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47 Cards in this Set
- Front
- Back
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What are the 5 factors that affect cognitive and sensory function? |
1)Developmental stage 2) Culture 3) Stress 4) Medications/Illness 5)Lifestyle and Personality |
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What is Sensory Deprivation? |
a decrease in or lack of meaningful stimuli |
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What is Sensory Overload? |
A person is unable to process or manage the amount or intensity of sensory stimuli |
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What is Sensory Deficit? |
Impaired reception, perception, or both of one or more of the senses |
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What are the symptoms of Sensory Deprivation? |
1) confined to a non stimulating or monotonous environment 2) have impaired vision or hearing 3) have mobility restrictions 4) are unable to process stimuli 5) have emotional disorders 6) have limited social contact with family and friends
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What are the symptoms of Sensory Overload? |
1) pain or discomfort 2) acutely ill 3) closely monitored in ICU with tubes 4) decreased cognitive abiity |
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What are the symptoms of Sensory Loss? |
1) Elderly 2) working with loud machinery/ listening to music (high decibels) 3) clients with strokes, diabetes, risk for tactile deficit 4) clients with brain trauma ( risk for vision, hearing, olfactory) |
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What are ways to improve visually impaired clients? |
1) eyeglasses (correct prescription) 2) adequate room lighting, night lights 3) use of sunglasses 4) magnifying glass 5) phone dialer with large numbers 6) clock with watch (large numbers) 7) large print books and reading materials |
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What are resources in the community to promote safety and support networks for clients with impaired mental status/sensory loss? |
1) Alzheimer’s Association
2) Alzheimer's Residential Care 3) Memory Care Units in Nursing Homes 4) Department of Senior Services 5) Assisted Living Facilities 6) Local community services in your area |
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What are the 3 main legal implications surrounding proper use of restraints? |
1) All restraints must be clinically justified 2) All restraints must be part of the prescribed medical/nursing plan of care 3) Must have physician's order which includes (restraint type, location, behaviors, limited time frame, NO PRN orders) |
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Explain alternatives to the use of restraints with focus on “least restrictive”
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1)Assign “Buddies” so that the client can be observed 2) Closely supervise 3)Limit “relocation shock” 4)Monitor all of the client’s medications 5)Replace full length siderails with half side rails 6) Use rocking chairs to help confused client’s expend some of their energy 7) use devices to keep client’s in proper position and alignment 8) |
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What are the 4 respiratory system processes? |
1) Pulmonary Ventilation 2) Alveolar Gas exchange 3) Transport of Oxygen 4) Systematic Diffusion |
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What is the main purpose of Pulmonary Ventilation? |
Inspiration and Expiration |
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What must be in place for Pulmonary Ventilation? |
Intact thoracic cavity capable of expanding and contracting Adequate pulmonary compliance and recoil |
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What is the main purpose of Alveolar Gas Exchange? |
Diffusion of O2 FROM the alveoli INTO the pulmonary blood vessels begins |
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What is the main purpose of the transport of oxygen & carbon dioxide? |
O2 FROM the lungs to the tissues CO2 FROM the tissues and back into the lungs |
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What is the purpose of Systematic Diffusion? |
Diffusion of oxygen and carbon dioxide BETWEEN the capillaries and the tissues/ cells |
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What is Orthopnea? |
Unable to breathe unless sitting up |
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Dyspnea |
Shortness of Breath |
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Cyanosis |
bluish discoloration of skin, nails, mucous membranes |
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Hypoxemia |
reduced o2 levels in blood |
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Hypoxia |
Insufficient o2 in the body |
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What factors affect the rate of oxygen transport from lungs to the tissues? |
Cardiac output # of erythrocytes and blood hematocrit Exercise |
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What factors affect respiratory functions?? |
Age Environment Lifestyle Health Status Medications Stress |
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Types of respiratory changes whichwill occur with age ?
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•Chest wall and airways/less elastic &more rigid
•Amount of exchanged air will decrease•Mucous membranes drier and more fragile•Cough reflex and cilia action aredecreased•Decrease in muscle strength &endurance•Decrease in immune system defenses |
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Tachypnea? |
Rapid Respirations |
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Bradypnea? |
Abnormally slow respirations |
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Apnea? |
No breathing |
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Hyperventilation |
increased movement of air in and out of the lungs |
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Hypoventilation |
slow shallow breathing |
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What are the interventions to maintain normal respiratory patterns? |
•Positioning techniques that allow for maximum chest expansion(Fowlers or semi fowlers positions)
•Assisting in frequent position changes•Teach yourpatient the Coughing/DeepBreathingtechnique, Pursed Lip Breathing and Huff Coughingtechniques •Provide/assist with ambulation and exercise opportunities •Comfort measures for pain |
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What is Macular Degeneration? |
occurs when the central part of the retina is damaged Responsible for detail, color, daylight |
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Which is more common? Wet or Dry Macular Degeneration? |
Dry is most common at 90% (slow and progressive) Wet 10% (sudden in onset with severe vision loss) |
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What are the symptoms of Macular Degeneration? |
Spotty loss of detail vision Loss of Central Vision! |
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What is Glaucoma? |
build up of fluid pressure within eye causing damage to optic nerve |
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What are the two types of Glaucoma? |
Open angle: most common (89%) increased aqueous humor production and normal chamber angles Closed angle: increased aqueous production from anterior chamber Narrowing of anterior chamber |
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What are the symptoms of Glaucoma? |
No early symptoms increased eye pressure subtle loss of contrast LOSS of Peripheral Vision! |
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What are Cataracts? |
An opacity or clouding of the lens of the eye |
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What are the symptoms of Cataracts? |
Hazy Vision Trouble distinguishing colors Sensitivity to glare |
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What is Diabetic Retinopathy? |
Diabetes damages the blood vessels inside the retina |
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What are the 4 stages of Diabetic Retinopathy? |
mild nonproliferative retinopathy Moderate Nonproliferative Retinopathy Severe Nonproliferative Retionpathy Proliferative Retinopathy |
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What are the symptoms of Diabetic Retinopathy? |
Specks of blood or floating spots severely blurred vision |
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What the nursing interventions for early stage Alzheimer's? |
assistance with making/keeping appointments
planning for the future as disease progresses helping with words/names/faces/planning/organizing encouraging client of who can help with money management and medications |
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What the nursing interventions for middle stage Alzheimer's?
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Provide simple tasks to avoid exhaustion with wandering
Organization and consistent placing of personal items is important |
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What the nursing interventions for late stage Alzheimer's?
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Use the senses to maintain quality of life! |
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When does sensory overload happen is Alzheimer's? |
Middle stage and first part of late stage |
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When does sensory deprivation happen in Alzheimer's? |
Third or Last Stage |
