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Med Surg Sensory Sample PDF
Med Surg Sensory Sample PDF
Med Surg Sensory Sample PDF
www.okcimc.com 800.654.4502
CIMC
Teacher Edition
www.okcimc.com
800-654-4502
13-123456789 HO1039
MODULE 2
s e n s o r y Nu r s i n g
T
his module provides an understanding of interactions with their environment and other
the sensory organs and their functions, individuals. Impairments of these senses must be
disorders that affect these organs, and handled appropriately and carefully by the nurse.
treatments of these disorders. The most com- Completion of this module should provide an
mon senses which display impairments are vision, understanding and knowledge of how to provide
hearing, taste and smell. Additionally, the sense of appropriate nursing care to individuals with sen-
touch, position and movement may be impaired. sory disorders and impairments.
These senses are important for an individual’s
i
Review the Learning
Objectives with the LEarning ObjEctivEs
students. Look ahead
to the Learning Activities
1. Explain the function of the sensory system.
in this module and plan to
introduce them. 2. Distinguish among sensory disorders.
3. Relate diagnostic tests and surgical procedures to the nursing care of
patients with sensory disorders.
Teaching
SUggestions 4. Evaluate pharmacological effects of medications used to treat sensory
disorders.
• A
long with many helpful 5. Contribute to the plan of care for patients experiencing alterations in
websites, there are now sensory or perceptual function.
many “apps” available to 6. Distinguish among patient education needs related to self-care for sensory
help students and nurses disorders.
obtain needed informa-
tion from their smart
phones, tablet devices,
etc. Search iTunes or
other application data-
bases for the most up-to-
date “apps” available for
each content area. See the
following links for pos-
sible apps related to the
sensory system.
• B
Free Sample Provided by CIMC
e sure to advise the
students that these “apps”
may cost to download.
800-654-4502
■ S ensory apps okcimc.com
ttp://itunes.
h
apple.com/us/app/
hd-five-senses/
id373600865?mt=8
■ H
earing
ttp://itunes.
h
apple.com/us/app/
senses-what-u-hear/ 2 CIMC • MEDICAL SURGICAL NURSING II
id398460048?mt=8
http://itunes.apple.com/us/app/uhear/id309811822?mt=8
http://itunes.apple.com/us/app/soundamp-r/id318126109?mt=8 (amplifier)
module O v e r v i e w
This module provides concise information regarding sensory disorders including their symptoms and associ-
ated medications, diagnostic tests, and nursing care. Students should be encouraged to reacquaint themselves
with the sensory system information from their Anatomy and Physiology course.
800-654-4502 learning
okcimc.com w ww
link
Tear sac
Vision
www.webmd.com/eye-
health/picture-of-the-eyes
MODULE 2 • SENSoRy NURSING • stUDEnt EDitiOn 3
Teaching SUggestions
• Review the following information with the students.
■ S tructure of the eye
■ A ccessories of the eye
■ I ntraocular anatomy
■ P hysiology and function of the eye
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 3
HEaring
learning
w ww
link
The ear consists of three sections, which work to-
gether to provide the sense of hearing. The outer ear Important Fact
It’s easy for a throat infection to spread to the
receives the sound waves and propels them to the in-
terior portions of the ear. The middle ear is small and ears because it can travel up the Eustachian
contains air and three bones. The three bones are the tubes into the middle ear. These structures are all
malleus (hammer), the incus (anvil), and the stapes lined with continuous mucous membrane.
(stirrup). The inner ear contains fluid-filled cavities
and canals. It also contains the cochlea, semicircular
Hearing canals, and the vestibulocochlear nerve.
www.youtube.com/watch Semicircular
?v=PeTriGTENoc&featu canals
Incus
re=related (anvil)
Malleus
(hammer) Auditory nerve
To brain
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D i d You Know?
Cerumen is earwax that protects
the ear by trapping foreign
particles and dust.
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The movement of endolymph within the semi-
circular canals stimulates these hair cells. The
message is sent to the brain, which interprets it to
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maintain balance and equilibrium.
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 5
Sour
Bitter
Sour
Sweet
Salty
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sense of smell will be lost since the body cannot
regenerate olfactory cells.
• Food does not taste good when you have a cold
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because the sense of smell is impaired by nasal
congestion. When we cannot smell what we eat,
some of the taste is lost. The senses of smell and
taste work together in our brain.
800-654-4502 Myopia
www.aoa.org/x4688.xml
for follow-up care as
directed
• Corrective lenses
okcimc.com www.nlm.nih.gov/
• Contact lens
medlineplus/ency/ar-
ticle/001023.htm
Presbyopia
www.aoa.org/x4697.xml
www.nlm.nih.gov/
medlineplus/ency/ar-
7
MODULE 2 • SENSoRy NURSING • stUDEnt EDitiOn
ticle/001026.htm
Astigmatism
www.aoa.org/Astigmatism.
xml
www.nlm.nih.gov/
medlineplus/ency/ar-
ticle/001015.htm
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 7
EyE injUriEs
learning
wwwlink
Eye injuries can result in permanent visual impair-
ment. Causes of eye injury include trauma, through
auto accidents and sports injuries, or chemical expo-
to the eye occurs, first aid measures include having
the victim lie down to prevent fluid from escap-
ing from the eye. The penetrating object should be
sure. The patient may experience pain, photophobia, stabilized (a Styrofoam cup works well to cover the
redness, edema, tearing, blood present in chamber, eye and the object), and the victim transported to an
abnormality in vision, abnormal intraocular pres- emergency department as soon as possible. Only a
sure, or deficits in peripheral vision. physician should remove the penetrating object.
Penetrating Eye Injury Penetrating wounds to the eye can result in complete To provide care for an eye injury, the nurse should
loss of vision and loss of the eye itself. It is important cover the eye with a dry sterile patch and a protec-
www.insidermedicine. for the nurse to assess the size of the object that is tive shield, stabilize any foreign objects, elevate head
com/insidermedicine-if- penetrating the eye and whether fluid is leaking from of bed 45 degrees, avoid pressure on the eye, and
the eye. When vitreous humor, the jelly-like fluid instruct patient not to blow their nose. In the case
i-had.aspx?Category=349 that gives the eyeball its shape, escapes from the eye, of chemical exposure, the eye should be irrigated as
vision is usually lost. When a penetrating wound soon as possible with sterile saline or water.
Hordeolum Infections and Inflammation of the Eye
http://health-pictures. Disorder Structure Affected Physical Findings
Treatment/Nursing
Care
com/hordeolum.htm
Hordeolum Sebaceous glands in the • Red • Treatment consists of
• Stye eyelid • Swollen application of warm,
www.ncbi.nlm.nih. • Tender area moist compresses four
gov/pubmedhealth/ times daily until healed
• Antibiotic ointment or
PMH0002004/ drops
Chalazion Sebaceous glands in the • Swelling • Warm, moist com-
Chalazion upper lid • Tender presses
• Red • If this treatment is
www.mayoclinic.com/ not effective, then an
health/medical/IM03093 ophthalmologist may
remove it surgically or
inject it with corticos-
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chalazia-topic-overview eyelash along the rim of • Burning • Antibiotic eyedrops
the eyelid • Crusting mucus
Blepharitis Conjunctivitis Inflammation of the • Redness of the eye • Antibiotic eyedrops
www.webmd.com/eye-health/eye-health-conjunctivitis
www.aoa.org/x4720.xml
Keratitis
www.lyme.org/gallery/keratitis.html
www.medicinenet.com/keratitis/article.htm
www.nlm.nih.gov/medlineplus/ency/article/001609.htm
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Postop care includes:
• Notify physician if
worsening pain is expe-
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rienced
• Avoid strenuous activity
• Do not strain with
stool or bend over
• Take a stool softener
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 9
Conditions Affecting Vision Continued
learning
w ww
link
Disorder
Narrow-angle
Structure Affected Physical Findings
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health/scleral-buckling-sur- • Straight lines appearing
wavy
gery-for-retinal-detachment • Loss of central vision
Diabetic Retinopathy
www.nei.nih.gov/health/diabetic/retinopathy.asp
Macular Degeneration
www.nei.nih.gov/health/maculardegen/armd_facts.asp
www.allaboutvision.com/conditions/amd.htm
www.macular.org/1_blindness.html
Q: How would you communicate with a patient with severe hearing loss?
Answer: Several tips for communicating with people who have severe hearing loss can be found at: www.mich-
dhh.org/hearing/comm_tips.html
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 11
Causes of Hearing Loss Continued
learning
w ww
link
Disorder
Meniere’s disease
Structure Affected
• Hearing loss
Treatment/Nursing
Care
• Treatment includes
labyrinth spaces, causing • Vertigo drugs such as:
swelling of the membranes • Loss of balance ▶ Atropine
of the cochlea • Dizziness ▶ Epinephrine
• Nausea ▶ Valium
Increased pressure in the ▶ Antihistamines
Meniere’s Disease inner ear, causing damage ▶ Antiemetics
to structures ▶ Anticholinergics
www.nidcd.nih.gov/health/ ▶ Vasodilators
balance/meniere.html ▶ Diuretics
• Surgical removal of the
endolymph sac
www.medicinenet.com/ • Assess and document
meniere_disease/article.htm symptoms and frequency
• Instruct patient on
Otitis Media safety precautions dur-
ing acute attacks
www.nidcd.nih.gov/health/ • Assist patient to de-
termine if they experi-
hearing/earinfections ence an aura and what
actions to take should
www.umm.edu/altmed/ar- it occur
• Instruct patient to rest
ticles/otitis-media-000121. in dark, quiet room
htm • Tell patient to avoid:
▶ Caffeine
Image of Tympanic ▶ Decongestants
▶ Stimuli that cause at-
Membrane with and tacks such as bright
without OM lights or noisy places
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• A low-sodium diet
educent/otitis_media.htm and diuretics may help
reduce excess fluid
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Otitis media Infection of the middle ear • Occurs after a respira- • Antibiotics, antihista-
from bacteria or viruses tory infection and causes mines, and/or decon-
fluid to build up gestants
• Pain in infected ear, • Incision may be made
fever into the eardrum and a
• Feeling of fullness in tube inserted to drain
the ear the fluid and equalize
• Impairment in hearing pressure
• Redness and bulging of • Administer pain meds
the tympanic membrane as needed
Teaching SUggestions
• R
emind students that when a patient experiences hearing loss while on a medication known to cause oto-
toxicity, it isn’t necessarily ototoxicity. The nurse should always assess if the patient has had prior hearing
loss or if the hearing loss they are experiencing is different from what they normally experience.
Otosclerosis
Structure Affected
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dients
Hyposomia Diminished sense of smell • Total or partial loss of • Assess to determine if
smell condition is related to ag-
Presbyosomia – loss
of smell due to aging okcimc.com • Think they smell bad
odors
• Headaches, dizziness,
ing or other conditions
• Determine if medica-
tions could be possible
shortness of breath, or cause
anxiety • Support treatment of
underlying cause such
as flu, cold, infection,
nasal swelling
• Recommend patient stop
smoking if applicable
• Tell patient to check for
spoilage of foods
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 13
Other Sensory Impairments Continued
learning
w ww
link
Disorder Structure Affected
• Over-sensitivity to
Treatment/Nursing
Care
• Therapeutic body
disorder or dysfunc- tain information received touch, movement, brushing to override
tion (SID) from the body’s basic sights, or sounds stimulation
sensory systems • Under-reactivity to • TENS units
touch, movement, • Music therapy
sights, or sounds • Biofeedback
Sensory Integration • Easily distracted
Disorder (SID) • Activity level that is un-
usually high or unusu-
www.sinetwork.org/ ally low
• Physical clumsiness or
apparent carelessness
www.youtube.com/ • Impulsivity or lack of
watch?v=6O6Cm0WxEZA self-control
• Difficulty in making
Benign Paroxysmal transitions from one
situation to another
Positional Vertigo • Inability to unwind or
calm self
www.mayoclinic.com/ Benign paroxysmal Inner ear • Dizziness • Teach exercises
health/vertigo/DS00534 positional vertigo • Unsteady gait/balance • Assess to determine
• Frequent falls cause and remove caus-
Movement Disorders • Labyrinth becomes ative agent
infected or swollen • Administer antibiotics
www.movementdisor- • Small calcium stones in as ordered
the inner ear become • Assist ambulation as
ders.org/education/ displaced needed
• Fluid in the inner ear
www.nlm.nih.gov/med- Movement disorders Disruption of any portion • Dystonia • Assist with physical
okcimc.com • Rigidity
• Postural instability
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one eye
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served for movement
Classroom Activity
• M
any of these eye/vision tests are easy to do on each other. Have the students pair up and complete the
tests on their partner.
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 15
Sensory Disorder Tests and Surgical Procedures Continued
learning
w ww Nursing Care
Test/ Procedure Purpose Procedure
Eye Surgery
http://eyerepublic.com/cataract-surgery-manila-phil- NOTE
ippines/preop-instructions.html
One of the primary nursing interventions for the
Postoperative Care for Eye Surgery postoperative care of the patient having had eye
surgery is to take measures to prevent increased
http://nursing411.org/Courses/MD0919_Nursing_
intraocular pressure (IOP). Assist the students with
care_sensory_neurologic/1-22_Nursing_Care_sen-
identifying common actions to avoid that may increase
sory_neuro.html
IOP (i.e. bending over to tie shoes, picking up small
http://eyerepublic.com/cataract-surgery-manila-phil- children, coughing and sneezing).
ippines/postop-instructions.html
www.neuroexam.com/neu-
okcimc.com There should not be sway-
roexam/content.php?p=37
ing or loss of balance
Audiometry Measure hearing acuity Headset is worn and vari- Explain purpose, proce-
ous intensities of sound dure and results of test Audiometry
are produced through the
headset one ear at a time www.ncbi.nlm.nih.gov/
books/NBK239/ http://
The results are based on
when the individual is first
able to hear sound
www.nlm.nih.gov/
medlineplus/ency/ar-
ticle/003341.htm
MODULE 2 • SENSoRy NURSING • stUDEnt EDitiOn 17
http://itunes.apple.com/
Class Discussion us/app/audiometry/
id298494364?mt=8
• A
t this point, consider asking your students about which nursing diagnoses
they think are appropriate for the patient having undergone ear surgery.
Then discuss interventions and rationales for each diagnosis.
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 17
Class Discussion Touch, position and movement conditions are diag- L E a r n i n g O b j E c t i v E
nosed using:
Obje c ti v e Evaluate pharmacological effects of
• Th
is portion of the • Brain imaging studies medications used to treat sensory
course provides a good • CT scan disorders.
opportunity to review • PET scan
the administration of
• MRI
ophthalmic medica-
• Blood and urine studies, positron emission
tions and the applica-
• Lumbar puncture
tion of eye patches/
dressings. Medications for Sensory Disorders
Category and
Uses Actions Side Effects Nursing Care
Examples
Antibiotics Used to treat Interferes • Confusion • Assess for possible
• Gentamicin or prevent with protein • Seizures allergic reaction to drug
sulfate bacterial infec- synthesis of the• Hypo/hypertension • Observe for signs and
• Neomycin sulfate tions of the eye bacterial cell • Oliguria symptoms of infection
• Polymyxin B • Hematuria • Get culture and sensi-
sulfate • Renal damage tivity before giving first
• Ciprofloxacin • Rash dose of medication
• Monitor changes in
vital signs
Mydriatic & Dilate pupils Used for surgi- • Restlessness • Assess for eye pain
cycloplegic and paralyze cal procedures • Dry mouth • Monitor intake and
• Atropine muscles of ac- of the eyes • Abdominal output
• Scopolamine commodation distress • Assess for abdominal
• Homatropine Enhances abil- • Blurred vision complications such as
ity to examine • Rash constipation
inside of eye • Assess mental status
and prevents Alteration in vital
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• Palpitations,
hypotension
Topical anesthetics Anesthetize Block nerve • Pain in the eye • Assess for possible
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• Alcaine the eye conduction • Redness allergic reaction to drug
• Pontocaine causing anes- • Eye irritation • Observe for signs and
thetic effect • Allergic reaction symptoms of infection
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M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 19
L E a r n i n g O b j E c t i v E L E a r n i n g O b j E c t i v E
Object i v e Contribute to the plan of care for Obje c ti v e Distinguish among patient
patients experiencing alterations in education needs related to self-care
sensory or perceptual function. for sensory disorders.
LPNs will be assigned the task of direct patient The patient should receive teaching that is appropri-
care and will be responsible for contributing to the ate for self-care of disorders of the senses. Examples
patient’s plan of care. The following is a partial list of patient teaching follow.
of nursing diagnoses that may be associated with
patients experiencing sensory impairments. Patient teaching for glaucoma:
• Always wear ID tab stating “glaucoma”
• Disturbed sensory perception related to (hear-
ing, visual, taste) deficit • Take medications as prescribed
• Risk of injury related to (hearing, visual, taste) • Do not take over-the-counter medications with-
impairment and inability to (hear, see, taste) out consulting physician
potential dangers
• Signs of increased intraocular pressure to report
• Self-care deficits related to sensory (hearing, include eye pain, blurry vision, and presence of
visual, taste) deficit halos
• Fear of inability to sense potential danger or • Prevention of increased intraocular pressure
accurately interpret environment includes low sodium diet, prevention of consti-
pation
• Grieving related to loss of function
Patient teaching after ear surgery:
Goals for the patient with a sensory impairment
include: • Avoid sneezing, coughing, or blowing nose
• Successfully adjusting to the impairment • Avoid heavy lifting or bending over for 3 weeks
• Verbalizing feelings related to the loss • Avoid flying until physician permits
• Using appropriate coping strategies • Do not drink from a straw or from plastic bottle
for 3 weeks
• Maintaining safety during daily life
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Activity
List two different nursing interventions for each of the nursing diagnoses listed below. Include rationale, or
reasoning, for the intervention.
• Glaucoma
• Ear surgery
Application
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 21
Le a r ni ng LEarning activity 2
Ac t i v i t y
A nsw e r s
naME
Answers will vary.
Introduction
It is important for the nurse to be able to answer questions and provide instructions to the patient as their
questions arise. Patients with sensory impairment often need reassurance and directions.
Activity
Work individually or in groups of three as assigned by the facilitator. Review the following scenario and
discuss nursing care and appropriate patient instructions to be given to the patient.
During a routine health physical, a patient reports changes in his vision. He states these changes have become
increasingly prevalent during the past 2 to 3 years. The patient is currently 78 years old. He asks questions
about what other changes can be anticipated in his visual abilities related to aging. What information should
be provided the patient? What recommendations concerning preventive behaviors can be made to the patient
at this time?
Application
Activity
A 78-year-old Native American patient with hearing loss who has had retinal reattachment surgery is as-
signed. The physician has explained surgical options to the patient, but the patient is still unsure of the differ-
ence between the various procedures.
Using the teaching plan developed by the RN and the information provided by the physician, determine
specific modifications to the teaching plan for the patient.
Application
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 23
Le a r ni ng LEarning activity 4
Ac t i v i t y
A nsw e r s
naME
Answers will vary.
Introduction
Patient teaching and safety are important for the patient with sensory impairment.
Activity
Prepare a list of safety instructions for a patient who has recently experienced severely impaired touch, taste,
and smell.
Application
Te ac hi ng Su g g e s t i o n
• H
ave students search for online resources related to this patient’s condition/situation. Guide students in
developing a teaching plan. Have the students blindfold themselves, wear ear plugs and role-play how they
would present the information to a patient with similar impairments. Discuss the challenges of this activity
and whether options exist to address them.
• Treatment for sensory disorders may include corrective lenses, medications, and/or surgery.
There are numerous disorders which may affect an individual’s hearing. Some of these
include otitis media, otosclerosis, and Meniere’s disease.
• There are two different types of hearing loss attributed to problems with the ear.
Sensorineural hearing loss is due to dysfunction of the auditory nerve. When the hearing
loss is caused by problems with sound transmission through the ear it is conductive hearing
loss.
• The sense of touch, position and movement assist in ambulation and mobility. If the patient
is unable to move or moves uncontrollably, optimum wellness may not be possible.
• Taste and smell disorders are identified by both subjective and objective data.
• Disorders that affect the senses provide unique challenges because they have significant
impact on the patient’s ability to interact with others and their ability to maintain safety.
HOSA Spotlight
Health Education Competitive Event www.hosa.org/natorg/sectb/cat-iv/he.pdf
• A
teamwork event for 2-4 members. One of the sensory disorders/diseases could be selected. A lesson is
prepared on the topic, instruction presented to a class of students, and results evaluated. This event includes
the use of multimedia presentation tools.
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 25
gLOssary
Narrow angle glaucoma: Also known as angle-closure glaucoma, this occurs due to a
narrow angle present where iris and cornea meet, causing susceptibility to angle
closure; requires immediate treatment.
Open angle glaucoma: This occurs when methods of drainage of aqueous humor are
blocked and intraocular pressure increases. It occurs gradually.
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Retinal detachment: A condition in which the sensory layer and the pigmented layer of
the retina become separated.
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Retinopathy: A condition in which vessels of the retina are destroyed.
Publications
Burke, L. (2007). Medical-Surgical Nursing Care (2nd ed.). Pearson, Prentice Hall.
DeWitt, Susan (2009). Medical Surgical Nursing Concepts and Practice. Portland; Saunders.
Nursing Focus. Stillwater, OK: Oklahoma Department of Career and Technology Education,
Curriculum and Instructional Materials Center, 2002.
Timby, B., Smith, N. (2007). Introductory Medical Surgical Nursing (9th ed.).
Lippincott, Williams &Williams.
White L. (2005). Foundations of Nursing (2nd ed.). United States; Thompson Delmar.
M O D U L E 2 • S e n s o r y N u r s i n g • T E ACH E R E D I T I O N 27
nOtEs