Ch 44 Sensory Stimulation/ Neuro Flashcards
What is “Presbycusis”?
Hearing decrease due to age (high tone + deterioration)
What is “Presbyopia”?
Visual impairment due to age.
What is R.A.S?
The reticular activating system (RAS) which monitors, regulates incoming sensory stimuli.
What is “Stereognosis”?
Sense that perceives the solidity of objects and their size, shape and texture.
- First sense to go with Alzheimer’s disease
What is “Kinesthesia”?
Refers to the awareness of positioning of body parts and body movement.
What is “Proprioception”?
Subconscious visual of position of body + limbs even blind-folded.
What is the “Locked-in Syndrome”?
It is a full consciousness, sleep wake cycle, quadriplegic, INTACT auditory, visual and emotional.
What defines a vegetative stage?
Patient cannot be aroused, posture withdrawals, random smile, grimace and only respond to noxious stimuli.
What are the different states of unconsciousness?
- Asleep
- Lethargic = very sleepy
- Stupor = can be aroused by extreme stimuli
- Coma = cannot be aroused
What are the different states of consciousness?
- Delirium =abrupt onset
- Dementia = not reversible
- Confusion = sign of electrolyte imbalance and is temporary
- Somnolence = oriented but sleepy
- Chronic vegetative state
What is “Sensory Deprivation”?
- decrease input
- monotonous input, meaningless and unpatterned
–> RAS is no longer able to project a normal level of activation to the brain.
What is “Sensory overload”?
Condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.
–> feeling “out of control”
What is “Sensory deficit”?
Impaired or absent functioning in one or more senses.
Ex: impaired sight + hearing, altered taste, numbness and paralysis.
What are signs of “Sensory deprivation”?
- Physical behaviors
- Escape behaviors
- Changes in perception = unusual body sensations
- Changes in cognitive behaviors = inability to concentrate
- Changes in affective behaviors = crying, increase irritability, panic.
What can the nurse do to assist a patient suffering from “Sensory overload”?
- Orient the patient to person, place, and time
- Decrease environment noise
- Encourage patient to participate in nursing care
What interventions can the nurse implement during “Sensory overload”?
- Identify distressing stimuli
- Reduce and eliminate stimuli (w/out causing sensory deprivation!)
- Provide periods of rest
- Elderly and CVA patients often experience confusion or agitation
How does the nurse appropriately communicates with a confused patient?
- Orient frequently
- Speak calmly, simply and directly
- Frequent face to face contact
- Allow adequate time to process
- Emphasize patient strength
- Reinforce reality
How does the nurse communicate with an unconscious patient?
- Be careful what is said in their presence
- Assume the person can hear you
- Speak to the person before touching
- Keep surrounding noises down to a minimum
What are the different types of language dysfunctions?
1) Aphasia = loss to comprehend
2) Dysphasia = impairment to comprehend language
3) Expressive Aphasia = difficulty to express speech
4) Receptive Aphasia = language content, trouble processing + making sense
5) Global Aphasia = impairment to comprehend + express –> usually non-verbal
What are the S x S of Hypoglycemia?
- Hunger
- Shakiness
- Nervousness
- Sweating
- Dizziness
- Confusion
- Anxiety
- Weakness
What are the S x S of Hyperglycemia?
- ⬆ thirst
- Headaches
- Difficulty concentrating
- Blurred vision
- Fatigue
- Frequent urination
What are the 3 components of the Glasgow Coma Scale?
1) Eye Opening
2) Motor Response
3) Verbal Response
How is “Eye Opening” scored on the Glasgow Coma Scale?
4 = Spontaneous 3 = To verbal command 2 = To pain 1 = No response
How is “Motor Response” scored on the Glasgow Coma Scale?
6 = To verbal command 5 = To localized pain 4 = Flexes/withdraws 3 = Flexes abnormally 2 = Extends abnormally 1 = No response
How is “Verbal Response” scored on the Glasgow Coma Scale?
5 = Oriented/Talks 4 = Disoriented/Talks 3 = Inappropriate words 2 = Incomprehensible sounds 1 = No response
What score on the Glasgow Coma Scale defines a state of coma?
A score of 7 or less.
Name 8 factors that can affect a person’s state of awareness?
1) Inadequate blood flow
2) Fluid and electrolyte imbalance
3) Altered nutrition and metabolism
4) Infectious process
5) Inadequate sleep and rest
When assessing swallowing capabilities, which cranial nerve is being tested?
Cranial nerve X = Vagus nerve
Cerebellar function includes what human responses and how can you assess this function?
1) Cerebellar response includes balance, coordination and fine motor skills.
2) Cerebellar function can be assessed by having the pt touch each finger to their thumb, also you can assess for ataxia.
What is Ataxia and what 2 tests can be used to assess for it?
1) Ataxia - Loss of voluntary control of muscles which is controlled by the cerebellum.
2) RN can use the pronator drift or Ronburg test to assess for it.
