Sensory and Perceptual Alterations: NCLEX-RN
In this section of the NCLEX-RN examination, you will be expected to demonstrate your knowledge and skills of sensory and perceptual alterations in order to:
- Identify time, place, and stimuli surrounding the appearance of symptoms
- Assist client to develop strategies for dealing with sensory and thought disturbances
- Provide care for a client experiencing visual, auditory or cognitive distortions (e.g., hallucinations)
- Provide care in a nonthreatening and nonjudgmental manner
- Provide reality-based diversions
Simply defined, according to the North American Nursing Diagnosis Association (NANDA), impaired and disturbed sensory perception is "a change in the amount or patterning of incoming stimuli accompanies by a diminished, exaggerated, distorted, or impaired response to such stimuli" as those associated with the client's visual, auditory, tactile, gustatory, olfactory and kinesthetic responses to these stimuli.
Some of the defining characteristics of impaired and disturbed sensory and perceptual alterations include the client's changes in terms of behavior, problem solving, sensory sharpness and acuity, and decision making which can lead to the client's restlessness, a lack of orientation, confusion, altered communication, poor concentration, hallucinations, and a lack of focus and attention.
Some of the risk factors associated with impaired and disturbed sensory and perceptual abilities are impaired sensory processing and the absence of the processing of stimuli secondary to disorders such as blindness, deafness, a loss of taste or smell, and an inability to feel things, some of which can occurs as the result of genetics, aging, trauma, biochemical causes, electrolyte imbalances and both excesses of stimulation and deficits in terms of sensory stimulation.
At times the signs and symptoms of a sensory and perceptual loss occur at a specific time, in a particular place, and when the client is exposed to other stimuli in the environment and, at other times, the signs and symptoms of a sensory and perceptual loss occur regardless of the time, place and stimuli. For example, visual disturbances including low vision can present risks, signs and symptoms during the nighttime hours, auditory deficits may be more profound within an environment that is filled with noise and other disruptive stimuli, and virtually all sensory and perceptual disorders will be further amplified in a strange and unfamiliar environment, such as a hospital room, that is not familiar to the hospitalized person.
As based on these individual, time, place and other stimuli variations among patients and these factors, nurses must assess the clients affected with sensory and perceptual disorders and plan care according. For example, the safety of the client with low vision and complete blindness must be insured and some clients may need to be placed in a low stimulation environment to protect them from sensory overload.
Clients' safety is the highest priority among many clients who are affected with thought and sensory disturbances.
Thought disturbance interventions for disorders that result from organic brain syndrome, dementia including Alzheimer's disease, delirium and psychiatric symptomatology include the:
- Provision of safety using, for example, falls risk protocols for those at risk for falls and keeping dangerous cleaning chemicals in a secure and safe place
- Frequent monitoring of the client
- Maintaining of the client's comfort
- Anticipation of the client's needs and then addressing them
- Provision of an environment that is not loaded with extraneous stimuli
- Reorientation of the client to time, place and person as often as necessary
- Explaining procedures to the client in a manner that they can understand while using assistive devices and aids such as pictures and gestures that can be helpful to facilitate the client's understanding
- Maintaining as much consistency in terms of the client's routines and those that provide nursing care to them
- Managing hallucinations with a medication such as a dopamine antagonist
- Using close ended questions that require a simple yes or no answer when necessary
- Communicating with the client at eye level and will maintaining eye contact
Tactile or kinesthetic sensory deficits can be addressed with the assessment and monitoring of vulnerable bodily parts such as the feet and lower extremities of clients who are affected with diabetic neuropathy and exposed bodily areas that can be subjected to frost bite, both of which may not be perceived when the client's sensory functioning is impaired.
Impaired sensory and perceptual disturbances affecting vision can be better coped with by the client when the nurse and other health care providers:
- Communicate with low vision clients at eye level and within the client's functioning field of vision
- Insure that the client with low vision has and uses corrective lenses, including eyeglasses, and other devices such as magnifiers
- Greet the client by name and introduce oneself when entering the client's space
- Use Braille and large print materials for low vision clients
- Maintain a clutter free and organized client environment
- Provide the client with details about the locations items within the client's immediate and extended environment
- Assist the client with meals by describing items on the plate or meal tray according to the position of a clock's hands, such as 1 o'clock or 3 o'clock.
Things that can be done to facilitate the coping of a client affected with a gustatory sensory Impairment that affects the person's sense of taste include the provision of foods that are highly attractive so that the appearance of the food will stimulate the client's desire to eat. The same attractive presentation is also helpful to clients who are cognitively impaired for one reason or another.
Clients with auditory deficits can better cope with this deficit when the nurse and other health care providers:
- Provide the client with their assistive devices such as a hearing aid
- Speak slowly while sitting at the client's eye level and clearly pronouncing words to facilitate lip reading
- Use written, rather than oral, communication when indicated
- Eliminate all extraneous environmental noises and distractions when communicating with the client
- Utilize the services of an American Sign Language interpreter when indicated
In addition to other concerns relating to sensory perception, nurses must also be aware of the fact that many clients, particularly those who are hospitalized in a strange environment, can be adversely affected with sensory overload and sensory deprivation.
Sensory overload occurs when the person gets more stimulation than they are able to manage and process; and sensory deprivation occurs when the client does not get enough sensory stimulation to sustain the person in a state of balance.
Sensory overload occurs when the client is subjected to an extraordinary amount of internal and external stimuli such as a high level of anxiety and a noisy environment with constant activity as often occurs in emergency departments and critical care areas, respectively.
The client affected with sensory overload may exhibit signs and symptoms of sensory overload like anxiety, restlessness, sleep deprivation, disordered thinking and cognitive processes, fatigue, poor problem solving and decision making skills, poor performance, and muscular tension.
Sensory deprivation, on the other hand, occurs when the client is deprived of a normal level of sensory stimulation as can occur among inmates and prisoners in isolation as well as residents in a private room without visitors and socialization.
The client who is affected with sensory deprivation may experience abnormal responses to the few stimuli that the client is exposed to, delusions, hallucinations, apathy, depression, a lack of orientation, lethargy, poor concentration, confusion, memory deficits and somatic complaints.
Visual, auditory and cognitive distortions not only create stress and distress within the client but they also potentially place the client and others at risk for injuries, accidents and even violent behavior. These distortions can occur as the result of many factors including psychiatric mental health disorders and other conditions such as:
- Intoxication with illicit drugs and/or alcohol
- Epilepsy when an olfactory aura occurs
- An extremely high fever and/or dehydration
- Some sleep disorders such as narcolepsy
- Severe physical disorders such as renal failure, hepatic failure, and AIDS
- Brain disorders such as traumatic brain injuries, brain tumors and structural defects
- Blindness which can be accompanied with the visual hallucinations secondary to Bonnet's syndrome
- Deafness that can be accompanied with auditory hallucinations secondary to Anton's syndrome
Auditory distortions can include auditory command hallucinations. Auditory hallucinations are the most commonly occurring of all types of hallucinations. These hallucinations are most common among those affected with schizophrenia, bipolar disorder, major depression and post traumatic stress. These command hallucinations can be assessed with both subjective and objective data. For example, the client may tell the health care professional that they hear "voices" in their head that are telling them to do one thing or another and a nurse may observe the client talking to themselves and appearing to be preoccupied by some stimulus that is not visible or apparent to the nurse. Some of these "voices" can give the client messages that are dangerous to the client and others. For example, relatively recent news stories tell about a young mother who was instructed by her "voices" to drown her children in a bath tub.
In addition to medications, the client affected with auditory command hallucinations can benefit from a number of combined therapies including crisis and coping strategy education, psychotherapy, and cognitive behavioral therapy.
Visual hallucinations occur when a client sees something that is not present. Visual hallucinations are most common among those affected with delirium, psychotic disorders like schizophrenia, dementia, Bonnet's syndrome that affects blind clients, Anton's syndrome that affects clients affected with cortical blindness, seizures, migraine headaches, some sleep disorders, hallucinogenic illicit drugs, optic path tumors, Creutzfeldt-Jakob disease and rare genetic inborn errors of metabolism.
In addition to correcting an underlying cause, benzodiazepines for hallucinations secondary to delirium tremens, and neuroleptic medications like dopamine antagonist drugs for psychosis induced hallucinations can be used for the client who is affected with hallucinations. Some of the other interventions for clients affected with visual hallucinations include crisis and coping strategy education, psychotherapy, and cognitive behavioral therapy.
Tactile hallucinations are characterized with the client's perception that something or someone is touching the affected person's body when in fact that is not occurring. For example, the affected person may feel insects crawling on their skin or the client may feel another person touching their body when, in fact, that is not occurring.
Tactile hallucinations can affect clients with schizophrenia, delirium, Parkinson's disease, illicit drug use, cocaine and alcohol use, and those clients who have had a recent amputation of a limb that causes phantom pain which is a type of tactile hallucination and one that can be a frequent occurrence after a planned or traumatic amputation of a limb.
At times the client may verbally tell the nurse that they have such things as bugs crawling on their skin, which is referred to as formication, and, at other times, the nurse may observe a client picking imaginary "bugs" off their bed linens or scratching their skin incessantly or brushing their skin off.
Again, the treatment of the underlying disorder is indicated as well as supportive medications and therapy.
Olfactory hallucinations, also referred to as phantosmia, cause the affected person to perceive and smell odors and scents that are not present. Phantosmia can be temporary or permanent, it can be constant or intermittent and it can be characterized with pleasant scents such as roses as well as unpleasant noxious odors.
Phantosmia is most frequently found among clients who are affected with seizures, cranial tumors, and Parkinson's disease.
Gustatory hallucinations are taste distortions which are most often unpleasant. Gustatory hallucinations are sometimes found among clients who are affected with schizophrenia, epilepsy and other disorders. Again, supportive therapy is provided for clients affected with gustatory hallucinations.
Nurses provide care to all clients of all ages for all disorders including physical disorders and psychological disorders. All of this nursing care must be provided in a supportive, nonthreatening, unbiased, caring, compassionate, and nonjudgmental manner. The client is the focus of care and all nurse-client relationships so nurses must support the clients and address their needs WITHOUT the nurse injecting their own bias and judgments.
Clients who are not oriented can benefit from reality based diversions and activities.
Some of these reality based diversions can include discussions about the month and day of the year, discussions about the weather of the season, reading the newspaper, participating in a daily "news of the day" or reality orientation group sessions, reminiscence therapy, and other individual and group activities according to the client's preferences and needs.
- Abuse and Neglect
- Behavioral Interventions
- Chemical and Other Dependencies/Substance Abuse Disorders
- Coping Mechanisms
- Crisis Intervention
- Cultural Awareness and Influences on Health
- End of Life Care
- Family Dynamics
- Grief and Loss
- Mental Health Concepts
- Religious and Spiritual Influences on Health
- Sensory/Perceptual Alterations (Currently here)
- Stress Management
- Support Systems
- Therapeutic Communication
- The Therapeutic Environment