Foundations Exam 3 - Stroke and sensory

What is sensory perception?

how the body receives, organizes, and interprets stimuli. It includes sight, hearing, touch, taste, smell, kinesthetic sense (the awareness of movement of body parts without seeing them), and stereognosis (the ability to recognize through touch without hearing or sight).

What is deficit sensory alteration ?

Complete or partial loss or impairment of a sense(s) (e.g., vision loss).

What is overload sensory alteration?

Too much sensory input (e.g., ICU alarms, bright lights)

What is deprivation sensory alteration?

Too little input; not enough stimulation (e.g., isolation or immobility (bedrest).

What are some factors affecting sensory perception?

Age, illness, medications, stress, and environment influence sensory perception

Special examples with older adults

can lose the ability to hear high- frequency sounds and detect sour/salty/bitter

What are some examples of medications that affect sensory perception?

can include antibiotics like Gentamicin and Vancomycin, other medications include Ibuprofen, Aspirin, loop diuretics (Lasix)

Nursing care: sensory deficit

• Assess the sensory deficit
• Protect the patient from injury (prioritize patient safety)
• Promote independence
• Communication Strategies

What increases fall risk?

Weakness, sensory deficits, neglect, visual changes, and poor balance

What are some interventions for falls ?

• Implement fall precautions
• Assist with ambulation
• Keep call light within reach
• Use gait belts when appropriate

Skin Integrity: Injury to the Affected Side

Patients may have decreased sensation, neglect, or paralysis

Interventions:

• Protect affected limbs
• Reposition frequently
• Inspect skin regularly
• Avoid heating pads or extreme temperatures

Visual nursing interventions

• Identify yourself when entering the room
• Stand in front of your patient, not at the head of the bed
• Explain interventions before you do them

Hearing nursing interventions

• Face the patient when you are speaking
• Speak slowly
• Low tone/Do not shout
• Minimize background noise

Nursing interventions for eyes

• Wear protective devices for eyes
• Encourage vision screening
• Provide large print, magnifying lens
• Clear pathways, night lights

For visual impairment : use the clock example to describe where the food is on the plate

Nursing interventions for ears

• Wear ear protection
• Flashing smoke detectors
• Ear irrigation
• Encourage hearing tests/wear hearing aide

Nursing interventions for touch

• Moorse Fall Risk Scale
• Braden Scale
• Daily foot care

These scores will tel us which nursing interventions to implement for our patient

Nursing interventions for smell/ taste

• Encourage oral hygiene
• Chew slowly
• Monitor for signs of dysphagia

Neuro exam and documentation

LOC → Speech → PERRLA → Motor function → Sensory function → Facial symmetry → compare left vs. right, baseline and current, and any changes

Conditions and primary area affected

Stroke → brain

Dementia → brain

Diabetes → peripheral nerves

HTN → blood vessels supplying sensory organs and brain

Ototoxic meds → Inner ear / auditory nerve

Isolation → sensory stimulation to brain

Sensory organ → Nerves → Brain → Response

Dementia

Causes progressive degeneration of brain cells, affecting memory, judgment,
perception, and interpretation of sensory information.

Patients may:

• Misinterpret sights and sounds
• Become confused in unfamiliar environments
• Have difficulty processing multiple stimuli at once

Nursing connection dementia

Maintain a calm environment, provide orientation cues, and use simple communication

Diabetes

• Chronic hyperglycemia damages blood vessels and peripheral nerves (diabetic neuropathy). This can result in:
• Decreased sensation in the hands and feet
• Numbness or tingling
• Reduced ability to detect pain, pressure, or temperature

Nursing connection diabetes

Patients may not notice injuries, burns, or pressure areas, increasing
the risk of infection and falls.

Peripheral neuropathy

damage of a peripheral nerve; primarily affects the hands and feet; numbness, tingling, pain, inability to detect temperature

Diabetic neuropathy

from high blood glucose levels over time; damage to nerves and small blood vessels supplying blood to nerves

Check this for diabetic neuropathy

• Inspect feet and in-between toes for skin breakdown

• Cutting of nails: straight edge AT HOME

• Shoes, socks, sandals, proper footwear

• Heat and cold

Hypertension

• Long-term hypertension damages blood vessels throughout the body, including those supplying the brain, eyes, and ears. This can contribute to:
• Vision changes
• Hearing loss
• Increased risk of stroke

Nursing connection HTN

Monitor for changes in vision, hearing, and neurological status

Promoting Independence and ADLs

Encourage self-care, adaptive devices, extra time to respond, simple language, using picture/communication boards and collaboration with therapy

What is a stroke ?

when blood flow to part of the brain is interrupted, causing brain cell injury
or death

Stroke

A stroke occurs when blood flow to part of the brain is interrupted, causing brain cell injury or death. If areas responsible for vision, hearing, touch, or perception are affected, patients may experience:
• Visual field deficits
• Numbness or decreased sensation
• Difficulty recognizing objects or people
• Unilateral neglect (ignoring one side of the body)

Nursing connection stroke

Sensory deficits increase the risk for falls, injury, and impaired communication

What do we monitor for strokes?

• Coughing during meals
• Wet or gurgling voice
• Difficulty swallowing

Stroke interventions

• Keep HOB elevated
• Follow swallowing precautions
• Ensure speech therapy evaluation when indicated

Patient and family education for strokes

Home safety, medication adherence, FAST signs, and emotional support

FAST acronym for stroke

F - face (drooping)

A - arm (weakness)

S - speech (difficulties)

T - time (to call)

Common sensory changes after strokes

• decreased sensation, numbness, or tingling

• difficulty feeling pain, pressure, heat or cold

• visual changes or loss of part of the visual field

• altered body awareness or neglect of one side

• difficulty recognizing position or movement of affected limb

• increased sensitivity, discomfort, or abnormal sensations

Nursing actions post stroke:

• Assess sensation, vision, strength, and awareness of the affected side
• Braden Scale: increased risk for skin integrity impairment:
assess skin regularly, especially areas with decreased sensation
• Morse Fall Risk: use fall precautions
• Mobility: ARM, PROM, assistive devices, monitor for contractures in limbs that are affected
• Ensure patient items are on the patient’s stronger or more aware side as appropriate
• Encourage the patient to scan the environment and attend to the affected side → this is promoting independence
• Teach the patient not to use heating pads or hot water
without checking temperature safely

Immediate concern assessment findings for strokes and what the nurse should recognize

Facial droop, weakness, speech changes = Acute stroke
Coughing or wet voice with eating = Aspiration risk
Sensory loss or neglect = Injury risk/Skin Integrity risk
Confusion or declining LOC = Neurological deterioration
Poor balance or weakness = Fall risk
Communication difficulties =Safety and care barriers
Difficulty with ADLs = loss of independence

Dysphagia

Difficulty swallowing. It is from damage to the nerve or muscle involved in swallowing after a stroke

Disoriented Patient Interventions

• Call pts by their name and identify yourself

• Maintain eye contact at eye level

• Use brief, simple sentences

• Ask only 1 question at a time

• Allow time for pts to respond

• Give directions one step at a time

• Avoid lengthy conversations

• Provide adequate sleep & pain management

• Clock & calendar in room

• Provide and use assistive devices

• Help with reading menus and opening containers or calling family members

Vision cues and what to do

• vision diagnoses

• visual aids (glasses, contacts)

• changes in vision

• medical history (diabetes, HTN, meds, eyes specific)

prevent injuries = fall risk precautions

ensure good lighting

accessibility - telephone, time pieces, reading materials

What to do if patient has vision issues

• Call pt by their name when approaching & identify yourself

• Stay within pt’s visual field if they have partial loss

• Give specific information about location of items

• Explain interventions before touching them

• Assess clothing and suggest changes if soiled

• Describe the arraignment of food on their tray

Conductive hearing problems

sound waves don’t work on eardrums

• Allergies (bulging eardrums)
• Ear infections (stiffen eardrums)
• Ear wax (blocks sound waves)
• Perfed eardrum (sound waves go through)

Sensorineural hearing problems

soundwaves not transmitted or received

• Inner ear damage caused by
• Presbycusis (age related changes)
• Ototoxic drugs
• Genetic
• Trauma
• Loud noise (one time or over time)
• Meniere’s disease

Hearing cues

• Hearing aids ?

• Dizziness, nausea, vertigo = fall risk precautions

• How does the patient communicate best?

What to do if patient has hearing problems

• Let them know you’re there – be seen or touch

• Long phrases instead of short

• Clear & accurate – articulate facing patient

• Remove background noises

• Introduce new subjects with clarity

• Moderate rate, normal tone and volume

• No gum, mints, etc

• Use written materials judiciously

Hearing aids

• Amplify sounds but do not help the pt interpret what they hear

• Use the lowest setting that allows hearing without feedback

• To clean the ear mold, use mild soap and water while keeping the hearing aid dry

• When not in use, turn hearing aid off or remove the batteries to conserve power

• Keep replacement batteries on hand

What cranial nerves control speech alterations / aphasia

cranial nerves V, X, XI, and XII

What is aphasia

disorder that affects a pt’s ability to articulate and understand speech as a written language
• Caused by some type of brain injury, stroke, dementia

Expressive/Broca’s aphasia

Broken speech

• Understands language
• Can't get words out

Receptive/Wernicke aphasia

Word salad

• Speaks fluently
• Doesn't make sense

Global aphasia

Both problems

• Difficulty speaking
• Difficulty understanding

Aphasia cues and what to do

• White board for communication
• Speak clearly & slowly using short sentences & simple words
• Do not shout
• Pause between statements to allow pt time to understand
• Tell pt’s when you do not understand them
• Ask questions that require simple answers
• Reinforce verbal with nonverbal communication (gestures, body language)
• Be patient with them; do not hurry or rush them ; encourage the patient to take their time
• Avoid interrupting them or finishing their sentences
• Speech therapy if appropriate

Communication and Education After Stroke

• use short simple sentences and visual aids

• teach family communication strategies

Different types of communication impairments and interventions

• Aphasia (difficulty understanding or expressing language)
• Dysarthria (slurred speech)

Interventions:
• Speak clearly and slowly
• Allow extra time for responses
• Use communication boards if needed

Priority assessments for strokes

• ABC’s: is their airway, breathing, or
  circulation impaired or worsening?

  • Signs of hypoxia (early vs. late)?

  • Changes in LOC?

  • Is their swallowing impaired?

• Aspiration, falls, injury to affected limbs
  (perfusion), skin integrity (perfusion),
  impaired communication, and decreased
  ability to perform ADLs.

Nursing concepts for strokes

• safety

• perfusion

• skin integrity

• communication

• mobility

Nursing Considerations Across the Board

Keep patients safe and free from injury
• Make sure the call light is easily accessible
• Orient pts to the room
• Keep furniture clear from the path to the bathroom
• Personal items within reach
• Place the bed in its lowest position
• Make sure IV poles, drainage tubes, and bags are easy to maneuver and out of the way

Key takeaways priority assessments

• Airway
• Breathing
• Circulation
• Neurological status

Key takeaways immediate risks

• Aspiration
• Falls
• Injury to affected side
• Communication deficits
• Loss of independence

Key takeaways nursing priorities

• Recognize new neurological changes
• Protect the airway
• Prevent injury
• Promote mobility and independence
• Support communication and nutrition