• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

Card Range To Study

through

image

Play button

image

Play button

image

Progress

1/54

Click to flip

Use LEFT and RIGHT arrow keys to navigate between flashcards;

Use UP and DOWN arrow keys to flip the card;

H to show hint;

A reads text to speech;

54 Cards in this Set

  • Front
  • Back
3 components of sensory experience
Sensory reception, perception, reaction
Stereognosis
is the ability to perceive and recognize the form of an object using cues from texture, size, spatial properties, and temperature. Stereognosis tests determine whether or not the parietal lobe of the brain is intact. Typically, these tests involved having the patient identify common objects (eg. keys, comb, safety pins) placed in their hand without any visual cues.
4 requirements for sensory experience
Stimuli capable of initiating a response by nervous system
Receptor or sense organ to receive stimuliys and convert it to nerve impulse
Nerve pathway to conduct impulse to brain
Area of brain must be able to receive and translate impulse into sensation
Reticular Activating System (RAS)
is an area of the brain responsible for regulating arousal and sleep-wake transitions.
Patients at risk for sensory deprivation
Institutionalized patients, patients confined to bed, patients with sensory alterations, depressed patients, patients with communicable diseases, patients with nervous system disease, patients from a different culture.
Patients at risk for sensory overload
Acutely ill or chronically ill patients, patients in pain, patients with invasive monitoring or treatment equipment, hospitalized patients (esp, ICU), patients with nervous system disturbances.
Factors affecting sensory stimulation
Age/developmental status, amount/presence or absence of meaningful stimuli, social interaction, environmental factors, culture
States of consciousness
Normal
Delirium
Dementia
Confusion
Somnolence/Lethargy
Chronic vegetative state
States of unconsciousness
Asleep
Stuporous
Comatose
cognition involves
Cerebral functioning - process of conscious thought, reality orientation, problem solving, judgement comprehension.
Components of Assesing sensory and perceptual function
Nursing history, mental status, physical examination, identify patients at risk, patient's environment, patient's social support system.
Acute confusion
Nursing diagnostic label - Abrupt onset of global, transient changes and disturbances in attention, cognition level, level of consciousness or sleep-wake cycle. Aka delirium
Chronic confusion
Irreversible, long-standing or progressive deterioration of intellect and personality with memory, behavioral changes. Aka dementia
Impaired memory
inability to recall information, behavioral skills
Expected outcomes related to sensory/perception
Patient will -
Live in developmentally stimulating/safe environment
Exhibit appropriate level of arousal
demonstrate intact functioning of the senses
maintain orientation to person, place, time
respond appropriately to sensory stimuli
Nursing interventions related to sensory/perception
Adjusting environmental stimuli
managing acute sensory deficits
Use of sensory aids
Sensoristasis
Sensoristasis is the term used to describe when a person is in optimal arousal.
Enables a person to be aware of position and movement of body parts
kinesthetic senses
Senses that enable a person to taste
Gustatory sense
Senses that enable a person to hear
Auditory
Senses that enable a person to smell
Olfactory
Recognition of an object's size shape and texture
Stereognosis
Senses of touch
tactile
Numbness and tingling of affected area, stumbling gait
peripheral neuropathy
results from vestibular dysfunction, vertigo
Disequilibrium
Decreased accomodation of the lens to see near objects clearly
presbyopia
Blurring of reading matter distortion or loss of central vision and vertical lines
Macular degeneration
Caused by clot, hemorrhage, or emboli to the brain
stroke
Opaque areas of the lense that cause glaring and blurred vision
cataract
decrease in salivary production, leading to thicker mucus and dry mouth
Xerostomia
Decreased tear production that results in itching and burning
Dry eyes
Progressive hearing disorder in older adults
Presbycusis
Earwax, causes conduction deafness
cerumen
Blood vessel changes of the retina, decreased vision, and macular edema
Diabetic retinopathy
Increase in intraocular pressure presses against optic nerve resulting in peripheral visual loss, halo effect surrounding lights, difficulty adjusting to darkness
glaucoma
List 3 types of sensory deprivation and give an example of each
Sensory input deprivation - hearing or vision loss
Elimination of patterns of meaning from input - when in a strange environment
Restrictive environments that produce monotony and boredom
Cognitive effects of sensory deprivation
Reduced capacity to learn, inability to think or problem-solve, poor task performance, disorientation, bizare thinking, increased need for socialization, altered mechanisms of attention
Affective effects of sensory deprivation
boredom, restlessness, increased anxiety, emotional liability, panic, increased need for physical stimulation
Perceptual effects of sensory deprivation
changes in visual/motor coordination, reduced color perception, less tactile accuracy, reduced ability to perceive shape and size, changes in spatial and time judgement
Sensory overload
When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli
Identify the 6 factors that influence the capacity to receive or perceive stimuli
age, presence of meaningful stimuli, amount of stimuli, social interaction, environmental factors, cultural factors
Groups at high risk for sensory alterations
Older adults, those living in confinement, acutely ill patients (especially ICU)
When assessing for changes in a client's mental status, the nurse needs to evaluate the following 3 areas-
Physical appearance and behavior (motor activity, posture, facial expression, hygiene)

Cognitive ability (LOC, abstract reasoning, calculation, attention, judgement, ability to converse, memory function)

Emotional stability (agitation, euphoria, irritability, hopelessness, wide mood swings, hallucinations, illusions, delusions)
Some behaviors associated with visual sensory deficits in a young child include
Self-stimulation including eye-rubbing, body rocking, sniffing/smelling, arm-twirling; hitching (using legs to propel while in a sitting position) instead of crawling.
Some behaviors associated with visual sensory deficits in an adult include
Poor coordination, squinting, underreaching or overreaching for objects, persistent repositioning of objects, impaired night vision, falls
Some behaviors associated with tactile sensory deficits in children include
inability to perform developmental tasks related to grasping objects or drawing, repeated injury from handling harmful objects (hot, sharp, etc)
Some behaviors associated with tactile sensory deficits in an adult include
Clumsiness, over or under-reaction to painful stimulus, failure to respond when touched, avoidance of touch. Sensation of pins & needles, numbness. Unable to identify object placed in hand.
A motor-based inability to name common objects or to express simple ideas in words or writing
Expressive aphasia
Sensory-based inability to understand written or spoken language
Receptive aphasia
List several nursing diagnoses for a client with impaired sensory alterations
Impaired adjustment
impaired verbal communication
risk for injury
impaired physical mobility
self-care deficit
situational low self-esteem
disturbed sensory perception
social isolation
disturbed thought processes
The most common visual problem is -
refractive error such as nearsightedness
Children at risk for hearing impairment are -
Those with a: family history, prenatal infection, low birth weight, chronic ear infections, down syndrome
An oversensitivity to tactile simuli
hyperesthesia
4 general approaches to maximize sensory function
Orientation to environment - use name tags, address client by name, explain transfers
Communication - work with clients limitations to maximize ability to communicate
Control sensory stimuli - attempt to minimize overstimulation, provide adequate stimulation.
Safety Measures - help with ambulation, frequent repositioning.