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53 Cards in this Set

  • Front
  • Back
Sensory reception is the process of
receiving stimuli or da
External stimuli are
visual ( sight), auditory ( hearing), olfactory ( smell), tactile ( touch), and gustatory ( taste - can be internal as well)
Kinesthetic refers to
awareness of the position and movement of body parts
stereognosis
the ability to perceive and understand an object through touch by its size, shape, and texture
Visceral refers to
any large organ within the body. Visceral organs may produce stimuli that make a person aware of them ( e. g., a full stomach)
Sensory perception involves
the conscious organization and translation of the data or stimuli into meaningful information
Perception
awareness and interpretation of stimuli, takes place in the brain, where specialized brain cells interpret the nature and quality of the sensory stimuli
The client’s level of consciousness affects?
the perception of the stimuli
The reticular activating system ( RAS) in the brainstem is thought to
mediate the arousal mechanism
The RAS has two components
the reticular excitatory area ( REA) and the reticular inhibitory area ( RIA)
The REA is responsible for
arousal and wakefulness
Sensoristasis
state in which a person is in optimal arousal.
Awareness is the ability to
perceive internal and external stimuli, and to respond appropriately through thought and action.
Full consciousness description
Alert; oriented to time, place, person; understands verbal and written words
Disoriented description
Not oriented to time, place, or person
Confused description
Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgment
Somnolent description
Extreme drowsiness but will respond to stimuli
Semicomatose description
Can be aroused by extreme or repeated stimuli
Coma description
Will not respond to verbal stimuli
Factors Affecting Sensory Function
- Developmental Stage
- Culture
- Stress
- Medications and Illness
furosemide ( Lasix) affect which sensory function?
auditory nerve - causing hearing loss; may be irreversible.
Diseases of the inner ear can affect
the kinesthetic sense.
Sensory deprivation is
decrease in or lack of meaningful stimuli.
Sensory deprivation clinical manifestation
Excessive yawning, drowsiness, sleeping
¦ Decreased attention span, difficulty concentrating, decreased problem solving
¦ Impaired memory
¦ Periodic disorientation, general confusion, or nocturnal confusion
¦ Preoccupation with somatic complaints, such as palpitations
¦ Hallucinations or delusions
¦ Crying, annoyance over small matters, depression
¦ Apathy, emotional lability
Sensory overload
occurs when a person is unable to process or manage the amount or intensity of sensory stimuli
Three factors contribute to sensory overload:
¦ Increased quantity or quality of internal stimuli, such as pain, dyspnea, or anxiety
¦ Increased quantity or quality of external stimuli,
¦ Inability to disregard stimuli selectively, perhaps as a result of nervous system disturbances or medications that stimulate the arousal mechanism
Sensory overload clinical manifestation
Complaints of fatigue, sleeplessness
¦ Irritability, anxiety, restlessness
¦ Periodic or general disorientation
¦ Reduced problem- solving ability and task performance
¦ Increased muscle tension
¦ Scattered attention and racing thoughts
A sensory deficit is
is impaired reception, perception, or both, of one or more of the senses.
Blindness and deafness are sensory ?
deficit
Nursing assessment of sensory- perceptual functioning in-cludes six components:
( a) nursing history,
( b) mental status examination, ( c) physical examination,
( d) identification of clients at risk,
( e) the client’s environment, and
( f) the client’s social support network.
Visual acuity testing
Snellen chart or other reading material such as a newspaper, and visual fields
Hearing acuity testing
observing the client’s conversation with others and by performing the whisper test and the Weber and Rinne tuning fork tests.
Nice to know: observing gives more information about hearing acuity
Olfactory sense testing
identifying specific aroma
Gustatory sense testing
identifying three tastes such as lemon, salt, and sugar
Tactile sense testing
ight touch, sharp and dull sensation, two- point discrimination, hot and cold sensation, vibration sense, position sense, and stereognosis
outcome criteria for clients with sensory- perception alterations are
- Prevent injury.
- Maintain the function of existing senses.
- Develop an effective communication mechanism.
- Prevent sensory overload or deprivation.
- Reduce social isolation. Perform activities of daily living ( ADLs) independently and safely.
outcome criteria for clients with sensory- perception alterations are
Prevent injury.
Maintain the function of existing senses.
Develop an effective communication mechanism. Prevent sensory overload or deprivation.
Reduce social isolation. Perform activities of daily living ( ADLs) independently and safely.
For clients with impaired vision, nurses need to do
- Orient the client to the arrangement of room
-Keep pathways clear and do not rearrange furniture without orienting the client.
- Organize self- care articles within the client’s reach and orient the client to his or her location.
-Keep the call light within easy reach and place the bed in the low position.
- Assist with ambulation by standing at the client’s side, walk-ing about 1 foot ahead, and allowing the person to grasp your arm.
For clients with impaired vision, nurses need to do
- Orient the client to the arrangement of room
-Keep pathways clear and do not rearrange furniture without orienting the client.
- Organize self- care articles within the client’s reach and orient the client to his or her location.
-Keep the call light within easy reach and place the bed in the low position.
- Assist with ambulation by standing at the client’s side, walk-ing about 1 foot ahead, and allowing the person to grasp your arm.
The most common vision diseases affecting older adults are
macular degeneration (leading cause), cataract, glaucoma, and diabetic retinopathy.
The most common vision diseases affecting older adults are
macular degeneration (leading cause), cataract, glaucoma, and diabetic retinopathy.
Travoprost is an anti- glaucoma drug that
decreases intraocular pressure in open- angle glaucoma.
Travoprost is an anti- glaucoma drug that
decreases intraocular pressure in open- angle glaucoma.
acute open- angle glaucoma
the anterior chamber angle remains open but drainage of the aqueous humor through the canal of Schlemm is impaired. This causes a slow rise of the intraocular pressure. The eye’s drainage angle becomes less efficient as a person ages and the risk of developing chronic open- angle glaucoma increases.
acute open- angle glaucoma
the anterior chamber angle remains open but drainage of the aqueous humor through the canal of Schlemm is impaired. This causes a slow rise of the intraocular pressure. The eye’s drainage angle becomes less efficient as a person ages and the risk of developing chronic open- angle glaucoma increases.
acute closed- angle glaucoma
the drainage angle narrows and closes or becomes blocked by the iris. The intraocular pressure can rise quickly and cause an acute attack.
acute closed- angle glaucoma
the drainage angle narrows and closes or becomes blocked by the iris. The intraocular pressure can rise quickly and cause an acute attack.
Diseases and conditions that are more common in older adults and which also alter sensory perception are
diabetes, strokes, and other neurologic disorders such as Parkinson’s disease.
Diseases and conditions that are more common in older adults and which also alter sensory perception are
diabetes, strokes, and other neurologic disorders such as Parkinson’s disease.
Clients with an impaired sense of smell need to be taught about the dangers of
cleaning and working with chemicals.
Clients with an impaired sense of smell need to be taught about the dangers of
cleaning and working with chemicals.
difference between acute confusion (delirium) and chronic confusion ( dementia)
-delirium has an abrupt onset and a cause that, when treated, reverses the confusion
- chronic confusion has symptoms that are gradual and irreversible
difference between acute confusion (delirium) and chronic confusion ( dementia)
-delirium has an abrupt onset and a cause that, when treated, reverses the confusion
- has symptoms that are gradual and irreversible