Welcome, this lecture is on
and it is part of the Psychosocial
Integrity part of the NCLEX exam.
My name is Diana Shenefield.
Let's get started.
So what is this topic include?
We are gonna look at
providing direct patient
care that promotes
and supports a patient's
needs based upon visual
auditory, and cognitive distortions.
You know we talk about vision and hearing
those are pretty easy. You are thinking about
can't see, can't hear. So what can I do as a nurse?
Or when you starting
taking in cognitively
and cognitive distortion. What all is that include
and are we think about that with our patients?
Our learning outcomes is we wanna
address our patient's need
based on visual, auditory
and cognitive disorders.
So again our patients that can't see. Are we making
sure that their environment safe? If they can't hear.
Are we making sure that we are communicating
to them? And then they understand what we
are saying. Or we are providing them
with resources for hearing
aid and those kinds of things.
And then as far as cognitive distortions,
we gonna talk about sensory deprivation,
sensory over-stimulation and
"What that does to our patients?".
They keeps them from
understanding our communication
and may altered their care
or causes serious injury.
We are also gonna talk
about providing care.
To make sure that our patient's
sensory needs are provided for.
So our practice question for this section
is called: The home care nurse
is visiting a patient
who is in a body cast.
So they got in to go home, they are in
body cast and they are in their own home.
The nurse is performing an
assessment and is assessing
the psychosocial adjustment
of the patient to the cast.
The nurse would most appropriately assess:
So think about your patient that is in
the body cast. They are in their own home.
The nurse is going in and trying to figure out if
the patient is psychosocially adapting to the cast.
So A. The type of transportation
available for follow-up care.
Or B. The ability to perform
activities of daily living.
Or C. The need for
D. The amount of home
care support available.
Now you may look at four of those answers and
say "Well she should be assessing all of those things."
And they would be.
But we are talking about
and so which one of
those fits that category.
And that would be C. The
need for sensory stimulation.
You have got your patient that is sitting
in a body cast and they are at their home.
They are probably not getting out going to
the store and doing those kinds of things.
So we need to worry about on their sensory deprivation
and what that to do into their self-esteem.
But also their desire and the
motivations to keep going.
So "What are things that
we are gonna look at?".
How does sensory alterations
affect our patients? What should we would be
watching for? What should we would be assessing?
What kind of signs and symptoms
are my patient going to show me
that I need to pickup on.
What are some factors that
change sensory perception?
Is it something that's gonna be short
term? Or is it something that the patients
gonna have to learn to live with?
And then "How do I identify
my patients at risk?".
"What kinds of things am I looking for?"
Things like diabetes who
might have a written apathy
because of diabetes. So watching
how their vision is and asking them.
Or is it your patient in in the ICU
who is ben sedated and then wakes up?
And there is alarms going on
and they are in the small room.
So what patients is
this going to be more
problems for and how I am gonna keep
them safe and keep them oriented.
So who is at risk? Let's kind of look at the
patients that you take care of or you will take care of
that might be at risk. But also patients
that might show up on the NCLEX exam
that you need to understand and
recognize that they are at rest.
You have patients that are confined
in non-stimulating environments.
Now to think about, "What is a non-stimulating
environment?" Think about may be
your patient that's in
the mental health facility.
Or your patient that
is stuck at home
and can't get out. May be
they are in a wheel chair
and they are stuck in their living room.
Until somebody can come and move them.
So be thinking about those patients and
are they getting the stimulation that they need.
What about patients with
impaired vision or hearing?
Just not being able to see totally
cuts off a lot of your environment
and makes it so that you can't
may be experience new things.
And do that kind of [inaudible: 04:37.520] or
[inaudible 0:04:38.280]. It also makes us think more about
our ailments our pain. And we
don't feel like we can get
people to understand because we can't visually
look at them. Or we can't hear them.
So "How do we know
if we are communicating?"
What about your patients that
have mobility restrictions? Again
"Are they in traction?".
"Are they in a body cast?"
You know do they have a double broken leg?
And may be this is only going to be for may be 6 weeks.
But we still need to watch for sensory
stimulation and watch how we were if
patient is somebody coming
in and visiting them.
Or they living at home by themselves and
only see a home healthcare nurse may be
once a day for an hour. And then you have
your patients with limited social contact.
Again some of our patients,
may be they are homeless.
May be they live somewhere where they don't know
anybody. May be their family has all passed away
and they are all by themselves.
So they withdrawal socially
they don't have any reason
to go out and be social.
That can cause a lot of
sensory problems as well.
Also our patients experiencing
pain. If your patients in pain
pain is what they are concentrate on
and so everything else gets distorted.
Sometimes if the patient is really bad.
It can also distort cognitively.
So if I am going in and I am trying to
teach my patient or talk to my patient
and they are in so much pain. That they
can't hear me or can't see me because of so
concentrated on the pain. I am going to
miss out on an opportunity for assessment
and my teaching is not
going to be well received.
What about my patient
that is acutely ill?
You have your patient that comes in to the
ER. May be they are having a heart attack.
Their mind is focused on what's happening with their
body and the whole rest of the world can go on.
So again is that the prime
time to teach or may be ask
real sensitive questions
and we need to watch that.
And we need to be congestive of our
patient. And are they in sensory over-load
to where nothing is making any sense?
And then our ICU patients.
We know our ICU patients because
of medications that they are on.
Whether [inaudible 0:06:39.880] them or
whether its pain medications?
That are combined to their ICU room.
They got one nurse. There is alarms going off.
But their whole world is now in that room.
They loose track of day and night.
They loose track of what day it is.
The lights are always
on. Its never dark.
So again be watching
those patients as well.
And then you have your patients that
already have a decrease cognitive ability.
Whether they were born that way? Or whether
they have had a head injury or trauma?
So be watching those patients. So be
thinking to yourself "Off all my patients
who is at risk for sensory
and perception difficulties?"
So things to keep in mind.
Organize your nursing care to
kind of keep stimulation down.
Now there will be questions on NCLEX
that will talk about "Should you
cluster your care?". "Should you do
it over a time?" And again
the only way you can answer that is to read
the question and what's going on with the patient.
Is it because the patient
gets short of breath? Or
is it because the patient is
over stimulated in the ICU?
So make sure you are thinking through about "Should
I be letting my patient have a lots of rest?"
Or does my patient
need my stimulation?
Orient the patient: We
say over and over again.
If you patient is
it all disoriented
then their sensory perception
is totally changed.
If you loose sight of "What
day it is?" or "Where you are?"
everything else seems
to get jumbled up.
And with that comes being
able to take care of yourself.
Being able to recognize signs
and symptoms in yourself.
So make sure that you are constantly
orienting people. Asking them their name
Making sure that they know the day of the
week, and a year and those kind of things.
So that we can
keep them oriented.
and nonjudgmental manner
in the way that you are. You know some may
comes in your life, "You are acting so weird".
All of the sudden that
person is gonna shut down.
Or if you are yelling at
a person who can't hear.
You know that may
be offensive to them.
So again be thinking about "How you
are perceived by your patient
and is that they way you
want to come off to them?".
Because we wanna make sure that they
feel comfortable and after they can talk
to us. But that we understand
what they are going for.
And then provide
reality based diversions.
One another thing is that can
we do in the hospital is TV.
And a lot of times people will have favorite
TV shows and if we can ask them that
and they are only on its certain times. That
can help get people back to reality by saying
"You know your favorite show is getting
ready to come on it. It's Tuesday night."
Those kinds of things and
hoping they keep them oriented.
If they have their vision and there is
not a the problem with them reading.
You know, make sure they have the glasses
so may be they can read the newspaper
and then encourage
people to come in and
talk to them to keep them
simulated and keep them
oriented to what's going on.
Sensory Disturbance: We are
gonna talk about deprivation,
deficit and overload.
And in some patients can fit in
all three categories during their
time in the hospital.
Some go in and out.
But as nurses we need to
realize that this happens.
We need to watch for it.
We need to do assessments
and then we need to intervene when it's going
to cause a safety problem with our patient.
So sensory deprivation: What we are
gonna assess for? Somebody that's deprived
they are gonna act bored. Now every
patient in the hospital usually acts bored.
They are stuck in the hospital.
But this kinda goes on to bored
to where they don't
even want to talk.
They don't wanna do may by crossword
puzzles. They just wanna watch TV.
They just wanna sit in the room.
Or you catch them daydreaming. They are
not paying any attention to what's going on.
Or they sleep a lot. And a lot of
times we say "Well, that's good
that helps them heal." But we know there is a fine
line between sleeping too much to avoid the world
and sleeping to heal. And so you need to keep
your eye on your patient and watch for that.
Then there is thought slowness.
You know if you go and talk to
somebody and they really seem to have
trouble getting their mind
around what you are talking about.
Again is that a sign
of sensory deprivation?
Or are they an older
person that just takes longer?
You have to know your patient and you have
to do a good assessment to be able to tell.
And then hallucinations, patients that
have hallucinations. Hallucinations may
cause by a lot of things. May be
narcotics that we are giving them.
May be they have been on
illegal drugs and now they are withdrawn.
So again being able to delve
into what's causing them
and not just assuming
one thing or another.
But just know the
hallucinations is a sign
of sensory deprivation
until be a cognitive of that.
So that you can assess for that. And that's
all we are gonna do. We have got our patient.
What can we do? We only have so many
limited resources in the hospital.
We can't bring in the circus and
every time we have what we have.
But there are thing we can do like
increase interaction with the staff.
You know may be you have a
housekeeper that likes to talk
You might wanna point out to them that
there is a patient that really need
somebody to talk to them. May be dietary
could stay a well. May be caseworkers.
So again make sure that
you are using your staff
If there is a chaplain,
can they come up and talk
just so the person stays engage.
Again the TV, some people like
TV. Some people don't.
But may be is their favorite
show. A lot of hospitals now
have video where they
can watch movies.
You know, "Is movies
available in the hospital?"
Or could they bring something from home?
Something that they enjoy to keep them stimulated.
Providing touch: Again so
many of our patients just need
the touch of a human hand. And so
remembering that with our back
rubs and as we are giving assessment,
you know touching their hand.
So that they feel
the human presence.
And then choose foods
with varied smells,
colors and textures.
People relate and are
stimulated by foods and smells.
And so you know, is there
something that they really like
to eat. That might be, like I
chips or white cookie or
something that's crunchy.
You would be amazed that the difference
of that makes in somebody that's
been sensory deprive to just
feel that in their mouth.
One of the places that
we get into a problem with
that is your patient that
has to have a purity diet.
And you will notice a lot times
that they have some sort of
sensory deprivation because all the food
feels exactly the same in their mouth.
And so "Is there something you can do
to help stimulate their sensors?".
And then use light smells. Now we
know you can't just spray and
perfume around in the hospital.
But you can use short smells may be a little
oil on your hand or something
just to give them something
to smell, something different.
Something that can stimulate their sensories,
perception. Make them smell something
different than what they have been
smelling all day along.
So these are just
all ideas. Again wherever you
are working in your facility
you know ask other nurses, ask
other healthcare providers
"What can you do? What's available to you?"
To keep this person engage
to with their environment.
Now the other ways, Sensory Overload.
A lot of times we find our patients in ICU
with patient overload.
It's a problem with
patients in the NICU.
Babies that are so sensitive
to sound and sight
get very overstimulated.
So "What we are assessing
for?". Well restlessness
if they can't seem to sleep or when
they are sleeping they are constantly
moving and they can't
get into a deep sleep.
They become very agitated; because,
they just can't take it anymore.
Have you ever been anywhere, where those
lots of loud noises and people talking
to you and then you get to a point where you
are just like "I just wanna quite"?
Well that's what these
patients has as well.
All their sensors are overstimulated
and they are struck
on one spot. They can't escape
and so their body reacts in different ways.
They become confuse. Their mind get's
all jumbled. They become restless.
They can become agitated.
Sometimes people will then go to
sleep to try to avoid the sounds.
So you can have deprivation
when your patient is sleeping.
As kind of a "I can't take it anymore" so
they go to sleep. So watch those patients too.
Or thought disorganization. You walk
in and the patient is talking about
something totally off the wall. Is their mind getting
scrambled because of all the noises and sounds?
And then again hallucinations.
It can show up
at any point in time.
So "What do I do?". I am in the iCU
the monitors have to be there
You know the phones have
to be ringing. How can I
keep my patient from
getting sensory overloaded?
Well things like restricting visitors.
We just talked about "How if somebody
needs stimulation?" Bring people in.
People in ICUs a lot of time you
got physicians making rounds.
You have got caseworkers coming in, raspatory,
and it's just too many people talking
too many noises. So
cutting out the people that
really don't need to be there.
May be allowing only
one or two family members.
And not have them talking
at the patient all the time.
It's kind of more of a common sense
thing. If you are struck in bed
and all these noises
what can be eliminated.
What about following routines?
So that the patient feels like "Okay,
they are doing this to me
is this time a day?" And trying to
keep your care on a regular basis.
be comes in every two hours.
Keep them on their schedules
as much as possible.
If one family member comes
during a day and another family
member comes at night, try
to keep that consistent
so the patient get
used to a routine.
And then organizing your care so
that they have long periods of rest.
And may be the monitors don't
have to be turned up for blast
in the room. May be only
out of the nurses station.
May be while you are in there you
are talking a little bit softer.
So again being cognisant of the noises
and things that are going on.
But then knowing
how to change that
and knowing what it is
doing to your patient.
If I go in and my patient is all over
stimulated their heart rate is gonna be up.
Their blood pressure is gonna be
up. I don't wanna just jump to
giving all kinds of medication. If it's over
stimulation and I haven't caught on to that.
And then sensory deficit.
What to watch for
if they can't distinguish between sounds?
Now most of the times
when we have sensory deficit
like cognitive hearing or sight.
It's something that happens gradually over time.
But sometimes if there is a trauma or
something like that it could be an immediate thing
and so we need to watch. Can
they hear? Can they not hear?
Why all of the sudden the change?
And then are they able to differentiate
between different sensations.
We know patients
that have had strokes
sometimes have a problem where
they can't tell between touch
or something that's hard
or something that's cold.
So we need to assess for that because
we can have some serious injuries.
So what we are gonna do? We
have to report our observations.
If somebody says, "I can't hear
you, I could hear you before",
We need to make sure we are passing that
on. We need to have a consult.
If their vision seems to be changing or
they say, "All of the sudden I am seeing double".
Or "I see fuzziness in front. Or "all
of the sudden I can't see". That
something that needs to
be reported and documented
and we need to reassess to
figure out what's going on.
And then again, do they need new
glasses? Do they need a hearing aid?
So many people because all
hearing loss and vision loss
sometimes happens gradually.
They don't even or even aware
how bad it's gotten. Because they haven't
notice that they are hearing less.
They just know people
are yelling at them.
So what resources as nurses
can we provide them with
case management and those kinds
of things? So that they can
have their hearing
and their seeing.
Or you know other is there
a surgery or something.
Because we know that
if they can't hear or see
or they have over stimulation. They are
not gonna be able to care for themselves.
So be watching in NCLEX
for questions about self care.
Questions about overload of sensory and
what can you do as a nurse.
What are the signs and symptoms
and do you pickup on that?
So that you can intervene or you
jumping right to intervention.
One thing you wanna remember too
in the NCLEX is you need to follow
the nursing process which
means we always assess
before we intervene. And so again if
you don't know exactly what's
going on with the patient, you can't
intervene. You need to assess.
So in closing, sensory
prevention and perception
adaption. You know
if eyes and ears
those aren't the hard things because
we have resources for that.
But remember to watch
your sensory deprivation
overload and deficit.
Because it can happen
right before our eyes. And again
as nurses as healthcare
we get very focus on what
we need to do for the patient.
But just remember a lot of the
step that we do for the patient and
on the patient is causing a height
and sense of stimulation which
can be making their progress worse.
It can also cause
a risk for injury.
So you wanna make sure that you
are being congestive of that.
Sensory deprivation: Again
it can happen to our patients. It can
happen without us even noticing
and what that can do is that,
it can cause injury.
If you have a patient that's
been sensory stimulated
and they forgive where they
are and what they are going.
They can get up and fall.
So again a lot of this has
to do with safety. It has to do
with recognizing signs and symptoms
i.e. high heart rate,
high blood pressures.
And is that the cause or
is it a medical cause.
So make sure that you are watching your patients.
That you pick up on those assessments.
Make sure that you are doing a good
assessment before you intervene.
So that you know exactly the
cause of what's going on
and don't let sensory deprivation and
over stimulation sneak up on you.
And watch those NCLEX questions
and again remember assess
before intervene and don't forget to
reevaluate. Good Luck.