Chapter 44 Sensory Functioning and Neuro Assessment Flashcards
describe the four conditions necessary that must be met in each sensory
stimulus: an agent, act or other influence capable of initiating a response by the nervous system.
A receptor :must receive the stimulus and convert it to a nerve impulse.
A nerve impulse :must be conducted along a nervous pathway from the receptor or sense organ to the brain
sensation:
The body’s basic orienting systems
kinesthetic and visceral senses
awareness of positioning of body parts and body movement; visceral pertains (to inner organs)
kinesthesia
The sensory experience consists of
reception: the process of receiving data about the external or internal environment through the senses; visual (vision) auditory(hearing) smell (olfactory), taste (gustatory).
perception: the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information.
The conscious process of selecting, organizing, and interpreting data from the senses into meaningful information
sensory perception
The process of receiving data about the external or internal environment through the senses; vision,hearing, smell, tast, and touch (tactile)
Sensory reception
explain the role of the reticular activating system in sensory experience
The RAS monitor and regulate incoming sensory stimuli, thus maintaining, enhancing or inhibiting cortical arousal.
Sensoristasis
The optimal arousal state of the RAS
Patient unable to rest because of machine beeping
The nurse would incorporate knowledge of sensory reception and perception. Patient is experiencing a continuous and large amount of auditory( beeping machine) visual( light in room and machine), tactile (being touched) and internal stimuli (pain, discomfort).
full consciousness; sleep-wake cycles present; quadriplegic, auditory and visual function preserved; emotion preserved.
Locked-in-syndrome
somnolence
extreme drowsiness, but will respond normally to stimuli
An unconscious states where a person can be aroused by extreme and/or repeated stimuli
stupor
vegetative state
cannot be aroused, sleep-wake cycles, postures or withdraws to noxious stimuli, occasional nonpurposeful movement, random smiling or grimacing.
A person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless.
sensory deprivation
Factors pacing a patient at high risk for sensory deprivation
environment with decreased or monotonous stimuli (patients on bed rest or in isolation).
impaired ability to receive environment stimuli (patient with vision hearing or tactile stimulation)
inability to process environmental stimuli (patients with spinal cord injuries or brain damage, confused/disoriented or drugs affecting the CNS).
Perceptual responses
result from inaccurate perception of sights, sounds, tastes, smells, body position, coordination and equilibrium (day-dreams, hallucinations).
inability to control the direction of thought content. Difficult with memory, problem solving, and task performance.
cognitive responses
Typically manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. Rapid mood changes also may occur.
emotional responses
condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.
sensory overload
factors that influence sensory overload.
age, culture, personality and lifestyle
sensory perception is influenced by
intensity, size, change or representation of stimuli, past experiences, knowledge, and attitudes.
patient in ICU exhibiting transient episodes of acute confusion. NI
be alert for factors contributing to sensory overload, such as bright lights, noises from the monitoring devices, frequent examinations. Also possible factors contributing to sensory deprivation (reduced auditory stimuli), restricted interacting with the environment.
how can the nurse help reduce disturbances in sensory perception
being sensitive to how visual stimuli, noise, touch are stimulating the patient.
paying attention to the patient’s need for privacy and for social interaction.
what is the max point for the glasgow coma scale
15
a patient is considered to be in a coma when the Glasgow coma scale is
less than 7
impaired or absent functioning in one or more sense
sensory deficit
Examples of sensory deficit
impaired sight and hearing, altered taste, numbness, paralysis, tactile perception and impaired kinesthetic sense
NI visual stimulation
colorful sheets, pajamas, robes, uniform tops for the nurse, face to face contact, clocks,calendars, wristwatches, flowers, greeting cards.
NI auditory stimulation
call person by name, use conversation that communicates caring as well as orients patient, reading to the patient, television, radio, ipod.
IN gustatory and olfactory stimulation
oral hygiene and properly fitting dentures, food of different textures, colors, temperatures served.
smelling food before eating and recalling pleasurable aromas from the past.
seasoning foods or having favorite foods brought from home (order)
NI tactile stimulation
backrubs and foot soaks, turning and repositioning, passive ROM, hair brushing, combing, washing, hugs, and touching or arms or shoulders.
NI cognitive input
orient patient to environment
encourage patient participation in self-care
discuss current events or patient’s occupation, hobbies or interests.
reinforce reality without arguing.
NI emotional imput
encourage patient to share fears, concerns and perceptions
reassure patient that illusions and misperceptions do occur with sensory deprivation.
incorporate culturally assistive, supportive, facilitative acts into care.
factors affecting states of awareness
inadequate blood flow altered nutrition and metabolism fluid and electrolyte imbalances infectious processes inadequate sleep and rest inability to organize incoming stimuli dementia sensory alterations and sensory deficits
NI for patient with sensory overload
provide a consistent, predictable pattern of stimulation to help patient develop a sense of control over the environment.
offer simple explanations before procedures, test and examinations.
establish a schedule with the patient for routine care.
speak calmly and move slowly, communicate confidence.
explore with the patient what stimuli are most distressing and develop a plan to reduce or eliminate.
be careful not to cause sensory deprivation.
identify and, whenever possible, eliminate culturally inappropriate stimuli
The deteriorating of nerves and structures within the inner ear. occurs as an individual ages.
Presbycusis
factors that place a patient at high risk for sensory deprivation
decrease environmental stimuli
impaired ability to receive environmental stimuli
inability to process environmental stimuli
manifestations of sensory deprivation
physical behaviors escape behaviors change in perception changes in cognitive behaviors changes in affective behaviors
Effects of sensory deprivation
perceptual responses
cognitive responses
emotional responses
sensory overload
increase internal stimuli, external stimuli
inability perceptually to disregard or selectively ignore some stimuli
communicating with unconscious patient
be careful what is said in their presence (hearing is the last sense lost).
assume the person can hear you.
speak to the person before touching.
keep surrounding noises down to a minimum.
the term used to describe the sense, at a subconscious level, or the movements and position of the body and especially its limbs, independent of vision
proprioception
The sense that perceives the solidity of objects and their size,shape and texture.
stereognosis
making up answers unrelated to facts
confabulation
involuntary repetitions of words spoken by another person
Echolalia
Mini-mental state Exam (MMSE)
use to diagnose dementia or delirium
tests orientations,short-term memory and attention, ability to perform calculations, language and construction
cannot be used if patient cannot read, write or speak english
loss or impairment of the power to use or comprehend words usually resulting from brain damage
Aphasia
loss of or deficiency in the power to use or understand language as a result of injury to a disease or the brain
dysphasia
The patient knows what to say, yet has difficulty communicating
Expressive aphasia
patient have difficulty understanding words
receptive aphasia
global aphasia
difficulty with using and understanding words
