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sensory part 1
test 3
| Question | Answer |
|---|---|
| sensory reception | process of receiving stimuli or data |
| sensory perception | conscious organization an dtranslation of data into meaningful info. |
| sensory perception: arousal mechanism | regulated by reticular activating system (SAR) located in the brain stem |
| routes for sensory input | external or internal |
| external sensory input | *visual *auditory *tactile(touch) *olfactory(smell) *gustatory(taste) |
| internal sensory input | gustaory(taste) *Kinesthetic (sterognosis) *visceral(ex. feeling nauseated, feeling full) |
| sensory alteration:sensory deprivation | level of sensory stimulation is too low to permit normal functioning. Can occur because of: sensory deficit* inadequate stimulation in enviroment *impairment of cerebral cortex centers(CVA) |
| sensory deprivation clinical manifestations | increased drowsiness, excessive yawning *shortened attention spain, inability to solve problems, decreased ability to concentrate *problems with memory, depression, crying, apathy *disorientation, confusion, increased confusion at night |
| sensory deprivation clinical manifestations | *delusions, hallucinations *increased complaints (vague pains, palpations) |
| sensory deprivation risk factors: | *nonstimulating or monotonous enviroment (ex. solitary enviroment) *impaired vision or hearing (new onset) *mobility restrictions *inability to process stimuli *emotional disorders *limited social contact |
| sensory alteration: sensory overload | individual coannot process or handle all sensory stimuli, he/she receives effectively *may be caused by increased quality or quantity of internal and/or external stimuli, or by inability to manage multiple stimuli |
| examples of causes of sensory overload | pain, noise, SOB, anxiety, healthcare setting, multiple diagnostic test, contact with multiple hospital personnel |
| sensory overload clinical manifestations | *fatigue, inability to sleep or stay asleep *anxiety, restlessness, irritability *inability to concentrate, racing thoughts *decrease in problem solving ability, task performance ability *muscle tension |
| sensory overload risk factors | pain or discomfort *admission to an acute care facility *monitoring in intensive care units *invasive tubes *decreased cognitive ability |
| sensory alteration: sensory deficit | impaired reception and/or perception of one or more of the senses * may be gradual or sudden *when one sense is affected, other senses may become more keen *those with sensory deficit are often at risk for sensory deprivation and sensory overload |
| factors affecting sensory function | development stage *culture *stress *medications and illness *lifestyle and personality |
| a 75 yr old patient leans forward when you are speaking and ask that you repeat your last statement. this patient exhibits | normal auditory changes |
| nursing assessment: nursing history | the nurse assess: present sensory perceptions *usual functioning *sensory deficits/alterations *potential problems (significant others may be able to provide info the patient cannot) |
| nursing assessment: nursing mental status examination | obtain data on the following: level of consciousness(LOC) (awake, alert) *orientation (person, time, place) *memory *attention span |
| nursing assessment: VISION | visual acuity:roenbaum eye chart, snellen chart, test each eye individually and then both eyes together *test peripheral visual fields *PERRLA? *check cornea for clarity |
| nursing assessment: HEARING | assess response to normal voice with back turned to ensure they are not reading your lips-perform *whisper test if has difficulty |
| nursing assessment: olfactory | any change in sense of smell? have patient close eyes and allow them to smell an object and try to determine what it is (ex. orange) |
| nursing assessment: gustatory | do foods taste the same as they used to? if not contraindicated, have patient close eyes and have him taste salt/sugar and identify |
| nursing assessment: tactile sence | assess if able to determine between sharp and dull *test light touch sensation *temperature |
| nursing assessment: kinesthetic | have patient close eyes, grasp toe or finger between to fingers, move into up, down, straight position and have pt determine which position |
| nursing assessment: stereognosis | have pt close eyes, place an ordinary object in pt hand, and have them identify object |
| identification of clients at risk for sensory deprivation overload | should be done so preventative measure can be initiated |
| client enviroment | the nurse should assess the pts enviroment for quantity, quality, and type of stimuli. determine if nonstimulating or overstimulating. adjust modifiable stimuli to the pt's needs |
| social support network assessment | does the pt live alone? who visits, and when? are there any signs that indicate social deprivation? |
| a patient is admitted to your floor with c/o ringing in his ear. upon further assessment you notice that he also has some vision impairment. which of the following could you contribute to your assessment findings to? | diabetes millitus and lasix |
| NANDA includes the following diagnostic labels for sensory perception alterations: | disturbed sensory perception (specify visual, auditory, kinesthetic, gustatory, tactile, olfactory) related to *acute confusion r/t *chronic confusion r/t *impaired memory r/t |
| NANDA diagnostic labels for sensory perception problems as the etiology: | risk for injury r/t sensory-perception disturbance(specify) * impaired home maintanance r/t sensory perception disturbance (specify) *risk for impaired skin integrity r/t sesory perception disturbance (specify) |
| ANDA diagnostic labels for sensory perception problems as the etiology: (continued) | impaired verbal communication r/t sensory perception disturbance (specify) *self care deficit:bathing/hygiene r/t sensory perception disturbance (specify) *social isolation r/t sensory perception disturbance (specify) |
| planning independent of setting: overall outcome criteria for clients with sensory perception alterations are to: | prevent injury, maintain the func of existing senses, develop an effective communication mechanism, prevent sensory overload or deprivations, reduce social isolation, perform ADL's independently and safely |
| discharge planning begins upon admission and includes: | reassessment of the client's abilities for self care *assessment of the instructional needs of the client and/or caregivers (the availability and skills of suppor ppl *financial resources *determination of the need for referrals and home health services |
| implementation: promoting healthy sensory function: | detecting sensory problems early through screening, regular health exams with vison and hearign screening *enviromental stimuli provide appropriate sensory stimulation is recommended |
| implementation: promoting healthy sensory function: | teach those at risk for sensory loss how to prevent or reduce loss; encourage regular eye exams, teach how to control chronic diseases, such as diabetes |
| implementation:ensuring client safety | implement safety precautions in health care settings for patients with sensory deficits. EX. bed in lowest position, call light with in reach and side rail up |
| implementation: preventing sensory overload | minimize unneccessary lights, sounds, and distractions. * control pain as indicated to level desired by paient, on a scale of 0-10 *introduce yourself by name, address your patient by name *limit visitors as needed |
| implementation: preventing sensory overload | plan care to allow for uninterrupted rest or sleep periods *care should be on a schedule so pt knows what should happen and when, explain test and procedures beforehand *speak in a low tone of voice if indicated, do not hurry your speach |
| to prevent sensory overload provide info in | small doses so the pt is not overwhelmed, have them repeat back info to determine understanding |
| implentation: preventing sensory overload | reduce oxious odors by emptying bedpan or beside commode immediatley, keep wounds clean and covered, provide good ventilation *take time to discuss pt concerns *assist client with stress reducing tech prn |
| implementation: preventing sensory DEPRIVATION | encourage pt to use sensory aids, such as glasses or hearing aids *address client by name and touch pt while speaking if not culturally offensive *communicate frequently with client and maintain meaningful interactions *provide telephone, radio, tv, |
| implementation: preventing sensory DEPRIVATION | provide clock, calender *have family bring fresh flowers or plants *if allowed bring pets *increase tactile stimulation through physical care measures, such as hair care, massage, foot soaks, if not contraindicated |
| implementation: preventing sensory DEPRIVATION | encourage social interaction, encourage use of puzzles or other mentally stimulating activities, or whistling, or singing, encourage enviroment changes |
| implentation: managing acute sensory deficits | encourage the use of sensory aids to support residual sensory function *promote the use of other senses *communicate effectively *ensure client safety |
| communicating effectively | convey respect *enhance self esteem *ensure the exchange of correct info |
| implementation: impaired vision | orient the client to the arrangement of the room and keep enviroment tidy and free of clutter *keep pathways clear, do not rearrange furniture *organize self care articles within the pt reach, orient pt to location |
| implementation:impaired vision | keep call light with in reach, place bed in low position *assist with ambulation by standing at the pt side, walking 1 foot ahead of the pt. allowo pt to grasp your arm |
| implementation impaired hearing | should be assesed/monitored frequently since they are unable to hear IV pump/cardiac monitor alarms *always speak slowly and in enviroments that are not noisy or that do not echo |
| implementation impaired olfactory sense | teach the dangers of cleaning with harsh chemicals such as ammonia *gas stoves and heaters should be kept in good working order *teach clients to carefully inspect food for freshness and check experation date |
| implementation impaired tactile sense | may not be aware of: hot temperature- burns (should have temp adjusted on hot water heater and test water temp before bathing *pressure on bony prominences-pressure ulcers (should change position frequently) |
| DELIRIUM(acute confusion) | acute, sudden onset *temporary, lasting days or hours *worsens at night *sleep cycles are disturbed and are often reversed *alertness fluctates-may be alert and oriented during the day but confused and disoriented at night |
| delirium | may have visual, auditory and tactile hallucinations * can be caused by cerebral and cardiovascular disease, infections, reduced hearing and vision, enviromental change, stress, sleep deprivation, being multiple medications, dehydration |
| DEMENTIA chronic confusion | memory impairment *irreversible *sleep wake cycle are disturbed, fragmented, awakens often during the night *judgment is impaired, unable to find words *may have delusions-usually will not have hallucinations |
| dementia can be caused by | alzheimers or mult. infact dementia |
| implementation the confused client: promoting a therapeutic enviroment | wear a name tag *address the pt by name, introduce yourself frequently *orient the client *speak calmly *eliminate unnecessary noise *provide clear explanations of procedures, treatments, and task |
| coma | is a deep state of unconsciousness that last for a period more than 2-4 weeks following a traumatic brain injury |
| implementation: the Unconscious client | introduce yourself *orient the pt frequently *talk to the client and explain procedures beforehand *provide olfactory stimuli that may include the clients favorites *provide oral care, ROM exercises, change clients position frequently |
| commonly recurring health problems of the older adult | cataracts, glaucoma, macular degeneration, conductive hearing loss, transient ischemic attacks (TIA), cerebral vascular accident (CVA) |
| cataracts | lens opacity or cloudness-may appear gray or milky *by age 80 more than half of all americans have cataracts *may develop in one or both eyes at any age |
| cataracts clinical manifestations | painless, blurry vision *surroundings seem dimmer *sensitivity to glare *reduced visual acuity *diplopia(double vision) (Reduced light transmission |
| cataracts assessment an ddiagnostic findings | snellen visual acuity test, ophthalmoscopy, and slit-lamp biomicroscopic examination are used to establish the degree of cataract formation *degree of opacity does not always correlate w/pt's functional status *visual acuity should not be used alone |
| cataract medical management | there are no nonsurgical treatments available to cure or prevent cataracts *in the early stages of cataract development, glasses, contact lenses, strong bifocals, or magnifying lenses may improve vision |
| surgical management for cataracts | if reduced vision from cataracts do not interfere with normal activities, surgery may not be needed *surgery is performed on an outpatient basis *usually takes less than an hour *if both eyes are affected, one eye is treated first and allowed to heal |
| nursing management of cataracts: pre-operative care | dilating drops (mydriatics) are instilled prior to surgery. *antibiotic, corticosteroid, and anti=inflammatory drops may be given prophylatically to prevent postop infectioin and inflammation |
| mydriatics | (medications that dilate the pupils) poentiate alph adrenergic sympathetic effects that result in the relaxation of the ciliary muscle that, in turn, dilates the pupil |
| Side effects of mydriatics | are blurred vision, dry mouth, fever, rash(rare), and blushing |
| mydriatics | Phenylephrine (Neo-Synephrine) Atrophine (Atropine Ophthalmic)Scopolamine (Isopto Hycosine Ophthalmic)Homatropine (Homatropine HBR) |
| mydriatics are contraindicated in pt's w/ | Glaucoma! |
| Post operative care for cataracts | after anestesia recovery, pt should receive verbal and written instructions: how to protect the eye, adm med's and what they are for, recognize signs of complications, and obtain emergency care. |
| Post operative care for cataracts GOAL | prevent hemorrhage and stress on the eye |
| post-op surgery for cataracts avoid: | straining, coughing, vomiting, report severe pain immediately |
| post-op surgery for cataracts teaching self care and continuing care | a proctective eye patch is worn for 24 hours aftr surgery, followed by eyeglasses worn during the day and a metal shield worn at night for 1-4 weeks. eye will be sensitive to light- sunglasses |
| post-op surgery for cataracts teaching self care and continuing care | increased chance of retinal detachment-pt to notify surgeon of new floaters, flashing lights, decrease in vision, pain, or increase in redness occurs. continuing care should be specific to the typw of surgery the pt had |
Created by:
chelsea309
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