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42 Cards in this Set

  • Front
  • Back
Where does stimulation come from?
Particularly via our sense.
Sight (visual)
Hearing (auditory)
Touch (tactile)
Smell (olafactory)
Taste (Gustatory)
What is a kinesthetic sense?
It enables the person to be aware of the position and movement of body parts without seeing them.
What is stereognosis sense?
A sense that allows a person to recognize an objects size, shape, and texture.
What happens when sensory function is altered?
The person's ability to relate and function within the environment is altered.
How can a hospital cause a sensory alteration?
Its filled with new sounds, sights, and stimuli. It also limits access to family and friends.
What is the function of the ear?
Transmits to the brain an accurate pattern of all sounds received from the environment, the relative intensity of these sounds, and the direction from they originate.
What is the function of they eye?
Transmits to the brain an accurate pattern of light reflected from solid objects in the environment and transformed into color and hue.
How does the nervous system typically process sensation?
Nervous System receives thousands of bits of information from sensory nerve organs, relays the information through appropriate channels, and integrates the information into a meaningful response.
What are the three components of any sensory experience?
3. Reaction
What is reception?
Reception begins with stimulation of a nerve cell, called the receptor, which is usually particular for one type of stimulus, such a light, touch, or sound. When a nerve impulse is created, it travels along pathways to the spinal cord and directly to the brain.
What is perception?
When the person becomes conscious of the stimuli. Perception includes integration and interpretation of the stimuli based on the persons experiences.
What are some of the most common sensory alterations?
Sensory Deficits
Sensory Deprivation
Sensory Overload
What are sensory deficits?
A deficit in the normal function of sensory reception and perception. A person loses sense of self with impaired senses.
What is a person's initial reaction when they experience a sensory deficit?
Initially a person withdraws by avoiding communication or socialization with others in an attempt to cope with sensory loss. It becomes difficult for the person to interact safely within the environment until he or she learns new skills.
What are some examples of common sensory deficits in vision?
Presbyopia-decline of the lens to focus objects that are close. Results in nearsightedness.

Cataracts- Cloudy, opaque areas in part of the lens or entire eye

Dry Eyes- tears glands produce too few tears resulting in itching, burning, or even vision loss.

Glaucoma- increase in intraocular pressure, resulting in decreased visual acuity, difficulty adapting to darkness, and halo effect around lights.

Diabetic Retinopathy- pathological changes in the retina yielding decreased vision or vision loss.

Macular Degeneration- Macula loses ability to function resulting in blurring of reading matter, distortion and loss of central vision, and distortion of vertical lines.
What are some examples of hearing sensory deficits?
Presbycusis- A common progressive hearing disorder in older adults.

Cerumen Accumulation- Buildup of earwax in the external auditory canal. Yields a conduction deafness.
What some examples of balance sensory deficits?
Dizziness and Disequilibrium- Common condition in older adulthood, frequent change in position of head yields an episode of vertigo or disequilibrium.
What are some examples of taste sensory deficit?
Xerostomia- decrease in salivary production that leads to a thicker mucus and dry mouth. Often interferes with the ability to eat and leads to nutritional problems.
What are some examples of neurological sensory deficits?
Peripheral neuropathy- Disorder of the peripheral nervous system, numbness and tingling of the affected area and stumbling gait.

Stroke- CVA caused by clot, hemorrhage, or emboli disrupting blood flow to the brain.
What is sensory deprivation?
Sensory stimulation must be of adequate quality and quantity to maintain a person's awareness. In healthcare settings, meaningful touch is limited, environments lack sensory stimulatory properties, meal are dull and bland, and bath times are unpleasant and distressing experiences. When a person experiences inadequate quality or quantity of stimulation, such as monotonous or meaningless stimuli, sensory deprivation occurs.
What are three types of sensory deprivation?
Reduced Sensory Input (sensory deficit from visual or hearing loss)

Elimination of Patterns or Meaning from Input (exposure to strange environments)

Restrictive Environments (bed rest) that produce monotony and boredom.
What are some symptoms of sensory deprivation?
Very similar to psychological illness, confusion, symptoms of severe electrolyte imbalance, or the symptoms of psychotropic drugs.
What is sensory overload?
When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli.
What are some factors affecting sensory function?
Meaningful Stimuli
Amount of Stimuli
Social Interaction
Environmental Factors
Cultural Factors
Give some examples of how age affects sensory function.
*Infants are at risk for hearing and visual impairment due to genetic, prenatal, and post natal conditions.

*Visual changes in adulthood occur from 40-50

*Hearing loss begins to change as early as 30.

*Gustatory and olfactory changes begin around 50.

*Proprioceptive changes common after age 60, affect balance, spatial orientation, and coordination.
Give some examples of how meaningful stimuli affects sensory function.
Meaningful stimuli reduce the incidence of sensory deprivation. In the home meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock.
Give some examples of how amount of stimuli affects sensory function.
Excessive stimuli in an environment causes sensory overload. The frequency of observations and procedures performed in an acute health care setting are often stressful.
Give an example of how social interaction affects sensory function.
The amount and quality of social contact with supportive family members and significant others influence sensory function.
Give an example of how environmental factors affect sensory function.
Occupation setting can put you at risk for peripheral, visual, and auditory alterations. Carpal tunnel can be work related. Clients who are hospitalized and bed ridden can suffer chronic immobility. Pt's with TB are isolated to one area, and can suffer from lack of social interaction.
What are some important elements to assess when considering sensory alterations?
1. Integrate knowledge of the pathophysiology of sensory deficits

2. Factors that affect sensory function

3. Therapeutic communication principles.
What should your focused health history include when assessing a pt for sensory alterations?
1. The clients current sensory status

2. The degree to which the deficit affects that person's lifestyle

3. Psychosocial Adjustment

4. Developmental Status

5. Self-Care ability

6. Health promotion habits and safety.
What types of populations are more at risk for sensory alterations and why?
Older adults are more at risk because of normal physiological changes involving sensory organs.

Those living in a confined environment such as a nursing home.
Who would you refer a client to if they had a sever hearing problem?
What is a screening tool used to asses hearing?
HHIE-S (Hearing Handicap Inventory for the Elderly) It is a 5 minute, ten item questionnaire.
What are the components of the mental status assessment for sensory deprivation?
Physical Appearance and Behavior- Motor activity, posture, facial expression, hygiene

Cognitive Ability- Level of consciousness, abstract reasoning, calculation, attention, judgement, ability to carry on conversation, ability to read and write, and copy figure. Recent and remote memory

Emotional Stability- Agitation, euphoria, irritability, hopelessness, or wide mood swings.
Illusions, delusions.
What should you do after you have assess your pt for sensory alterations?
You should look critically for patterns and trends suggestive or health problem relating sensory alterations.
What is an example of a nsg d/x when a pt presents with advanced age, apathy, inattentiveness during conversations, and self-rating of hearing as "poor".
disturbed sensory perception:auditory
What are some nsg d/x that you could use when the sensory alteration is the etiology of the d/x?
Risk-prone health behavior
Impaired verbal communication
Impaired physical mobility
Risk for Injury
Self-Care deficit
Situational Low Self Esteem
What are the primary considerations for planning with a pt with a sensory alteration?
-Select strategies to assist the client in remaining functional in the home

-Adapt therapies depending on whether sensory deficit is short term or long term

-Involve the family in helping the client adjust to limitations

-Refer to appropriate healthcare professionals.
Give some examples of Goals and Outcomes for a client with a hearing alteration.
-The client will achieve improvement in hearing acuity within two weeks.

The client will report using communication techniques for improved reception of messages within 2 weeks.

-The client will successfully demonstrate technique for cleansing hearing aid within 1 week.
What do the most effective interventions do for pt's with sensory alterations?
They enable the client with sensory alterations to function safely with existing deficits and to continue a normal lifestyle.
What are some examples of health promotion in regards to sensory alterations?
1. Screening- *. screening for rubella and syphillis in women who are considering pregnancy*advocating adequate prenatal care to prevent premature birth*periodic screening of all children.

2. Preventative Safety *use of protective gear for sports*regular immunizations against rubella, mumps, measles.

3. Use of assistive devices
4. Promoting meaningful stimuli