Sensory cognitive alterations

Alterations

Stimuli from environment (external) and body (internal)

• Smells

• Pain

• Thoughts

Cognitive

Process of thinking

• Memory

• Judgement

• Attention

Sensory reception

process of receiving data of external and internal environment via the senses

• Visual

• Auditory

• Gustatory (taste)

• Tactile (touch)

• Olfactory (smell)

• Kinesthetic

  • awareness of body position and movement

• Stereognosis (done by touch)

  • sense that perceives solidity of objects and their size, shape, and texture

Functional sensory input

process of interpreting sensory or stimuli

• reception → perception → reaction

• reticular activating system (RAS)

  • Poorly defined network

  • extends from the hypothalamus to the medulla

  • mediates arousal

  • optimal arousal state: sensoristasis

  • monitors and regulates incoming sensory stimuli

• eg. hand on hot surface

  • stimuli - signal to the brain that the surface is hot

  • perception - “this is hot”

  • reaction - remove hand

Somnolent

extreme drowsiness but will respond normally to stimuli

stupor (unconscious)

can be aroused by extreme and or repeated stimuli

• eg. sternum rub to get a response

coma (unconscious)

cannot be aroused and does not respond to stimuli

normal awareness

alert, aware, and responsive

sensory deprivation

• reeducation in the absence of usual and accustomed stimuli

  • deprived environment - normally pt. who are isolated or who have contact precautions

  • deprived sensory reception - spinal cord injury. brain damage. sleep deprivation

signs and symptoms of sensory deprivation

• anxiety

• depression

• boredom

• unsettled feeling

• hallucinations

causes of sensory deprivation

• altered sensory reception

• deprived environments

interventions for sensory deprivation

• increase visitation

• therapy (music/pet)

• increase daylight

• clock in room

sensory overload

one or more of the senses are overloaded

signs and symptoms of sensory overload

• agitation

• racing thoughts

• confusion

causes of sensory overload

• internal stimuli (pain, nausea, anxiety)

• external stimuli (roommate, environment)

• taking in new information → new medications w/ new affects treating internal stimuli or stressor

interventions of sensory overload

• pain = give something to treat their pain

• treatment for external stimuli or stressors = remove noises from the room

sensory deficit

• impairment or lack of senses

  • impaired vision, hearing, taste, smell, or tactile perception

• can be reversible or permanent

  • depends on the underlying cause

• interventions

sensory processing disorder

• difficulty in the way the brain receives sensory information, or the way the brain organizes and uses that information

• leads to challenges interacting in the environment

sensory under responsivity (the sensory disregarder-ho hum)

• withdrawn and disengaged

• tired and takes a long time to get going

• clumsy, bumping into objects and people

sensory craver

• desire to touch everything and an increased craving for moments

• risk-taker and often seen as a troublemaker

• never seems to get dizzy after spinning

dyspraxia

• clumsy and move awkwardly

• misjudges objects when reaching out to grab them

• slow in her movements even with simple tasks like brushing her teeth and getting dressed

• lacks motivation to engage in sports

• emotionally insecure often saying “I can’t do that”

postural disorder (the sensory slumper - I don’t want to)

• poor posture, slumps over desks

• trouble keeping up with other children

• difficulty with coordination (running, skipping, and riding a bike)

• movement activities are daunting

sensory discrimination disorder (sensory jumbler - huh?)

• always seems confused even with basic concepts

• has poor body awareness and falls over frequently

• has trouble hearing word sounds and gets mixed up

• has inappropriate force with objects (break pencils and bumps into other children)

sensory overresponsivity (the sensory avoider - oh no)

• gets easily distressed and responds to situation in extreme ways (running away, lashing out, or hiding)

• takes long periods of time to calm down after becoming upset

factors affecting sensory function

• age (75+ 50% have some level of hearing loss)

• culture (loud or quiet)

• personality/lifestyle (close or personal space)

• stress and illness (chronic diseases)

• medication (toxicity, mental capacities)

Common visual alterations

• Presbyopia: age-related farsightedness (reading glasses)

• Cataracts: clouding of the lens (age 80+ seen in 50%)

• Glaucoma: intraocular pressure causing a damaged optic nerve (irreversible)

• Retinopathy: non-inflammatory damage to retina (uncontrolled diabetes)

• Degeneration: loss of vision in center of the visual field

Common hearing alterations

• Presbycusis: age-related hearing loss

• Cerumen accumulation: built-up ear wax

common neurological alterations

• peripheral neuropathy: damage to peripheral nervous system caused by damage to nerves (shingles, vitamin deficiency)

• CVA/stroke: long-term affects

What is the concern of a patient with taste and smell alterations?

they can’t tell if a food or drink is spoiled

Assessment of sensory alterations

• Thorough history

• Mental status

• Physical assessment

• Self-care abilities

• Health promotion

• Safety

• Communication

• Support

Diagnosis of sensory alterations

underlying cause of health status

Planning of sensory alterations

temporary or permanent

implementation of sensory alteration

• health promotion

• screening

• safety

• promoting stimulation and communication

cognition

• the systematic way in which a person thinks, reasons, and uses language

• the mental process of knowing, including aspects such as awareness, perception, reasoning, and judgement

  • main concern is can the pt stay safe

Normal cognition

allows knowledge to be gained, manipulated & expressed

• intelligence

• reality perception

• orientation

• judgement

• recall & recognition

• language

Normal consciousness

awareness and responsiveness

Normal attention

acquire & express information

normal memory

ability to retail & forget information

normal learning

stimuli must be meaningful & linked to previous knowledge

• storing & recalling requires comprehension & application

normal communication

verbal & non-verbal cues

factors affecting cognitive function

• age

• nutrition & metabolism

• sleep & rest

• self-concept

• infectious processes

• degenerative processes

• head trauma

• pharmacologic agents

• environmental factors

• culture, values & beliefs

Brief confusion assessment method (bCAM)

• Assess delirium in pts

• Feature 1: Altered mental status of fluctuating course

• Feature 2: Inattention - ask the patient to recite the months of the year backward

• Feature 3: Altered level of consciousness - evaluated using the Richmond Agitation Sedation Scale (RASS)

• Feature 4: Disorganized thinking - assessed through simple questions to gauge the patient's thought process

Medications and cognitive alterations

• Polypharmacy - multiple medications at one time

  • May lead to drug interactions that can impair cognitive function

  • Highest risk among elderly pts

• Beer’s criteria (the America Geriatrics Society)

  • List of medications that should not be used (or should be used cautiously) in adults over the age of 65

Oxygen saturation and cognitive alterations

• Hypoxia - low impaired mental function

• Acute Hypoxia - anxious, restlessness

• Severe Hypoxia - pallor, cyanosis

Glucose and cognitive alterations

• Brain consumes 25% of glucose levels

• Normal 70-110

Sodium and cognitive alterations

• Normal 135-145

• Quick drop by 5-10 points or under 120 higher risks of seizures

Calcium and cognitive alterations

• Normal 8.5-10.5

• Greater than 14 causes drowsiness, lethargy, confusion

Ammonia & urea and cognitive alterations

By product of protein metabolism that can become toxic to the brain and cause alterations in cognitive function

WBC, Hgb, Hct and cognitive alterations

Increase will indicate infections which can cause changes in cognitive function in elderly people

Drug toxicity and cognitive alterations

drugs w/ a toxic range can cause brain alterations

impaired thought processes

• Goal - find main cause and fit it right away

  • acute altered cognitive function → adjusted or improving oxygen, electrolyte imbalances, medications

    • disorganized thinking

    • altered level of arousal

    • altered attention

    • memory impairment

Impaired communication

• Expressive aphasia (Broca’s aphasia) - use picture board for nurse to better understand pt

• Receptive aphasia (Wernicke’s aphasia)

• Dysarthria

Expressive aphasia (Broca’s aphasia)

• Inability to express words one wants to say (verbal or written)

• Limited speech; slow or takes great effort; reduced grammar; poor articulation

• Person knows what he/she wants to say but can’t find words

Receptive aphasia (Wernicke’s aphasia)

• Difficulty understanding verbal or written words

• Impaired auditory comprehension and feedback

Dysarthria

• Motor speech disorder (r/t stroke or brain injury)

• Speech is slowed or garbled, slow, soft

Delirium

• Acute confusional state; typically, sudden onset

• Can potentially be reversed; often due to a physiological cause

• Requires prompt assessment and intervention

Causes of delirium

• New environment

• Infection

• Dehydration

• Hypoxic

• Liver or kidney dysfunction

• Metabolic deficiency (vitamin)

Hypoactive and hyperactive delirium

• Nocturnal sleep pattern

• Hallucinations

• Paranoid

• Soulutions - redirect pt, help to decipher day vs night, evaluate medications, treat infection or electrolyte imbalance

Dementia

• Generalized impairment of intellectual functioning, interferes with social and occupational functioning

• Gradual onset, progressive and irreversible

Signs and symptoms of dementia

• Anxiety

• Repetitive questions or behaviors

• Socially or sexually inappropriate behavior

• Wandering

• Aggression

Types of dementia

• Alzheimer’s disease

  • Most common

• Diffuse Lewy body disease

• Frontotemporal dementia

• Vascular dementia

7 As of dementia - progressive symptoms

• Anosognosia

  • no knowledge of condition or illness

• Aphasia

  • difficulty or loss of language

• Agnosia

  • loss of recognition (auditory, tactile, visual)

• Apraxia

  • loss of purposeful movement (buccal-facial, limb kinetic, ideomotor, ideational, verbal, constructional, oculomotor)

• Amnesia

  • loss of memory (anterograde, retrograde, transient global)

• Altered perception

  • loss of visual perception

• Apathy

  • loss of interest in everyday life

Depression

• reversible condition

• may be mistaken for dementia

  • identify if its depression, dementia, or delirium to ensure you are treating pt correctly

signs and symptoms of depression

• feelings of sadness, fatigue, anger

• abandoning or losing interest in hobbies or other pleasurable pastimes

• social withdrawal and isolation (reluctance to be with friends, engage in activities, or leave home)

• weight loss, anorexia

• sleep disturbances (difficulty falling asleep or staying asleep, oversleeping, or daytime sleepiness)

• loss of self-worth (worries about being a burden, feelings of worthlessness, self-loathing)

Health concerns of physiological altered cognition

• Prevention and management of diseases

• Nutrition needs

• Encouraging exercise

• Assisting with sensory impairments

• Medication use

Health concerns of psychosocial altered cognition

• therapeutic communication

• touch

• reality orientation

• validation

• reminiscence

• body image intervention

Diagnosis of cognitive alteration

• acute or chronic confusion

• impaired memory

• impaired verbal communication

planning of cognitive alterations

focusing of patient safety

implementation of cognitive alterations

• safety

• health promotion

• orientation to surroundings

• communication methods