Sensory Functioning chapter 43 – Flashcards

Unlock all answers in this set

Unlock answers
question
Sensory Reception
answer
Receiving stimuli or data through sensory organs
question
Sensory Perception
answer
Conscious organization and translation of the data into meaningful information (more important than sensory reception)
question
Senses Involved in Sensory Reception
answer
Visual, Auditory, Olfactory, Gustatory, tactile, Stereognosis, and Kinesthetic & Visceral
question
Stereognosis
answer
perception of solidity or objects
question
Kinesthetic and Visceral
answer
basic internal orienting systems
question
Gustatory
answer
taste
question
Tactile
answer
touch
question
Special senses (external stimuli)
answer
Vision, Hearing, Smell, and Taste
question
Somatic Senses (internal stimuli)
answer
Touch, Kinesthetic, Proprioception & Visceral
question
Kinesthetic
answer
awareness of position and movement of body parts and movement without relying on information from the senses, - orientation of self - external sense of position
question
Visceral
answer
large organs within the body have sensations that make us aware of them
question
Full Stomach
answer
most common visceral sense
question
Sensory Awareness (consciousness)
answer
Ability to perceive environmental stimuli and body reactions and to respond appropriately
question
(RAS) Reticular Activating System (need to be conscious)
answer
-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
question
Destruction of RAS
answer
coma
question
Sensory Process
answer
Reception and Perception
question
Reception & Perception
answer
to be aware of surrounding needs
question
Reception
answer
process of receiving - converts the stimulus to a nerve impulse - most receptors sensitive to only one stimulus
question
Thermoreceptors
answer
variations in temperature
question
Propreoceptors
answer
in skin, muscle, tendons, ligaments and joints = sense the position of our body in space
question
Mechanoreceptors
answer
in skin and hair follicles - detect touch, pressure, and vibration
question
Hair cells (in cochlea)
answer
receptors for hearing (dectect sound waves) In the vestibular apparatus of ear = equilibrium and balance, acceleration of body and position of the head
question
Photoreceptors, olfactory, & chemoreceptors
answer
taste
question
Impulse conduction
answer
Impluse travels along nerve pathway to spinal cord or brain
question
Specialized location in brain
answer
-where perception occurs -Auditory to the temporal lobe -Vision to occipital lobe
question
Sensory perception
answer
-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
question
Sensoristasis (normal sensory perception)
answer
-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
question
Adaptation (normal sensory perception)
answer
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")
question
Sensory Deprivation (disturbed sensory perception)
answer
-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
question
Sensory Deprivation (high risk factors)
answer
-Altered Sensory Reception -Deprived Environments -Impaired Sensory Stimuli
question
Altered Sensory Reception
answer
Interference with CNS to receive adequate information -Spinal cord injury, brain damage, sleep deprivation and chronic illness -Altered socialization
question
Deprived Environments
answer
Effects Sensoristasis -Environment with decreased or monotonous stimuli -Isolation, institutionalization, immobilization
question
Impaired Sensory Stimuli
answer
-vision and hearing impairments -Affective disorders - tactile stimuli
question
Affective disorders
answer
-Depressed -learning disability
question
Clinical Signs of Sensory Deprivation (Taylor - 1635)
answer
Perceptual Response, Cognitive Response, Emotional Response & Behavioral
question
perceptual Response
answer
-Unuasual body sensations -Preoccupation with somatic complaints (pain, heart palpitations, itching) -Changes in body image -Delusions and Hallucinations
question
Cognitive Response
answer
DEcrease attention span and memory, difficulty concentration, & decreased problem solving
question
Emotional Response
answer
-Crying, annoyance over small matters, depression -Apathy, emotional swings
question
Behavioral
answer
-Excessive yarnin, drowsiness, sleeping -Exercising, eating
question
Factors Affecting Sensory Perception
answer
variations in stimulation -sensory overload -environment -previous experiences -lifestyle and habits -stress & illness -medications
question
Sensory Overload (factors affecting sensory perception)
answer
-RAS is overwhelmed with input -Person is unable to process or manage the amount or intensity of sensory stimuli - no meaningful response
question
Reasons for Sensory Overload (person unable to process or manage the amount or intensity of sensory stimuli - no meaningful response)
answer
-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
question
Environment (factors affecting sensory perception)
answer
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
question
Previous Experience (factors affecting sensory perception)
answer
-More alert to stimuli of interest -Mindless music until favorite song plays -Effect response - grit teeth and turn away before injection even starts
question
Lifestyle and Habits (factors affecting sensory perception)
answer
Enjoy abundant stimuli vs quiet environment
question
Culture (lifestyle and habits) - factors affecting sensory perception
answer
-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.
question
Habits (lifestyle and habits) - factors affecting sensory perception
answer
-cigarettes diminish taste and smell -cocaine - changes smell -alcohol - neuropathy
question
Stress & Illness (factors affecting sensory perception)
answer
-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
question
medications (factors affecting sensory perception)
answer
-potential to alter or depress neurosensory system - Damage auditory nerve - Gentamicin, aspirin, lasix -CNS depressants - decreased sensation
question
Assessment (factors affecting sensory perception)
answer
-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
question
Clinical Signs of Sensory Overload (Taylor 1636)
answer
-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
question
Sensory Deficit
answer
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)
question
Sensory Poverty
answer
-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
question
NEWBORN AND INFANTS - Developmental Considerations (factors affecting Sensory Stimulation
answer
*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
question
TODDLER AND PRESCHOOLER - Development Considerations (factors affecting Sensory Stimulation)
answer
*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
question
SCHOOL AGE CHILD AND ADOLESCENT
answer
Mastery of tasks based on sensory input -reading, music, smell
question
ADULT AND OLDER ADULT (Taylor - p 1639)
answer
*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
question
Assessment (Subjective Data) Taylor p 1641
answer
*Normal Pattern *Typical day, changes in life, living arrangements, lifestyles -How does he handle change -Socialization and transportation
question
Assessment (Subjective Data)
answer
Risk Identification *Cultural & language barriers *Loss of hearing, vision, taste, touch, smell, kinesthetic *What is experience in healthcare setting - ICU, ER, isolation *Medication history
question
Assessment (Subjective Data)
answer
Dysfunction Identification *Sensory deficits: depression, anxiety, withdrawal
question
Assessment - Physical Assessment (Objective Data)
answer
*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
question
Assessment - Physical Assessment (Objective Data) Neurological Status:
answer
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
question
Assessment (Cognitive Function Tests)
answer
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
question
Level of Consciousness - State of Awareness - Jarvis ALERT
answer
full consciousness orientated to time, place, person: understands verbal and written words
question
Level of Consciousness - State of Awareness - Jarvis DISORIENTED
answer
not oriented to time, place & person
question
Level of Consciousness - State of Awareness - Jarvis CONFUSED
answer
reduced awareness, easily bewildered, poor memory misinterprets stimuli, impaired judgement
question
Level of Consciousness - State of Awareness - Jarvis SOMNOLENT
answer
(lethargy) Extreme drowsiness, but will respond to stimuli (must call them or touch them)
question
Level of Consciousness - State of Awareness - Jarvis SEMI-COMATOSE
answer
Can be aroused by extreme or repeated stimuli
question
Level of Consciousness - State of Awareness - Jarvis COMA
answer
will not respond to stimuli
question
Diagnostic Tests and procedures
answer
-CAT Scan of brain -Cerebral angiography -Electrolytes alterations -Elevations in taxic wast: Ammonia, BUN, Drugs -MRI
question
MRI: Magnetic Resonance Imaging
answer
*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
question
MRI: Magnetic Resonance Imaging (prep)
answer
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
question
CAT Scan:
answer
*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
question
PET Scan (Nuclear Imaging Studies)
answer
*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
question
Nursing Diagnoses (pg 1643 - Taylor) ACUTE CONFUSION
answer
abrupt onset of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness and/or sleep wake cycle
question
Nursing Diagnoses (pg 1643 - Taylor) CHRONIC CONFUSION
answer
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
question
Nursing Diagnoses (pg 1643 - Taylor) IMPAIRED MEMORY
answer
-The state in which an individual experiences fthe inability to remember or recall bits of information or behavior skills -Maybe pathophysiological or situational
question
Outcome Identification and Planning - For clients with impaired cognition (Focus of Goals)
answer
-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)
question
Communicating with a patient who is confused
answer
-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
question
Nursing Diagnosis (Taylor p - 1644) DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (specify)
answer
Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory
question
Nursing Diagnosis (Taylor p - 1644) DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (define)
answer
Change in the amount or patterning of incoming stimuli, accompanied by a diminished exaggerated, distorted or impaired response to such stimuli
question
DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (visual)
answer
R/T eye patches after surgery
question
DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (auditory)
answer
R/T effects of aging
question
DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (gustatory or olfactory)
answer
R/T chemotherapy)
question
DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (tactile)
answer
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
question
DISTURBED SENSORY PERCEPTION: EXCESS OR DEFICIT (isolation)
answer
R/T "I can't leave my room - everyone is in yellow gowns - I'm beginning to think they are laughing under those masks
question
Diagnosis used to describe persons whose perception has been changed by physiologic factors:
answer
Pain, Sleep deprivation, Immobility, Excessive or decreased meaningful stimuli
question
Diagnosis that can relate to sensory deprivation
answer
Chronic & acute confusion, impaired memory, Risk for Injury
question
Outcome Identification and Planning Goals: (disturbed sensory perception)
answer
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.
question
Improving Sensory Functioning
answer
-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
question
Implementation: Health Promotion - Sensory Functioning/Stimulation (client teaching) Taylor 1647
answer
-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
question
Preventing Sensory Alterations (table 43-1)
answer
-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
question
Caring for visually impaired patients
answer
-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
question
Caring for hearing - Impaired patients
answer
-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
question
Implementation (procedure preparation) - Sensation (sensory) Information
answer
-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
question
Implementation (procedure preparation) - Nurse-Client Interaction
answer
Orientation & re-orientation, develop therapeutic relationship, touch, explanations and teaching - use of self - spend appropriate time
question
Implementation (procedure preparation) - Nurse-Client Interaction (examples)
answer
-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
question
STIMULATION REDUCTION (to decrease sensory overload)
answer
-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
question
Implementation (Nursing Interventions for Altered Sensory Perception Function)
answer
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
question
Communicating With an Uncounscious Patient
answer
-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
question
Evaluation :Sample Goal
answer
Client will demonstrate understanding of contributing factors by reducing or eliminating them
question
Evaluation: Sample Outcome
answer
Client uses ear plugs and eye shades during sleep for the next 3 nights
question
Evaluation:
answer
Use previously developed goals and outcomes to evaluate client responses to nursing interventions
question
Rooting: Feeding reflex (Jarvis
answer
-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
question
Palmar Grasp
answer
-after 4 months of age it is abnormal -present your fingers to the little finger side of the baby's palms
question
Plantar Grasp
answer
-After 10 months of age it is abnormal -Touch the ball of the baby's foot with the thumb
question
Moro (the moro reflex)
answer
-After 4 months of age it is abnormal -Support the head & back then quickly lowre the infant
question
Moro
answer
-The arms & Legs first abduct & then adduct -The index finger & thumb go into a C position
question
Tonic neck Reflex - Fencing
answer
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
question
Babinski Reflex
answer
-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
question
Adult Babinski reflex
answer
GOOGLE IT (smile)
question
Sensory process involves what two components
answer
Sensory Reception and Sensory Perception
Get an explanation on any task
Get unstuck with the help of our AI assistant in seconds
New