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139 Cards in this Set
- Front
- Back
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GUSTATORY
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-taste
(read dates on food packing to avoid contaminated or spoiled food that cannot be detected through taste) |
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KINESTHETIC
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-sense that enables a person to be aware of the position and movement of body parts without seeing them
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STEROGNOSIS
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sense that allows a perosn to recognize an object's size, shape and texture
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What are the 5 senses?
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-visual
-auditory -tactile -olfactory -gustatory *the ability to Speak is NOT a sense |
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Allows a person to Learn about the environment & is necessary for Health Functioning & normal development
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-Meaningful Stimuli
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What is the function of the EAR?
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-transmits to the brain an accurate pattern of all sounds:
-received from the environment -relative intensity of these sounds -direction from which they originate |
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EXTERNAL EAR canal?
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-shelters the eardrum and maintains relatively constant temp and humidity to maintain elasticity
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MIDDLE EAR?
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-air-containing space b/w the eardrum and oval window.
-contains 3 small bones= Ossicles |
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Transfers sound to the fluid-filled inner ear?
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-eardrum
-ossicles |
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Union of the Vestibular?
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-Balance
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COCHLEAR
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-Hearing
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What is the function of the EYE?
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Transmits to the brain an accurate pattern of light reflected from solid objects in the environment & transformed into color and hue
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5 SENSORY DEFICITS?
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-Visual deficits
-Hearing Deficits -Balance Deficits -Taste Deficits -Neurological Deficits |
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Visual Deficits:PRESBYOPIA
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-gradual decline in the ability of the lens to accomodate or to focus on close objects
-unable to see NEAR objects clearly |
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Visual Deficit:CATARACT
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-cloudy or opaque areas of lens that interfere w/ passage of light
-glare & blurred vision -develop gradually, w/o pain, redness or tearing in the eye |
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Visual Deficit: GLAUCOMA
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-slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve, resulting in
-PERIPHERAL visual loss -decreased visual acuity w/ difficulty adapting to darkness, and a halo effect around lights, if left untreated |
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Visual Deficits:DRY EYES
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-tear glands produce too few tears
-sx: itching, burning, reduced vision |
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Visual Deficits: Diabetic retinopathy
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Pathological changes occur in the blood vessels of the retina, resulting in decreased vision or vision loss due to hemorrhage & macular edema
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Visual Deficits:MACULAR DEGENERATION
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-Condition in which the macula (responsible for central vision) loses its ability to function efficiently. First signs may include blurring of reading matter, distortion or loss of central vision, and distortion of vertical lines
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Hearing Deficits: Cerumen Accumulation
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Buildup of earwax in the external auditory canal. Cerumen, becomes hard and collects in the canal and causes a conduction deafness
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Hearing Deficits: Prebycusis
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-Progressive hearing disorder in older adults.
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Balance Deficits:
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Common condition in older adulthood, usually resulting from vestibular dysfunction. Frequently an episode of vertigo or disequilibrium is precipitated by a change in position of the head
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Taste Deficit: Xerostomia
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-Decrease in salivary production that leads to thicker mucus and a dry mouth. Result of medications such as antihistamines.
- interfere with the ability to eat and leads to appetite and nutritional problems |
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**Neurological Deficits: Peripheral neuropathy
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Disorder of the peripheral nervous system.
Commonly caused by diabetes, Guillain-Barre syndrome, and neoplasms. Symptoms include numbness and tingling of the affected area and stumbling gait. |
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Neurological Deficits: STROKE
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- CVA caused by clot, hemorrhage, or emboli disrupting blood flow to the brain.
-Creates altered proprioception with marked incoordination and imbalance. -Loss of sensation and motor function in extremities controlled by the affected area of the brain -stroke affecting left hemisphere of brain results in sx on the right side (difficulty w/ speech) -stroke on RIGHT hemisphere of brain results in sx on the LEFT side, (VISUAL SPATIAL ALTERATIONS such as loss of half of a visual field or inattention & neglect |
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3 types of Sensory ALTERATIONS:
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1. sensory DEFICITS
2. sensory DEPRIVATION 3. sensory OVERLOAD |
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PERCEPTION:
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-includes integration & interpretation of the stimuli based on the person's Experiences
ie. a person's Level of Consciousness -Any factors lowering consciousness impair sensory perception |
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sensory DEFICITS:
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-a deficit in the normal function of sensory reception and perception
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Initially reaction of a client w/ sensory Deficits?
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-withdrawls by avoiding communication or socialization w/ others in an attempt to cope w/ the sensory Loss
-difficult to interact safely w/ the environment until new skills are learned -learn to rely on unaffected senses -some senses may become more acute to compensate for an alteration ie. blind client develops an acute sense of hearing |
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Behavior of a client w/ Sensory Deficits?
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-change behavior in adaptive or maladaptive ways
ie. HOH client turns unaffected ear toward the speaker to hear better whereas another client avoids other people b/c they embarrassed about not being able to understand speech ie. unable to feel hot/cold to feet ie. no peripheral vision ie. poor sensation to peripheral extremities (legs, feet, hands, arms) |
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When does SENSORY DEPRIVATION occur?
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-when a person experiences an inadequate Quality or Quanity of stimulation, such as Monotonous or Meaningless stimuli
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Three types of sensory DEPRIVATION
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1. reduced sensory input(sensory deficit from visual or hearing loss);
2. elimination of order or meaning from input (e.g., exposure to strange environment); 3. restriction of the environment that produces monotony and boredom (e.g., bed rest) |
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Sx of Sensory Deprivation in older adults:
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-similiar to Psychological:
-illness, -confusion, -symptoms of severe electrolye imbalance - the influence of psychotropic drugs |
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*CONGITIVE effects of Sensory DEPRIVATION:
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-reduced capacity to learn
-inability to think or problem solve -Poor task performance -disorientation -bizarre thinking -increased need for socialization, altered mechanisms of attention |
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*AFFECTIVE effects of Sensory DEPRIVATION:
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-boredom
-restlessness -increased anxiety -emotional lability -panic -increased need for physical stimulation |
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*PERCEPTUAL effects of Sensory DEPRIVATION:
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-changes in Visual/Motor coordination
-reduced color perception -less tactile accuracy -changes in ability to perceive size and shape -changes in spatial & time judgment |
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*SENSORY OVERLOAD
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when a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli
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Example of sensory OVERLOAD:
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A client who is hospitalized in an ICU, where the activity is constant. Lights are always on. Sounds can be heard from monitoring equipment, staff conversations, equipment alarms, and the activities of people entering the unit. Even at night, an ICU can be noisy
-mechanical ventilator -cardiac monitor -roommate -iv equipment |
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Older adults have difficulty discriminating, what consonants and high-frequency sounds
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consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k)
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Over-stimulation can be a problem if a client is
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in pain, has many tubes and dressings, or is restricted by casts or traction.
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Symptoms to look for in clients associated w/ Sensory Overload?
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-racing thoughts
-scattered attention -restlessness -anixety |
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A person's tolerance to Sensory Overload varies by?
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-level of fatigue
-attitude -emotional & social well being |
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The absence of meaningful conversation can cause?
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a person to become sensorially Deprived
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Excessive stimuli in an environment can cause ?
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-Sensory Overload
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The ____ or _____ of Meaningful Stimuli influence alertness and the ability to participate in care.
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presence or absence
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Who is easily a victim of sensory Overload?
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-acutely ill client
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Overload prevents meaningful response by the brain including:
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-the clients thoughts Race
-attention scatters in many directions -anxiety & restlessness occur |
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Risk Factors for Sensory Deprivation?
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-private room
-eyes bandaged -bed rest -sensory aid not available (hearing aid, glasses) -Isolation (nurse has < contact w/ client) -few vistors |
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What are some ways Sensory Function affects older Adults?
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-visual changes
-presbyopia -cornea becomes flatter/thicker leading to Astigmatism -risk for glaucoma -reduced visual fields -increased glare sensitivity -impaired night vision -reduced depth perception -reduced color discrimination |
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Children with hearing deficits will be
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inattentive, uncooperative, or easily bored
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Clients with hearing loss tend to
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decrease time spent with social activities and with verbal communication
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Meaningful stimuli include:
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pets, music playing on a cassette player, television, pictures of family members, and a calendar and clock.
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otolaryngologist
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deals with the anatomy, function, and diseases of the ear, nose, and throat.
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Older adults experience tactile changes including:
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declining sensitivity to pain, pressure, and temperature
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PROPRIOCEPTIVE changes after age 60 include:
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difficulty with balance,
spatial orientation coordination |
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Hearing changes, which begin at age 30, include:
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DECREASED:
-hearing acuity, -speech intelligibility, -pitch discrimination, and -hearing threshold |
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Normal changes associated with aging include:
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-reduced visual fields,
-increased glare sensitivity - -impaired night vision, -reduced accommodation -depth perception - reduced color discrimination |
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___ are unable to discriminate sensory stimuli because nerve pathway are immature
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-Infants
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___-pitched sounds are easies to hear
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-low
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What age does gustatory and olfactory senses changes?
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-around50 y/o
- includes a decrease in the number of taste buds -decrease in the number of sensory cells in the nasal lining |
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Occupational and Leisure Activities That Pose Risk for Sensory Alterations: Peripheral Nerve Injury-Repetitive Motion
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Computer programmer; Manicurist; Factory worker on assembly line
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Occupational and Leisure Activities That Pose Risk for Sensory Alterations: Vision
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Exposure to irritating gases; Welder; Exposure to high-speed machinery; Racquetball, squash, or fencing; Motorcycle riding; Power tool use
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Occupations and Leisure Activities That Pose Risk for Sensory Alterations: Hearing
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Factory worker; Airport worker; Rock musician; Construction worker with jackhammer; Farmer working with farm machines
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What are some ie. of physical impediments?
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-cases
-traction |
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Whites have a higher incidence of _____ ______ than African or Asian Americans?
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Hearing Impairment
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Culture that has a high rate of otitis media in children?
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-Native American
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Glaucoma is 3 x's as common in African Amer as in _____?
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-whites
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Culture with an increased incidence of Diabeic Retinopathy?
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-Hispanic
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Culture who has a incidence of Macular Degeneration?
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-whites
(higher than afr amer, hisp, Asian amer) |
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What is Hearing Handicap Inventory for the Elderly (HHIE-S)?
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-5 min,
-10-item questionnarie developed to assess how the individual perceives the social & emotional effects of hearing loss *the higher the score, the greater the handicapping effect of a hearing impairment |
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What is an example of a tool used to "formally" measure disorientation, alter conceptualization and abstract thinking and change in problem-solving abilities?
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-The Mini-Mental State Examination (MMSE)
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What is an important step to prevent Cognition-related disability?
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-EDUCATION by nursed about disease process, available services & assistive devices
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Assess clients' functional abilities in their home environment or health care setting, including:
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-feeding
-dressing -grooming -toileting activities |
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HPD's?
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hearing protective devices
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Assessment of Mental status:
Physical Appearance & Behavior: |
-motor activity
-posture -facial expression -hygiene |
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Assessment of Mental status:
COGNITIVE ABILITY: |
-LEVEL of consciousness, abstract reasoning, calculation, attention, judgement
-ABILITY to carry on conversation, ability to read, write, and copy figure -RECENT and REMOTE memory |
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Assessment of Mental status:
EMOTIONAL STABILITY: |
-agitation
-euphoria -irritability -hopelessness -wide mood swings -auditory -visual tactile hallucinations -ILLUSIONS -DELUSIONS |
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What is the function of the EYE?
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Transmits to the brain an accurate pattern of light reflected from solid objects in the environment & transformed into color and hue
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EXPRESSIVE APHASIA?
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-Motor type of aphasia
-inability to name commonn objects or to express simple ideas in words or writing ie. Client understands a question but is unable to express an answer |
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RECEPTIVE APHASIA?
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-Sensory
-inability to understand written or spoken language. -client may be able to express words but is unable to understand questions or comments of others |
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Global Aphasia?
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-inability to understand language or communicate orally
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Reception begins with
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stimulation of a nerve cell called a receptor, which us usually designed for only one type of stimulus, such as light, touch, or sound
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HYPERESTHESIA
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overly sensitive to tactile stimuli
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Excessive cerumen occluding the ear canal can cause this
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CONDUCTIVE HEARING LOSS
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safety tips for clients who continue to drive with visual alterations
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drive in familiar areas, do not drive during rush hour, avoid interstate highways for local drives, drive defensively-use rear-view mirrors when changing lanes, avoid driving at dusk or night, go slow but not too slow, keep the car in good working condition, and carry a portable or preprogrammed cellular phone
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Some antibiotics are ____ and can permanently damage the auditory nerve
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-OTOTOXIC
ie. streptomycin, gentamycin, tobramycin |
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To understand the nature of a communication problem, the nurse must know whether
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a client has trouble speaking, understanding, naming, reading, or writing
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Common hazards that can be problematic to clients with sensory alterations
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Uneven, cracked walkways leading to front/back door, Extension and phone cords in the main route of walking traffic, Doormats with slippery backing, Loose area rugs and runners placed over carpeting, Bathrooms without shower or tub grab bars, Water faucets unmarked to designate hot and cold, Bathroom floor with slippery surface, Absence of smoke detectors in rooms, Unlit stairways, lack of handrails, Cluttered floors, furniture, including footstools
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A nursing history can also reveal any recent changes in a client's behavior. Friends and family are the best resources for this info, because the client may be unaware of any changes. The nurse can asks the following
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Has the client shown any recent mood swings (e.g., outbursts of anger, nervousness, fear, or irritability)? Have you noticed the client avoiding social activities?
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What is the most important defining characteristics for the nursing diagnosis of disturbed sensory perception?
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the client's self-rating for hearing
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The nurse begins sensory alterations history by asking the client to describe the sensory deficit
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Describe your hearing loss for me; Describe how your vision is affected; Explain how use of your hands has changed; Knowledge about the onset and duration of the sensory alteration can be helpful; How long have you had a visual problem?; When did you begin to feel numbness in your hands?; In your legs?; How long have you noticed being unable to hear conversations clearly?
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Adults are at risk for eye injury while
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playing sports and working in jobs involving exposure to chemicals or flying objects
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________is a common cause of blindness in children
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trauma
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The loss of hearing in young adults 20 to 30 years old is attributed to
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exposure to noise at constantly high levels, such as from portable music devices, automobile music systems, concerts, and loud music in aerobics classes
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Assesment of Sensory Function
*List Behavior indicating VISION deficit in Children when asked to read book, letter on menu, identify colors, |
-Self stimulation, including:
eye rubing body rocking sniffing or smelling arm twirling hitching (using legs to propel while in sitting position) instead of crawling |
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Assesment of Sensory Function
*What are some Behaviors indicating VISION deficit in ADULTS when asked to read a magazine, colors on color chart, client performing ADL's? |
-poor coordination
-squinting -under reaching -overreaching for objects -persistent repositioning of objects -impaired night vision -accidental falls |
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Assesment of Sensory Function
*What are some Behaviors indicating HEARING deficit in CHILDREN ? |
-frightened when unfamiliar people approach
-no reflex or purposeful response to sounds -failure to be awakened by loud noise, slow or absent development of speech -greater response to mvmt than sound -avoidance of social interaction w/ other children (assess clients hearing acuity & hx of tinnitus) |
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Assesment of Sensory Function
* What are some Behaviors indicating HEARING deficit in ADULTS? |
-blank looks
-decreased attention span -lack of reaction to loud noises -increased volume of speech -positioning of head toward sound -smiling and nodding of head in approval when someone speaks -use of other means of communication such as lipreading or writing -complaints of ringing in ears |
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Assesment of Sensory Function
*What are some Behavior indicating TOUCH deficit in CHILDREN? |
-inability to perform developmental tasks related to grasping objects
-drawing -repeated injury from handling of harmful objects (hot, stove, sharp knife) |
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Assesment of Sensory Function
*What are some Behaviors indicating TOUCH deficit in ADULTS? |
-clumsiness
-overreaction or underreaction to painful stimulus -failure to respond touched -avoidance of touch -sensation of pins & needles -numbness -unable to identify objects placed in hands |
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Assesment of Sensory Function
*Behaviors indicating SMELL Deficit in CHILDREN? |
-difficult to asess until child is 6 or 7 y/o
-difficulty discriminating noxious odors |
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Assesment of Sensory Function
*Behaviors indicating SMELL Deficit in ADULTS? |
-failure to react to Noxious or strong odors
-increased body odor -decreased sensitivity to odors |
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Assessment of Sensory Function
*Behavior Indicating TASTE Deficit in CHILDREN? |
-inability to tell whether food is salty or sweet
-ingestion of strange-tasting things |
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Assessment of Sensory Function
*Behavior Indicating TASTE Deficit in ADULTS? |
-change in appetite
-excessive use of seasoning and sugar -complaints about taste of foods -weight change |
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Client w/ sensory alterations have strengthened other senses & except caregivers to anticipate their needs, What are 2 examples?
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-safety and security
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APATHY?
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-an absence of emotion or enthusiasm
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What are 3 interventions recommended for the prevention of Visual Impairment?
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1.screen for rubella or syphilis in women who are considering pregnancy
2. advocating adequate prenatal care to prevent premature birth(with the danger of exposure of the infant to excessive O2) 3. sceening children & newborns through preschool for congenital blindness & visual impairment |
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STRABISMUS
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-eyes do not line up in the same direction when focusing. The condition is more commonly known as "crossed eyes."
Symptoms: Crossed eyes Double vision Eyes that do not align in the same direction Uncoordinated eye movements (eyes do not move together) Vision loss in one eye, includes a loss of the ability to see in 3-D (loss of depth perception) caused by: a lack of coordination between the eyes |
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REFRACTIVE ERROR
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-failure of the eye to focus images sharply on the retina, causing blurred vision
ie. nearsightedness, farsightness |
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** What are 2 Signs of Visual Impairment include:
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-failure to react to light
-reduced eye contact from the infant |
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Nursing role for refractive error is ?
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-detection
-education -referral |
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Common cause of impaired hearing in children is?
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-chronic middle ear infections
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If untreated glaucoma leads to:
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-permenant visual Loss
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Key role for an Occupational health nurse?
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-reinforcing the use of Protective devices
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What conditions causes Hearing Aids to be contraindicated?
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-visible congenital or traumatic deformity of the ear
-active drainage in last 90 days -sudden or progressive hearing loss within 90 days -acute or chronic dizziness -unilateral sudden hearing loss w/in 90 days -visible cerumenaccumulaton -foreign body in ear canal -pain -discomfort in ear -audiometric air-bone gap of 15 decibels or greater |
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What are the federal regulations for purchase a hearing aid?
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-must get medical from a physician
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What are the normal changes of aging PUPLILs?
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-ability to adjust to light diminishes resulting in:
*older adults being very sensitive to Glare |
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With aging what perceptions of colors Decline?
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-blue
-violet -green |
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What colors are easier to see with aging?
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-red
-orange -yellow |
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What are clients with severe hearing loss able to hear?
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-music recorded in low-frequency sound cycles
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What caues CONDUCTIVE HEARING LOSS?
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-cerumen
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What keeps taste buds well-hydrated?
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-Good oral Hygiene
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What juice flavors add tartness to foods?
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-vinegar
-lemon |
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When preparing foods aging client's should avoid?
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-blending or mixing foods
(makes it difficult to identify taste) |
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What juice flavors add tartness to foods?
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-vinegar
-lemon |
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When preparing foods aging client's should avoid?
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-blending or mixing foods
(makes it difficult to identify taste) |
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Ways of improving smell?
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-strengthening pleasant olfactory stimulation (cologne, mild room deodorizers, flowers
-removal of unpleasant odors |
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What are ways to increase tactile contact?
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-hair brushing
-combing -back rub -touching of arms or shoulders -turning and repositioning - firm pressure may be used in order for the client to feel the nurse's hand |
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HYPERESTHESIA?
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-overly sensitive to tactile stimuli
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What is necessary for a client to feel independent?
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-Security
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With reduced peripheral vision a client cannot see __________?
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Panoramically b/c the outer visual field is less discrete
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Depth perception?
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-person is unable to judge how far away objects are located
(increase danger when person attempts to walk down stairs or over uneven surfaces) |
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What should the hot water temp be for person with reduced tactile sensation?
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-no higher than 120F (48.8 F)
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What are Communication Methods for clients with an Artificial Airway?
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-use pictures, objects or word cards so the client can point
-offer a pad & pencil -give client time to write message -provide voice box (vibator) for the client w/ a Laryngectomy to use to speak |
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Maladaptive behaviors
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refer to types of behaviors that inhibit a person’s ability to adjust to particular situations. This type of behavior is often used to reduce one’s anxiety, but the result is dysfunctional and non-productive. For example, avoiding situations because you have unrealistic fears may initially reduce your anxiety, but it is non-productive in alleviating the actual problem in the long term.
Ie. client with hear loss will answer questions incorrectly |
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A client has partial paralysis & reduced sensations, dresses what side FIRST?
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-dresses the AFFECTED side first
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Who is the ONLY person that will know if their sensory abilities are improved?
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-The CLIENT
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What should Never occur with a deaf or hearing-impaired client?
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-Restrict BOTH Arms
ie. with Restraints or IV lines (they need hands to communicate) |
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Adaptive Behavior?
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includes the age-appropriate behaviors necessary for people to live independently and to function safely and appropriately in daily life. Adaptive behaviors include real life skills such as grooming, dressing, safety, safe food handling, school rules, ability to work, money management, cleaning, making friends, social skills, and personal responsibility.
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