Decreased Sensation Nursing Care Plans Diagnosis and Interventions
Decreased Sensation NCLEX Review and Nursing Care Plans
Sensation is the ability of a person to feel something physically, by touching, or a physical feeling that results from the ability to feel a burning sensation, numbness, tingling, weakness, and pain.
A sensation is also a mental process such as seeing, hearing, or smelling that results from the immediate external stimulation of a sense organ that is often distinguished from a conscious awareness of the sensory process of a person.
Sensation is also a state of consciousness due to internal changes in the person’s body and an indefinite bodily feeling.
It is very difficult if a person does not have a sense of sight, hearing, and smelling and cannot feel objects. Human beings depend on sensory stimuli to give meaning to the events that happen in the environment.
Stimulation comes from different sources in and outside of a person’s body, particularly through a person’s sense of sight, hearing, smell, touch, and taste. A person’s body has a kinesthetic sense that helps a person to be aware of the position and any movements of the body part even without seeing them.
A stereognosis is a sense that helps the person to recognize the shape, size, and even the texture of an object.
Stimuli allow a person to know the environment and are important for a person’s healthy functioning and help a person’s normal development. When a person’s sensory function is changed, the ability of the person to relate to and function within the person’s environment changes extremely.
Some patients may have existing decreased sensation, while some may develop sensory alterations due to the medical treatment such as hearing loss because of antibiotic use, hearing or visual loss because of brain tumor removal, or hospitalization.
The patient may be unfamiliar with the health care environment’s sight, sounds, and smell. When a person feels depersonalized and when a person is unable to receive meaningful stimuli, alteration of sense may develop.
Decreased sensation may lead to injury and problems related to gait and balance. It can occur temporarily that happens after an injury or after a chronic condition that results from diabetes or other illnesses.
The nervous system receives thousands of information from the sensory nerve organs, relays information through different channels, and integrates the information into a meaningful response.
The nervous system is the body’s command center that originates from the brain which controls movement, thoughts, and responses to the world around a person. The sensory organs are reached by the sensory stimuli that elicit an immediate reaction and present information to the brain. The nervous system and the sensory stimuli must be intact for the sensory stimuli to reach the brain centers to help the person perceive the sensation.
A person will be able to react to a stimulus after interpreting the significance of a sensation. The normal sensation is when a person recognizes the feeling and perceived it as normal that results from the body’s sensory nerves.
Sensation can be classified into two categories:
- Sensation which includes the sense of touch, pain, proprioception, temperature, and pressure
- Special senses such as vision, hearing, taste, and sense of taste carry sensation to the brain through the cranial nerves
The peripheral nervous system and the central nervous system help the sensory receptors to communicate with other parts of the person’s body. Sense organs that are made up of sensory receptors and other cells operate the person’s sense of vision, hearing, equilibrium, smell, and taste.
Special senses include:
- Sense of sight. Sense of sight is the ability of the eyes to focus and identify images of visible light on a person’s retina that produce electrical nerve impulses for varying colors, hues, and brightness. Vision is important for the person’s balance and movement. Impaired vision may have a huge impact on a person’s functional activities.
- Sense of hearing. The sense of hearing is the sense of sound perception which helps a person to communicate. The inner ear has mechanoreceptors that turn vibration motion into electrical nerve pulses. The eardrum mechanically conducts the vibrations from the ear drum through the series of tiny bones to hair-like fibers of the inner ear which detects the mechanical motion of the fibers. Sounds can be detected as a vibration directed to the person’s ear. The person’s inability to hear is called hearing impairment or deafness which may lead to problems with communication, and decreased awareness of the environmental clues.
- Sense of taste. The sense of taste refers to the ability to sense substances such as food, certain minerals, and poisons. A person receives a sense of taste through the sense organs called the taste buds that are concentrated on the upper surface of a person’s tongue. The person’s inability to taste is called ageusia.
- Sense of smell. The olfactory system of a person is the sensory system used for the sense of smell that is mediated by sensory cells of the nasal cavity. Olfaction occurs when odorant molecules are bonded to the specific sites on the olfactory receptors in the nasal cavity, these receptors are used to detect the presence of smell. The lack of ability of a person to smell is called anosmia.
- Sense of touch. The sense of touch results from the activation of the neural receptors of the person’s skin including the hair follicles, tongue, throat, and mucosa. If a person has an impairment or inability to feel anything touched it is called tactile anesthesia. The sense of touch consists of many senses which include, pressure, heat cold, tickle, and pain.
Signs and Symptoms of Decreased Sensation
A person with decreased sensation should seek medical attention immediately if the following symptoms are present:
- Loss of balance
- Sudden confusion
- Severe headache with unknown cause
- Sudden weakness of the one side of the person’s body
- Trouble seeing
Diagnosis of Decreased Sensation
A person with decreased sensation may be advised to have the following test for proper diagnosis:
- Magnetic resonance imaging(MRI). Magnetic resonance imaging or MRI helps for the visualization of the organs and tissues in the body through computer-generated radio waves that create detailed images of the organs and the tissues.
- Computed tomography(CT-Scan). Computed tomography or CT Scan is a tool for diagnosing disease and injuries of a person that provides detailed information through the use of computer and x-ray machines that creates cross-sectional images of the body.
- Nerve conduction velocity studies. A nerve conduction velocity or NCV test helps in identifying nerve damage and nerve dysfunction. It measures how the electrical signals of the body travel down to a person’s nerve.
- Reflex test. A reflex test is a physical test of the nervous system function that measures the presence and strength of the reflexes.
Types of Decreased Sensation
1. Sensory deficits. A sensory deficit refers to the deficit in the normal functioning of the sensory perception and reception of the person. A person may experience a loss of sense of self if the senses are impaired. A person will initially withdraw by avoiding socialization and communication with others to cope with the sensory loss. A person with a sensory deficit may experience changes in behavior in adaptive and maladaptive ways. Common sensory deficits are:
- Visual deficits. Visual deficits include presbyopia, cataract, dry eyes, glaucoma, diabetic retinopathy, and macular degeneration.
- Hearing deficits. Hearing deficits that include, presbycusis and cerumen accumulation.
- Balance deficit. Dizziness and disequilibrium are examples of balance deficit that is common in older adults resulting from the dysfunction of the vestibule.
- Taste deficit. Taste deficit like Xerostomia is due to a decrease in salivary production which leads to a thicker mucus and a dry mouth that interferes with a person’s ability to eat.
- Neurological deficits. Neurological deficits such as peripheral neuropathy and stroke affect the neurologic function of the person.
2. Sensory Deprivation. Sensory deprivation is when the reticular activating system in the person’s brainstem mediates all sensory stimuli to the cerebral cortex, thus the person can receive stimuli even if the person is sleeping deeply. Sensory stimulation must be adequate in terms of quality and quantity to maintain a person’s awareness. There are 3 types of sensory deprivation which includes:
- Cognitive. Cognitive sensory deprivation includes the reduced capacity to learn, inability to think or solve a problem, poor task performance, disorientation, bizarre thinking, and the increased need for socialization.
- Affective. Affective sensory deprivation includes boredom, restlessness, increased anxiety, emotional lability, panic, and increased need for physical stimulation.
- Perceptual. Perceptual sensory deprivation includes changes in visual or motor coordination, reduced color perception, less tactile accuracy, changes in the ability to perceive size and shape, and changes in spatial and time judgment.
Related Factors to Decreased Sensation
Many factors may influence the capacity to perceive stimuli. These related factors that should be considered include:
- Age. Because of several prenatal, genetic, and postnatal conditions, infants and children are at risk for visual and hearing impairment. High-risk neonates have early, intensely visual and auditory stimulation that can affect adversely the visual and auditory pathways that may alter the development course of the sensory organs. On the other hand, hearing changes and hearing acuity may begin at the age of 30. Changes related to aging include speech intelligibility and pitch discrimination.
- Meaningful stimuli. A meaningful stimulus decreases the incidence of sensory deprivation. Meaningful stimulus is also referred to as the familiar or nameable stimulus that may influence alertness and the ability to participate in care.
- Amount of stimuli. Sensory overload may happen because of excessive stimuli in the environment.
- Social interaction. The amount and quality of social contact and support of the significant others may influence the sensory function of a person.
- Environmental factors.Environmental factors such as noise and other hazards may affect the person’s hearing and visual and peripheral nerve alterations.
- Cultural factors. Certain alterations of the senses may be affected by the ethnic groups. The culture of a person may influence sensory responses, such as smell, taste sound, and touch to visual stimuli.
Nursing Considerations on Decreased Sensation
Nurses and other healthcare professionals work to meet the needs of patients with existing sensory alterations such as decreased sensation, as well as identifying the patients most at risk for developing sensory problems.
The nurse should help the patients that are experiencing partial or complete loss of the major senses to find alternative ways to function safely in the environment. Applying the nursing process and the use of critical thinking in the approach for the care of the patients are important to achieve desired outcomes.
The nurse should:
- During the patient assessment the nurse should critically analyze the findings to ensure patient-centered clinical decisions for safe nursing care.
- When conducting an assessment, the nurse should value the patient as a full partner in making the planning, implementation, and evaluation of patient care.
- Gather information by establishing therapeutic communication with the patient.
- Assess the patient for any risk for sensory alteration and consider the pathophysiology of the existing deficit and the factors that may influence the sensory function of the patient.
- The nurse should know the sensory alteration history including the nature and characteristics of sensory alteration and also the problems related to an alteration.
Decreased Sensation Nursing Diagnosis
Decreased Sensation Nursing Care Plan 1
Nursing Diagnosis: Risk for Injury related to decreased sensation secondary to stroke.
- The patient will appropriately interact with the environment and will not show evidence of injury due to sensory and perceptual deficits.
- The patient will voice out proper coping to decrease sensation.
|Nursing Interventions for Decreased Sensation||Rationale|
|1. Check the type and degree of the damage to the hemisphere injury and check the body part that is affected by the decreased sensation.||This will help the nurse to describe the right and left hemisphere’s injuries and the extent of the decreased sensation. Decreased sensation is common in patients after stroke.|
|2. Check the patient for any changes of the senses such as visual deficits. Check for the loss of visual fields and changes in in-depth perception and check for any presence of diplopia.||The patient may experience a visual disorder that negatively affects the patient’s ability to recognize the environment and relearn the motor skills and may increase the risk of accident and injury.|
|3. Check for the patient’s sensory awareness, and check for the changes and presence of sharpness, the position of body parts, and joint sense.||Reduced sensor awareness and impairment of kinesthetic sense can harmfully affect balance and positioning and appropriateness of movement that interfere with ambulation and will increase the risk of trauma.|
|4. Check for the inattention to body parts, segments of the environment, and the patient’s lack of recognition of the environment and the familiar objects.||The patient may experience agnosia, the loss of visual, auditory, or other sensations, which may lead to unilateral neglect and inability to recognize environmental cues, safe care deficits, and disorientation.|
|5. Check the patient’s environment for hazards that may affect the patient’s safety and remove the hazardous objects from the bedside.||Patients with decreased sensation should always be kept safe because they might not recognize hazardous objects.|
Decreased Sensation Nursing Care Plan 2
Risk for Impaired Skin Integrity
Nursing Diagnosis: Risk for Impaired Skin Integrity related to decreased sensation secondary to diabetic neuropathy.
- The patient will maintain proper circulation and sensation and will not be affected by peripheral neuropathy and arterial obstruction.
- The patient’s skin on the legs and feet remains intact and will show understanding about proper wound care.
|Nursing Interventions for Decreased Sensation||Rationale|
|1. Do the baseline assessment through assessment of the following: |
-Skin dryness, lesion, fissures, cellulitis, and gangrene of the lower extremities
-Assess the foot, ankle, joint of range motion, and abnormalities of the bone.
-Perform neurological assessment that includes assessment of the sense of touch, pain, and temperature.
-Vascular examination of the patient’s lower extremities as well as the skin temperature, hydration status, skin lesions, and capillary refill. Patients with diabetes are at risk of having peripheral neuropathies and lower extremities gangrene due to the altered perception of pain, pressure, and temperature.
Dryness of the skin, lesions on the skin, and the hydration of the skin can cause infection and may delay healing.
|2. Check for skin integrity and check the knee and tendon reflexes.||This assessment may help the nurse to assess for neuropathy. The patient’s skin on the lower extremities’ pressure points is at risk for ulceration.|
|3. Check the patient’s feet every day for the presence of erythema and trauma.||Erythema and trauma indicate that the skin needs preventive care.|
|4. Wash the feet of the patient daily using mild soap and warm water. Check the water temperature first before immersing the feet of the patient in the water.||The risk for burns and dermal injury may happen due to the decrease in sensation. Washing the feet daily reduces the risk of burns and dermal injury.|
|5. Instruct the patient that all cuts and blisters should be cleaned and should be treated with an antiseptic preparation.||Proper wound treatment will help avoid infection of the wound. If the wound is infected, the nurse should encourage the patient to inform the primary health care provider as soon as possible.|
Decreased Sensation Nursing Care Plan 3
Nursing Diagnosis: Impaired Skin Integrity related to decreased sensation secondary to fracture as evidenced by the patient’s report of pain, numbness, and disruption of skin surface and tissues.
- The patient will express the relief of the skin discomfort and decreased sensation.
- The patient will show behaviors and techniques that will help in preventing skin breakdown and facilitate wound healing as indicated.
- The patient will be able to attain timely wound and lesion healing if present.
|Nursing Interventions for Decreased Sensation||Rationale|
|1. Check the skin of the patient for the presence of open wounds, foreign bodies, rash, bleeding, discoloration of the skin, duskiness, blanching, and decreased sensation.||Assessment of the skin will help the nurse to evaluate the presence of problems and problems in the circulation of the skin and the presence of decreased sensation of the affected part. Cast, splint, and traction apparatus may cause skin circulation problems and edema formation that may require medical intervention.|
|2. Check the splint ring of the traction device if it is in the proper position.||Skin injury and skin breakdown may happen due to improper positioning.|
|3. Change the position of the patient frequently and encourage the patient to use a trapeze if possible.||Trapeze may decrease the risk of having abrasion to the elbows and heels. Skin breakdown may be minimized through decrease constant pressure. Frequent position changes may help improve circulation and reduce the area to be deprived by blood flow.|
|4. Teach the patient about the ways and techniques that may help the patient to prevent skin breakdown.||The patient’s understanding and knowledge about the techniques that may help in preventing skin breakdown is important to prevent the risk of complications.|
|5. Provide tools such as foam blocks, and pillows to elevate the extremities and use a bed cradle and footboard to relieve pressure from the bed linens.||Using these tools will help maintain skin integrity and will prevent pressure on the patient’s skin and will promote moisture of the skin.|
Decreased Sensation Nursing Care Plan 4
Nursing Diagnosis: Activity Intolerance related to decreased sensation secondary to chronic renal failure as evidenced by reports of fatigue on exertion and lack of energy.
- The patient will achieve proper tolerance of the activities after the interventions.
- The patient will utilize the techniques that may help the patient to tolerate the activities and will help the patient to relax.
|Nursing Interventions for Decreased Sensation||Rationale|
|1. Check for the extent of the weakness, fatigue, inability to participate in the activities, and decreased sensation.||This will provide information regarding the impact of activities that influence the tolerance of the patient. Activity tolerance may be affected by decreased sensation experienced by the patient.|
|2. Encourage the patient the relaxation activities such as watching television and reading books during times of fatigue.||These activities will provide relaxation, and stimulation and will require minimal energy spending.|
|3. Allow the patient to have frequent rest periods and schedule care following an activity. Allow the patient to set his/her limits on the amount of exertion that the patient can tolerate.||This will promote independence and will help the patient to have control of the situation. Frequent rest periods will help to conserve energy that will help the patient to tolerate other activities.|
|4. Encourage the patient, patient’s family, and significant others to participate in the activities, and assisting the patient may be necessary and maintain the safety always. Advise them to report decreased sensation if the situation worsens.||Family participation in the activities and their knowledge will help the patient to tolerate activities and will also help to prevent the risk of increased complications.|
|5. Evaluate the tolerance of the patient after the activities and their understanding of the situation and condition.||Evaluation of the interventions will help the nurse to know if an additional plan of care and intervention is needed.|
Decreased Sensation Nursing Care Plan 5
Risk for Autonomic Dysreflexia
Nursing Diagnosis: Risk for Autonomic Dysreflexia related to decreased sensation secondary to spinal cord injury.
- The patient will distinguish the signs and symptoms of autonomic dysreflexia.
- The patient will identify the prevention and the corrective measures of autonomic dysreflexia.
- The patient will verbalize no episodes of dysreflexia.
|Nursing Interventions for Decreased Sensation||Rationale|
|1. Assess for the precipitating risk factors such as bowel and bladder manipulation, bladder spasms, stones, infection, skin, and tissue pressure areas, and decreased sensation of the senses.||Autonomic dysreflexia may cause visceral distention which is considered an emergency. Acute episodes should be treated immediately by removing the stimulus and treating the unresolved symptoms, and interventions for prevention must be done.|
|2. Observe for the changes in the patient’s vital signs, paroxysmal hypotension, presence of autonomic response such as sweating, flushing above the level of lesion, pallor below the patient’s injury, chills, nasal stuffiness, severe pounding headache, chest pain, blurring of vision and metallic taste.||Detection of the signs and symptoms and providing immediate intervention may prevent serious complications.|
|3. Stay with the patient during the episodes of autonomic dysreflexia and advise the family and significant others to also stay with the patient during the episodes.||Continuous monitoring of the patient is important to help reduce the level of anxiety of the patient because of the condition.|
|4. Remove causative stimuli such as the pressure on the bladder, bowel, and skin by loosening tight leg bands or clothing and removing the abdominal binder or elastic stockings, and decreasing the extreme temperature.||Removing the stimulus may prevent serious autonomic dysreflexia. To promote venous pooling constrictive clothing and vascular support should be removed.|
|5. Educate the patient and significant others on the ways to avoid the onset of the syndrome such as gooseflesh, sweating, piloerection, and sunburn.||Avoiding pressure from over-distension of visceral organs or pressure on the skin may control lifelong problems.|
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