them. It can
lead to fatigue, stress, or confusion.

FACTORS AFFECTING SENSORY FUNCTION

1. Age: Sensory function naturally declines with age.
2. Meaningful Stimuli: Engaging stimuli, such as social interactions or environmental enrichments, can reduce the risk of
sensory deprivation.
3. Amount of Stimuli: Too much stimulation can lead to sensory overload, while too little can cause deprivation.
4. Social Interaction: Lack of interaction with others (e.g., family, friends) can exacerbate sensory deficits, leading to isolation
and reduced stimulation.
5. Environmental Factors: Occupational or recreational exposures, such as noise or exposure to chemicals, can affect sensory
function.
6. Cultural Factors: Different cultures may have varying perceptions of sensory alterations and may emphasize different
approaches to managing them.

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 CRITICAL THINKING
 Nurses should integrate their understanding of the pathophysiology of sensory deficits, factors affecting sensory function,
and communication principles when caring for patients with sensory alterations.
 Use of Criteria: Organizations like the American Academy of Ophthalmology and the American Speech-Language-Hearing
Association provide screening criteria for identifying sensory problems.

NURSING PROCESS: ASSESSMENT

 Through the Patient’s Eyes: Understand the patient's perspective and how they perceive their sensory impairment.
 Persons at Risk: Identify individuals at higher risk for sensory alterations, such as the elderly or those with certain health
conditions.
 Sensory Alteration History: Collect a comprehensive history of the patient's sensory deficits or impairments.
 Mental Status: Assess the patient’s cognitive function, as mental status can influence sensory perception.
 Physical Assessment: Conduct a thorough physical examination, including testing the function of sensory organs.
 Ability to Perform Self-Care: Evaluate the patient's ability to perform activities of daily living with sensory deficits.
 Health Promotion Habits: Discuss the patient's habits and lifestyle that may affect sensory health (e.g., smoking, diet).
 Environmental Hazards: Identify environmental factors that may be contributing to sensory loss, such as noise pollution or
chemical exposure.
 Communication Methods:
o Aphasia: The nurse must assess whether the patient has any form of aphasia (language impairment), which can
affect communication.
 Expressive Aphasia (Motor): Difficulty in producing speech.
 Receptive Aphasia (Sensory): Difficulty in understanding speech.
 Global Aphasia: Difficulty with both speech production and comprehension.
 Assistive Devices: Assess the use of devices like hearing aids, glasses, or mobility aids to support sensory function.
 Social Support: Evaluate the presence of a support network, which is essential for managing sensory impairments.
NURSING DIAGNOSIS FOR SENSORY ALTERATIONS
When working with patients who have sensory impairments, nursing diagnoses often include the following:
1. Risk-prone Health Behavior: Patients may engage in behaviors that increase the risk of further sensory impairment or
harm.
2. Impaired Verbal Communication: Difficulty in producing or understanding speech due to sensory or cognitive issues.
3. Risk for Injury: Increased likelihood of injury due to sensory deficits, such as vision or hearing impairments, which affect
balance or awareness of surroundings.
4. Impaired Physical Mobility: Reduced ability to move or navigate safely due to sensory deficits.
5. Bathing Self-care Deficit: Difficulty performing personal hygiene activities, often due to physical limitations stemming from
sensory impairments.
6. Situational Low Self-esteem: Emotional distress and a decrease in self-esteem as a result of losing sensory function.
7. Risk for Falls: Higher chance of falls, particularly in patients with visual or balance impairments.
8. Social Isolation: A feeling of being disconnected from others, which can occur with sensory impairments if the person
withdraws socially or is unable to engage in communication effectively.

IMPLEMENTATION FOR SENSORY ALTERATIONS

Health Promotion
 Screening: Regular assessments to detect sensory impairments early (e.g., vision or hearing tests).
 Preventive Measures: Educating patients on lifestyle choices and precautions to prevent sensory deficits or injuries (e.g.,
eye protection, hearing protection in noisy environments).
 Use of Assistive Devices: Ensure patients are aware of and have access to tools like hearing aids, glasses, mobility aids, or
communication devices to support sensory function.
 Promoting Meaningful Stimuli: Create environments that stimulate the senses appropriately to reduce sensory
deprivation (e.g., providing tactile objects or engaging in stimulating conversations for those with hearing impairments).
 Establishing Safe Environments: Ensure that the patient's living space is free of hazards and facilitates mobility (e.g.,
remove obstacles, use night lights for visually impaired patients).
 Communication: Teach effective communication methods, such as using clear speech, gestures, or writing for patients
with impaired communication abilities.
Acute Care
 Orientation to the Environment: Help patients adjust to their surroundings, providing them with guidance and support in
new or unfamiliar settings.
 Communication: Use appropriate communication strategies, including gestures, writing, or adaptive technologies to
enhance interaction with patients who have sensory impairments.
 Controlling Sensory Stimuli: Adjust the level of sensory stimuli to prevent overload or deprivation (e.g., controlling light
and noise levels for patients with sensory sensitivities).
 Safety Measures: Implement strategies to reduce the risk of injury, such as fall precautions for patients with visual or
balance impairments.
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Restorative and Continuing Care
 Maintaining Healthy Lifestyles: Encourage healthy behaviors that support sensory function, such as good nutrition,
regular physical activity, and adequate sleep.
 Understanding Sensory Loss: Provide ongoing education for patients and families about managing sensory loss and its
impact on daily life.
 Socialization: Promote social interactions to combat isolation, such as encouraging participation in group activities or
support groups for patients with sensory impairments.
 Promoting Self-care: Encourage independence by teaching patients strategies to manage their own care, using assistive
devices and tools to help with daily tasks like eating, bathing, and mobility.

SEXUALITY AND NURSING CARE

Sexuality is a core component of an individual’s personality and contributes to their overall health. Nurses are essential in
addressing sexual health concerns and providing education to patients who may feel uncomfortable discussing such topics.
Through open, matter-of-fact communication, nurses can create a supportive environment for discussing sexuality, thus
empowering patients to share their concerns.
Sexuality and Its Influences
 Cultural and Religious Factors: Religious teachings, cultural influences, and beliefs about sexual orientation can
significantly shape both patients' and healthcare providers' perceptions of sexuality.
 Holistic Understanding: Sexuality involves biological, sociological, psychological, spiritual, economic, political, and cultural
factors. Nurses must recognize that these diverse influences shape sexual expression, behavior, and health.
 Sexual Health vs. Sexuality: According to the WHO, sexual health is defined as a state of physical, emotional, mental, and
social well-being in relation to sexuality, beyond the absence of disease or dysfunction.
Scientific Knowledge Base
 Sexual Development: Sexuality evolves at different stages of life, from infancy and childhood to adolescence, adulthood,
and older age.
 Sexual Orientation: Adolescents, in particular, explore their sexual identity through peer networks, and understanding this
is essential for guiding sexual health discussions.

CONTRACEPTION AND STI PREVENTION

 Non-prescription Methods: These include abstinence, barrier methods, spermicides, and the rhythm method.
 Prescribed Methods: Hormonal contraception (e.g., birth control pills), intrauterine devices (IUDs), diaphragms, cervical
caps, and sterilization (e.g., tubal ligation, vasectomy) require healthcare provider involvement.

SEXUALLY TRANSMITTED INFECTIONS (STIS)

 Prevalence: About 20 million new STI cases occur in the U.S. each year, with nearly half of those cases in individuals aged
15–24 years.
 Common STIs:
o Curable: Syphilis, gonorrhea, chlamydia, trichomoniasis
o Viral STIs: Human papillomavirus (HPV), herpes simplex virus (HSV-2), human immunodeficiency virus (HIV), and
acquired immunodeficiency syndrome (AIDS).
 Transmission: STIs can be spread through intimate sexual contact, and symptoms may be absent or mild, leading to
undiagnosed infections.
o Common Symptoms: Discharge from the genital area, pain during urination or sexual activity, blisters or sores,
fever.
 Embarrassment: Patients may feel embarrassed or reluctant to discuss their sexual health, making it essential for
healthcare providers to approach these topics in a sensitive, non-judgmental manner.

FACTORS INFLUENCING SEXUALITY

 Sociocultural Dimensions: Cultural beliefs, gender roles, pregnancy, menstruation, and sexuality discussions can affect a
person’s experience of sexuality.
 Sexual Assessment: Nurses must incorporate sexual health assessments and interventions into patient care, particularly
when dealing with pregnancy, reproductive health, or STI concerns.

NURSING KNOWLEDGE AND PRACTICE

 Addressing Discomfort: Nurses who are uncomfortable discussing sexuality need to explore their feelings and create a
plan to address such discomfort, ensuring they can effectively support their patients’ sexual health needs.
Decisional Issues in Sexual Health
 Contraception: Effectiveness depends on method, understanding, and consistency. Nurses should educate patients on
proper use.
 Abortion: Nurses must separate personal beliefs from patient care and ensure the patient receives appropriate support.
 STI Prevention: Abstinence is 100% effective; nurses should educate about safer sex and regular screenings.
Alterations in Sexual Health
NOTE NI BINSSS
  Infertility: Inability to conceive after 1 year of unprotected intercourse.
 Sexual Abuse: Nurses must report suspected abuse to authorities.
 Sexual Dysfunction: Affected by illness, medications, and emotional factors.
Critical Thinking
 Nurses should integrate knowledge from multiple disciplines to address sexual health issues with professionalism and
sensitivity.
Nursing Process
 Assessment: Understand patient expectations, assess factors affecting sexuality, and take a thorough sexual health history.
 PLISSIT Model: Permission to discuss, provide limited information, specific suggestions, and refer to specialists if needed.
Nursing Diagnoses
 Anxiety, ineffective coping, social isolation, sexual dysfunction, and deficient knowledge on contraception/STIs.
Implementation
 Health Promotion: Educate on sexual health and prevention.
 Acute Care: Address sexual health during illness or surgery.
 Restorative Care: Offer support and strategies for maintaining sexual activity in chronic illness.

SPIRITUAL HEALTH
 Definition: Spirituality, derived from the Latin spiritus (breath or wind),
refers to the life force at the center of a person’s existence, connecting
individuals to their inner self, a higher being, nature, or a greater
purpose.
 Health Balance: Spirituality plays a key role in balancing physical,
psychological, sociological, cultural, developmental, and spiritual aspects
of health, helping individuals maintain well-being and cope with illness.
 Spirituality vs. Religion: Spirituality is a broader, more unifying concept
than religion. It encompasses a sense of purpose and connection beyond
religious practice.
 Nurses' Role: Nurses must be aware of their own spirituality and respect
patients’ beliefs to provide holistic care. Developing caring relationships
helps nurses understand the spiritual needs of patients.

CURRENT CONCEPTS IN SPIRITUAL HEALTH

 Constructs of spirituality
 Self-transcendence: Going beyond oneself to connect with a higher purpose or being.
 Connectedness: Feeling at one with others, nature, or a higher power.
 Faith: Belief in something beyond oneself, providing strength and guidance.
 Hope: Positive expectation for the future, offering purpose and optimism.
 Spiritual Well-being: Peace and balance from aligning with spiritual beliefs.
 Faith: A belief that provides comfort and strength.
 Religion: Organized beliefs and practices providing structure to spirituality.
 Hope: Belief in improvement and meaning, even during struggles.

RELIGIOUS VS. SPIRITUAL CARE

 Religious Care: Supports patients in maintaining their faith and worship practices.
 Spiritual Care: Helps individuals find meaning and purpose, look beyond the present, and nurture their relationship with a
higher being or life force.

SPIRITUAL HEALTH
 Represents balance and matures with increased awareness of life’s meaning, purpose, and values.

CRITICAL THINKING
 Apply knowledge, experience, and standards in patient care.
 Personal experience with spiritual distress helps guide coping options.
 The Joint Commission requires pastoral care in health organizations.

NURSING PROCESS: ASSESSMENT

 Faith History: Understand the patient’s beliefs about life, health, and a higher being.
 Tools: Listening, FICA (Faith, Importance, Community, Address), Spiritual Well-being scale.
 Ask about life satisfaction, self-responsibility, connectedness, and support networks.

NURSING PROCESS: DIAGNOSIS

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  Potential diagnoses include anxiety, ineffective coping, spiritual distress, and readiness for enhanced spiritual well-being.

NURSING PROCESS: PLANNING

 Set individualized goals based on what is most important to the patient.
 Collaborate with pastoral care in a hospital setting.
NURSING PROCESS: IMPLEMENTATION
 Health Promotion: Establish presence, provide support, mobilize hope, and interpret suffering.
 Acute Care: Offer support systems and respect rituals.
 Restorative Care: Use prayer, meditation, and grief support.

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