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Sensory Reception

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Receiving stimuli or data through sensory organs

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Sensory Perception

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Conscious organization and translation of the data into meaningful information (more important than sensory reception)

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Senses Involved in Sensory Reception

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Visual, Auditory, Olfactory, Gustatory, tactile, Stereognosis, and Kinesthetic & Visceral

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Stereognosis

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perception of solidity or objects

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Kinesthetic and Visceral

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basic internal orienting systems

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Gustatory

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taste

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Tactile

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touch

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Special senses (external stimuli)

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Vision, Hearing, Smell, and Taste

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Somatic Senses (internal stimuli)

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Touch, Kinesthetic, Proprioception & Visceral

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Kinesthetic

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awareness of position and movement of body parts and movement without relying on information from the senses, - orientation of self - external sense of position

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Visceral

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large organs within the body have sensations that make us aware of them

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Full Stomach

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most common visceral sense

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Sensory Awareness (consciousness)

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Ability to perceive environmental stimuli and body reactions and to respond appropriately

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(RAS) Reticular Activating System (need to be conscious)

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-Located in the nerves centers of the brain stem & medulla oblongata -Makes connections between the spinal cord, cerebellum, thalamus, & cerebral cortes -Relays visual, auditory, visceral, kinesthetic and cognitive input -Allows brain to perceive stimulus and be aroused and wakeful -Allows Selective information at a level that is comfortable for the client is allowed - Wake for infant at night & not doorbell

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Destruction of RAS

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coma

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Sensory Process

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Reception and Perception

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Reception & Perception

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to be aware of surrounding needs

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Reception

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process of receiving - converts the stimulus to a nerve impulse - most receptors sensitive to only one stimulus

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Thermoreceptors

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variations in temperature

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Propreoceptors

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in skin, muscle, tendons, ligaments and joints = sense the position of our body in space

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Mechanoreceptors

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in skin and hair follicles - detect touch, pressure, and vibration

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Hair cells (in cochlea)

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receptors for hearing (dectect sound waves) In the vestibular apparatus of ear = equilibrium and balance, acceleration of body and position of the head

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Photoreceptors, olfactory, & chemoreceptors

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taste

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Impulse conduction

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Impluse travels along nerve pathway to spinal cord or brain

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Specialized location in brain

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-where perception occurs -Auditory to the temporal lobe -Vision to occipital lobe

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Sensory perception

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-ability to interpret the impulses transmitted and give meaning to the stimuli -Discards 99% of all sensory information as unimportant -requires intact sense organs, nervous pathways, and the brain

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Sensoristasis (normal sensory perception)

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-State of when a person is at optimal arousal -person performs best at comfort zone -Beyond this state and person must adapt to increased or decreased stimuli

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Adaptation (normal sensory perception)

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Decrease response to repeated stimuli until it is no longer or minimally perceived - Unless the stimuli becomes: -varied and irregular - needed for you to perceive the stimuli (EX: Nurses on unit no longer respond to lights, activity, alarms - "tune them out")

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Sensory Deprivation (disturbed sensory perception)

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-Decrease in or lack of meaningful stimuli -Monotonous sensory input -Interference with the processing of information -RAS unable to maintain normal stimulation to cerebral cortex - remaining stimuli becomes overly noticeable and distorted - fills in sensory gap (EX: pain, distant noises) -Alterations in perception, cognition, and emotion

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Sensory Deprivation (high risk factors)

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-Altered Sensory Reception -Deprived Environments -Impaired Sensory Stimuli

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Altered Sensory Reception

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Interference with CNS to receive adequate information -Spinal cord injury, brain damage, sleep deprivation and chronic illness -Altered socialization

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Deprived Environments

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Effects Sensoristasis -Environment with decreased or monotonous stimuli -Isolation, institutionalization, immobilization

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Impaired Sensory Stimuli

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-vision and hearing impairments -Affective disorders - tactile stimuli

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Affective disorders

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-Depressed -learning disability

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Clinical Signs of Sensory Deprivation (Taylor - 1635)

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Perceptual Response, Cognitive Response, Emotional Response & Behavioral

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perceptual Response

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-Unuasual body sensations -Preoccupation with somatic complaints (pain, heart palpitations, itching) -Changes in body image -Delusions and Hallucinations

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Cognitive Response

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DEcrease attention span and memory, difficulty concentration, & decreased problem solving

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Emotional Response

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-Crying, annoyance over small matters, depression -Apathy, emotional swings

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Behavioral

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-Excessive yarnin, drowsiness, sleeping -Exercising, eating

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Factors Affecting Sensory Perception

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variations in stimulation -sensory overload -environment -previous experiences -lifestyle and habits -stress & illness -medications

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Sensory Overload (factors affecting sensory perception)

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-RAS is overwhelmed with input -Person is unable to process or manage the amount or intensity of sensory stimuli - no meaningful response

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Reasons for Sensory Overload (person unable to process or manage the amount or intensity of sensory stimuli - no meaningful response)

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-Increased quantity or quality of Internal Factors: pain hypoxia, anxiety, electrolyte imbalances -Increase quantity or quality of external stimuli (environment) noisy healthcare setting, intrusive diagnostic studies, contacts with strangers -Increased quantity or intensity of information: severity or amount of medical or teaching data -Inability perceptually to disregard or ignore stimuli: NS disorder, (attention deficit disorders) CNS stimulation: drugs, caffeine

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Environment (factors affecting sensory perception)

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Sensory stimuli in environment affect perception -on vacation may notice quiet environment - notice stars, smell flowers etc. -Excessive stimuli (crowded living conditions, traffic congestion) may have negative physical outcomes

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Previous Experience (factors affecting sensory perception)

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-More alert to stimuli of interest -Mindless music until favorite song plays -Effect response - grit teeth and turn away before injection even starts

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Lifestyle and Habits (factors affecting sensory perception)

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Enjoy abundant stimuli vs quiet environment

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Culture (lifestyle and habits) - factors affecting sensory perception

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-small vs large family noise -male vs female roles culturally defined -income - what experiences you can purchase -influences the type of care you desire - home vs hosp.

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Habits (lifestyle and habits) - factors affecting sensory perception

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-cigarettes diminish taste and smell -cocaine - changes smell -alcohol - neuropathy

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Stress & Illness (factors affecting sensory perception)

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-Diabetes & Hypertension = damage to vessels & nerves, retinopathy, night blindness, decreased sensation or neuropathy (increased sensation) -Cardiovascular: decreased blood to brain -CVA= cognitive impairments -Pain, fatique, & stress = effects perception of stimuli -Hospitalization is not normal stimuli - can over whelm a person

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medications (factors affecting sensory perception)

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-potential to alter or depress neurosensory system - Damage auditory nerve - Gentamicin, aspirin, lasix -CNS depressants - decreased sensation

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Assessment (factors affecting sensory perception)

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-Stimulation: Recent changes in sensory stimulation -Reception: ie recent changes or new correctice devices -Transimission - Perception: Cognition -Sensory Overload or Deprivation -Ability to Perform Self Care

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Clinical Signs of Sensory Overload (Taylor 1636)

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-Similar to Sensory deprivation -Complaints of fatigue or sleeplessness -Irritability, anziety, restlessness -Periodic disorientation - confusion -Reduced attention span, decreased problem solving ability -Increased muscle tension -Scattered attention and racing thoughts -Preoccupation with somatic complaint - heart palpitations, pain

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Sensory Deficit

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Impaired reception, perception, or both of one or more of the senses -Blindness and deafness are sensory deficits -Altered tactile perception, taste, numbness, paralysis -May be temporary or permanent -When one sense affected others may compensate -Gradual loss leads to compensation and adaptation -Sudden loss this may take days or weeks -Clients may be at risk for sensory deprivation and overload (strangers in room, unable to read or watch TV)

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Sensory Poverty

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-Learning about the world through technology and not experiencing it -Lives may be poorer as we lose the ability to be sensory present in the world we experience

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NEWBORN AND INFANTS - Developmental Considerations (factors affecting Sensory Stimulation

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*Rudimentary sensory perception -track & respond to light -Discriminate sweet from sour - react to odors - mom -Sense of touch - hands, feet & face most sensitive *Repeated stimulation needed for maturity *Touch major source of stimulation: cuddling, soothing, rocking, changing position = bonding, comfort and pleasure *5 S's (Swaddling, Side/Stomach position, Shushing, Swinging, Sucking) *Learn to feel comfortable in their body & space *Binocular vision begins at 6 weeks - established by 4 mos. *Can localize sound by 1 year

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TODDLER AND PRESCHOOLER - Development Considerations (factors affecting Sensory Stimulation)

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*Growth and Development & attachment associated with sensory stimulation -Visual acuity improves - depth perception by preschool -Hearing fully developed - loss = infections *Exploration with senses - begin to interact with people and things -Toddler: active exploration of environment -Preschooler: exploration thru play and language *Lack of meaningful stimulation = delayed growth and development

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SCHOOL AGE CHILD AND ADOLESCENT

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Mastery of tasks based on sensory input -reading, music, smell

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ADULT AND OLDER ADULT (Taylor - p 1639)

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*Learned response to sensory cues *Loss of senses - profound effect *Normal diminishing of senses with age or illness is gradual *By middle age: eyesight & hearing diminishes - Age 60 - 70 marked loss *Need additional time to process sensory stimuli *Taste buds - atrophy and decrease in number = decrease taste esp. sweetness *Touch - decrease ability to perceive light touch, pain and temperature variations *Kinesthesia - Decrease in muscle fibers and diminished conduction speed of nerve fivers slow reaction time, decrease speed and power of muscles contrations and impair balance = increased risk of falling *Changes related to Aging (Box 43-4) - Diabetic Neuropathy, phantom limb pain, Acute sensory loss

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Assessment (Subjective Data) Taylor p 1641

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*Normal Pattern *Typical day, changes in life, living arrangements, lifestyles -How does he handle change -Socialization and transportation

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Assessment (Subjective Data)

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Risk Identification *Cultural & language barriers *Loss of hearing, vision, taste, touch, smell, kinesthetic *What is experience in healthcare setting - ICU, ER, isolation *Medication history

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Assessment (Subjective Data)

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Dysfunction Identification *Sensory deficits: depression, anxiety, withdrawal

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Assessment - Physical Assessment (Objective Data)

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*Visual acuity: Snellen chart, reading, newspaper, visual fields *Hearing: conversation, Whisper test *Smell: Identify special aromas *Tactile sense: light touch, sharp and dull, hot and cold *Taste: identify three tastes - sugar, salt and lemon

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Assessment - Physical Assessment (Objective Data) Neurological Status:

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Level of Awareness *Orientation to time, place, and person - Orient X 3 -Time: day, dated and approximate time (morning, evening, etc) -Place: Where are you? Name of City - State -Person: What is your name? *Deficits: time first, orientation next, and person last *Analyze date in context of environment

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Assessment (Cognitive Function Tests)

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Mini mental Status Exam -Objective evaluation of mental status -Should be administered at regular intervals in order to detect changes in baseline behavior over time -Score 20 or less - significant cognitive impairment

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Level of Consciousness - State of Awareness - Jarvis ALERT

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full consciousness orientated to time, place, person: understands verbal and written words

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Level of Consciousness - State of Awareness - Jarvis DISORIENTED

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not oriented to time, place & person

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Level of Consciousness - State of Awareness - Jarvis CONFUSED

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reduced awareness, easily bewildered, poor memory misinterprets stimuli, impaired judgement

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Level of Consciousness - State of Awareness - Jarvis SOMNOLENT

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(lethargy) Extreme drowsiness, but will respond to stimuli (must call them or touch them)

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Level of Consciousness - State of Awareness - Jarvis SEMI-COMATOSE

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Can be aroused by extreme or repeated stimuli

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Level of Consciousness - State of Awareness - Jarvis COMA

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will not respond to stimuli

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Diagnostic Tests and procedures

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-CAT Scan of brain -Cerebral angiography -Electrolytes alterations -Elevations in taxic wast: Ammonia, BUN, Drugs -MRI

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MRI: Magnetic Resonance Imaging

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*Noninvasive *uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body *Provides contrast between different soft tissues of the body - especially useful in imaging brain, muscles, the heart, and cancers *uses no ionizing radiation - contrast is not iodine *No metal implants (pacemakers, hip implants) check tatoos, metal body piercings must be removed, transdermal patches *Two way communication between client and radiologists - Earplugs for loud noises - Thumps

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MRI: Magnetic Resonance Imaging (prep)

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Remove all metallic objects before test, jewelry, keys etc. -Remove eye makeup -Notify MD or technician if you have a pacemaker, aneurysm clips, metal plates, cardiac valves, bone or joint replacements or if PREGNANT

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CAT Scan:

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*Computerized analysis of multiple tomography X-Ray films - 100 times radiation than X-Ray *Successive layers - provides 3 D view *Appears as if you were viewing object from the top *Dx: intercranial tumors, cerebral infarctions, venticular displacement or enlargement aneurysms, hemorrhage, hematoma *Image of cerebral blood flow - inhale Xenon gas - immediate uptake b brain *Contraindications: Allergy to iodine or shellfish, pregnancy, >300lbs Informed consent: NPO for 4 hours, no metal objects

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PET Scan (Nuclear Imaging Studies)

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*Studies the Physiology of function vs anatomic structures *Radioactive tracers that emit positrons are used. The positrons are tracked by the system to generate a 3D image over time *Variation PET scan = Position emission tomography images created as radioisotope is distributed in body Isotope is inhaled or injected *PET scan reveals the cellular level metabolic changes occurring in an organ or tissue - such vital functions as blood flow, oxygen use, and glucose metabolism *Takes 2-4 hours

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Nursing Diagnoses (pg 1643 - Taylor) ACUTE CONFUSION

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abrupt onset of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness and/or sleep wake cycle

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Nursing Diagnoses (pg 1643 - Taylor) CHRONIC CONFUSION

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An irreversible long standing and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes

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Nursing Diagnoses (pg 1643 - Taylor) IMPAIRED MEMORY

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-The state in which an individual experiences fthe inability to remember or recall bits of information or behavior skills -Maybe pathophysiological or situational

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Outcome Identification and Planning - For clients with impaired cognition (Focus of Goals)

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-Prevention and early recognition of disturbance -Reversal of contributing factors, if possible -Environmental modification -Client safety -Return to baseline cognitive abilities Acute (normal) Chronic (baseline of individual)

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Communicating with a patient who is confused

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-Use frequent face to face contact to communicate the social process -Speak calmly, simply, and directly to the pt -Orient and reorient the pt to the environment -Orient the pt to time, place, and person -Communicate that the pt is expected to perform self-care activities -Offer explanations for care -Reinforce reality if the patient is delusional

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Nursing Diagnosis (Taylor p - 1644) DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (specify)

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Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory

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Nursing Diagnosis (Taylor p - 1644) DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (define)

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Change in the amount or patterning of incoming stimuli, accompanied by a diminished exaggerated, distorted or impaired response to such stimuli

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DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (visual)

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R/T eye patches after surgery

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DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (auditory)

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R/T effects of aging

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DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (gustatory or olfactory)

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R/T chemotherapy)

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DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (tactile)

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R/T Clinitron bed therapy aeb "I've been in bed for 2 weeks - I have this weightless feeling - sort of floating in jello - Don't know where I begin or the the bed ends

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DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (isolation)

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R/T "I can't leave my room - everyone is in yellow gowns - I'm beginning to think they are laughing under those masks

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Diagnosis used to describe persons whose perception has been changed by physiologic factors:

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Pain, Sleep deprivation, Immobility, Excessive or decreased meaningful stimuli

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Diagnosis that can relate to sensory deprivation

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Chronic & acute confusion, impaired memory, Risk for Injury

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Outcome Identification and Planning Goals: (disturbed sensory perception)

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The Client Will: -Remain safe -Understand contributing factors to disturbed sensory perception -Achieve sensoristasis through a decrease in the symptoms of sensory overload or deprivation -Maintain orientation to time, person and place -Demonstrate functioning senses: vision, hearing, taste etc.

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Improving Sensory Functioning

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-Teach pt and significant others methods for stimulating the senses -Teach pt with intact and impaired senses self-care behaviors -Interact therapeutically with pt with sensory impairments

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Implementation: Health Promotion - Sensory Functioning/Stimulation (client teaching) Taylor 1647

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-Yearly vision and hearing screening -prenatal care - rubella + deafness -Immunizations - HIB, MENINGOCOCCAL, MMR -Dental care - decay, gum disease effects taste -chronic disease management: Diabetes -Work safety: glasses - ear plugs -IPODS etc = hearing loss -Children: Proper safety education - Don't run with scissors

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Preventing Sensory Alterations (table 43-1)

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-Control pt discomfort whenever possible -Offer care that provides rest and comfort -Be aware of need for sensory aids and prostheses -Use social activities to stimulate senses and mind -Enlist aid of family members to participate in or encourage activities -Encourage physical activity and exercise -Provide stimulation for as many senses as possible

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Caring for visually impaired patients

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-Teach pt self-care behaviors to maintain vision and prevent blindness -Acknowledge your presence in the pt room -Speak in a normal tone of voice -Explain the reason for touching the pt before doing so -Keep the call light within reach -Orient the patient to sounds in the environment -Orient pt to the room arrangement & furnishings -Assist with ambulation - walk slightly ahead of pt -Stay in the pt field of vision if he has partial vision -Provide diversion using other senses -Indicate conversation has ended when leaving room

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Caring for hearing - Impaired patients

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-Teach measures to prevent hearing problems -Orient pt to your presence before speaking -Decrease background noises before speaking -Check the patient's hearing aids -Position yourself so that light is on your face -Talk directly to the pt while facing him or her -Use pantomime or sign language as appropriate -Write any ideas you cannot convey in another manner

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Implementation (procedure preparation) - Sensation (sensory) Information

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-Goal: improve coping by alleviating distress to a threatening stimuli - overstimulation -Describes what client will see, hear, smell, taste, and feel -Should be in client's point of view -Client teaching to help client gain control over situation

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Implementation (procedure preparation) - Nurse-Client Interaction

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Orientation & re-orientation, develop therapeutic relationship, touch, explanations and teaching - use of self - spend appropriate time

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Implementation (procedure preparation) - Nurse-Client Interaction (examples)

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-encouraging the client to dress for the day's activities -encouraging visitors, opening the drapes, and turning on lights -place the bed or chair so the client can see or hear activities in the area

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STIMULATION REDUCTION (to decrease sensory overload)

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-Decrease stimuli including ADL's, may be too much stimuli -Limit extraneous lights, clutter, interruptions, pain & stress -Plan care to avoid unnecessary disturbances -Reduce noxious odors: bedpans, commodes, foods, mediations -Introduce yourself and speak in calm even voice -Private room - decrease vistors -Explain all procedures and activites -Providing orientation: clocks, calendars, name tags

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Implementation (Nursing Interventions for Altered Sensory Perception Function)

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Stimulation Provision: -Meaningful stimulation -Play TV, Radio Clock, Calendar, dress for the time of the day Family interaction, pictures, calls, tapes Tactile stimulation: massage -Activity - up in chair, walks -Mental functioning - Crosswords, card games -Orientation to environment, check on client -Allow client to do what they like - read, sing, etc

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Communicating With an Uncounscious Patient

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-Be careful what is said in the pt presence; hearing is the last sense that is lost -Assume that the pt can hear you and talk in a normal tone of voice -Speak to the patient before touching -Keep environmental noises at a low level

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Evaluation :Sample Goal

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Client will demonstrate understanding of contributing factors by reducing or eliminating them

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Evaluation: Sample Outcome

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Client uses ear plugs and eye shades during sleep for the next 3 nights

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Evaluation:

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Use previously developed goals and outcomes to evaluate client responses to nursing interventions

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Rooting: Feeding reflex (Jarvis

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-after 4 months of age it is abnormal -touch the baby's cheek near the mouth -the bay head should turn towards the stimulus and the mouth should open

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Palmar Grasp

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-after 4 months of age it is abnormal -present your fingers to the little finger side of the baby's palms

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Plantar Grasp

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-After 10 months of age it is abnormal -Touch the ball of the baby's foot with the thumb

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Moro (the moro reflex)

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-After 4 months of age it is abnormal -Support the head & back then quickly lowre the infant

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Moro

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-The arms & Legs first abduct & then adduct -The index finger & thumb go into a C position

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Tonic neck Reflex - Fencing

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Appears 2-3 months -After 6 months of age it is abnormal -Turn head to one side -Infant extend arm and leg on that side

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Babinski Reflex

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-After 24 months of age it is abnormal - walking one year -Stroke lateral sole on bottom of foot -If the big toe, points upwards ???? positive Babinski refles -It may be recorded as: Plantar reflex (up) or + Babinski

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Adult Babinski reflex

answer

GOOGLE IT (smile)

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Sensory process involves what two components

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Sensory Reception and Sensory Perception

Sensory Functioning chapter 43 – Flashcards

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