Chapter 49 Sensory Alterations

Question 1

5 Senses =

Answer 1

Visual
Auditory
Tactile (touch)
Olfactory
Gustatory (taste)

Question 2

Kinesthetic sense =

Answer 2

enables a person to be aware of the position and movement of body parts without seeing them

Question 3

Stereognosis =

Answer 3

sense that allows a person to recognize the size, shape, and texture of an object

Question 4

Meaningful stimuli allow

Answer 4

a person to learn about the environment and is necessary for healthy functioning and normal development.

Question 5

Normal sensation:

Answer 5

continually receives thousands of bits of info from sensory nerve organs, relays the info through appreciate channels, and integrates the info into a meaningful response

Question 6

Sensory Alterations:

Answer 6

Sensory Deficits
Sensory Deprivation
Sensory Overload

Question 7

Sensory Deficits:

Answer 7

a deficit in the normal function of sensory reception and perception
-A person loses a sense of self with impaired senses.

Question 8

Sensory Deprivation: 3 types

Answer 8

1. Reduced sensory input (cognitive)
2. Elimination of patterns or meaning from input (affective)
3. Restrictive environments that produce monotony and boredom (perceptual)

Question 9

Sensory stimulation must be of sufficient…

Answer 9

quality and quantity

Question 10

Effects of sensory deprivation:

Answer 10

Psychological illness, confusion, severe electrolyte imbalance, or influence of psychotropic drugs

Question 11

Sensory Overload =

Answer 11

When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli

Question 12

Overload is

Answer 12

individualized based on level of fatigue, attitude, emotional and physical well-being.

Question 13

Common sensory deficits:

Answer 13

Visual Deficits
Hearing
Balance
Taste
Neurological

Question 14

Factors Influencing Sensory Function:

Answer 14

Age
Meaningful Stimuli
Amount of Stimuli
Social Interaction
Environmental Factors
Cultural Factors

Question 15

Infants and children are at risk due to

Answer 15

genetic, prenatal, and postnatal conditions

Question 16

Hearing changes begin at age

Answer 16

30

Question 17

Glustatory and Olfactory changes begin at age

Answer 17

50

Question 18

Proprioceptive changes common after age

Answer 18

60

-increased difficulty with balance, spatial orientation, and coordination

Question 19

Meaningful stimuli reduce the incidence of

Answer 19

sensory deprivation

Ex. pets, music, TV, pictures, calendar, clock = same for home and health care

Question 20

Amount of Stimuli: excessive stimuli can cause

Answer 20

overload

Ex. patient is in pain or restricted by a cast, in a room near repetitive or loud noises

Question 21

Social Interaction:

Answer 21

absence of visitors/conversation = isolation, loneliness, anxiety, and depression

Question 22

Environmental factors:

Answer 22

A person’s occupation places put them at risk

Ex. Factory = high noise levels, repetitive wrist movement = pressure on median nerve

Question 23

Cultural Factors:

Answer 23

African ethnicity perform significantly worse than European descent on tests of visual function

Question 24

Assessment:

Answer 24

Health promotion practices
Nursing history = look at risks
Review factors
Extent of lifestyle and self-care alterations
Patient's expectations

Question 25

Persons at Risk:

Answer 25

Older adults - do not automatically assume

Question 26

Otolarynogologist =

Answer 26

Doctors who treat serious hearing problems

Question 27

During history it is useful to assess the patient's

Answer 27

self rating for a sensory deficit

Question 28

Assessment also includes:

Answer 28

``` Mental Status Physical Assessment - 5 senses Ability to Perform Self-Care Health Promotion Habits Environmental Hazards Communication Methods Social Support Use of Assistive Devices ```

Question 29

HHIE-S =

Answer 29

Hearing Handicap Inventory for the Elderly

Question 30

MMSE =

Answer 30

Mini-Mental State Examination

Question 31

IADL:

Answer 31

Instrumental Activities of Daily Living | Ex. reading bills, writing checks, driving

Question 32

Common hazards include:

Answer 32

``` Uneven walkways Extension cords in walking route Loose area rugs BRs w/o bath grab bars Water faucets unmarked H or C Unlit stairways, lack of rails ```

Question 33

Look for safety hazards, this includes:

Answer 33

Call light w/in reach? Are IV poles on wheels and easy to move? Are IV pumps positioned so a patient can rise from a bed or chair easily?

Question 34

Patients with aphasia have varied degrees of

Answer 34

inability to speak, interpret, or understand language

Question 35

Expressive aphasia:

Answer 35

motor type, inability to name common objects or express simple ideas in words or writing

Question 36

Receptive aphasia:

Answer 36

inability to understand written or spoken language - a patient is able to understand words but unable to understand questions or comments of others

Question 37

Global aphasia:

Answer 37

inability to understand language or communicate orally

Question 38

Some antibiotics are ototoxic which means it

Answer 38

permanently damages the auditory nerve

Question 39

Opioid analgesics, sedatives, and antidepressant medications often alter

Answer 39

perception of stimuli

Question 40

Nursing Diagnosis :

Answer 40

``` Risk-prone health behavior Impaired verbal communication Risk for injury Impaired physical mobility Bathing self-care deficit Dressing self-care deficit Toileting self-care deficit Situational low self-esteem Risk for falls Social Isolation ```

Question 41

Goals and Outcomes:

Answer 41

- The patient and family will report using communication to send and receive messages in 2 days. - The patient will successfully demonstrate correct technique for cleaning a hearing aid within 1 week. - The patient will self-report improved hearing acuity.

Question 42

Health Promotion:

Answer 42

``` Screening Preventive Safety Use of Assistive Devices Promoting Meaningful Stimulation Establishing Safe Env. Communication ```

Question 43

Four recommended interventions for screening children for preventing blindness =

Answer 43

1. Screening for rubella, syphilis, chlamydia, & gonorrhea in women who are considering pregnancy 2. Advocating adequate prenatal care to prevent premature birth (excessive O2) 3. Administering eye prophylaxis in the form of erythromycin ointment apprx. 1 hr after infants birth 4. Periodic screening of all children

Question 44

Refracted error =

Answer 44

common visual problem | Ex. near sightedness

Question 45

Trauma is a common cause of

Answer 45

blindness in children

Question 46

Promoting meaningful stimulation: Vision

Answer 46

Sensitive ti glare - Suggest use of amber or yellow shaded lenses and shades or blinds on windows to minimize glare - Include warm incandescent lighting and colors with shard contrast and intensity

Question 47

Promoting meaningful stimulation: Hearing

Answer 47

- Recorded music can be heard in low-frequency cycles - Cerumen thickens and builds up in ear - inserting warm mineral oil plus 3% hydrogen peroxide in warm water removes this

Question 48

Conductive hearing loss=

Answer 48

excessive cerumen occluding the ear canal

Question 49

Promoting meaningful stimulation: Taste and Smell

Answer 49

- Good oral hygiene - Differently textured food - Aromas - brewed coffee, garlic, baked breads - Avoid mixing foods - Cologne, deodorizer, flowers, etc.

Question 50

Promoting meaningful stimulation: Touch

Answer 50

- Touch therapy | - Hair brushing, back rub, touching arms/shoulders

Question 51

Hyperesthesia:

Answer 51

overly sensitive to tactile stimuli -keep bed linens loose dorsiflex= relieve nerve pressure

Question 52

Environment: Adaptions for Visual Loss -Driving

Answer 52

``` Do not drive during rush hour Avoid interstate highways Drive defensively Use rear view and side view mirrors when changing lanes Avoid driving at night Go slow but not too slow Car in good conditions Carry a preprogrammed cell phone ```

Question 53

Environment: Adaptions for Reduced Hearing

Answer 53

-Change env. sounds to amplified or lower pitched

Question 54

Environment: Adaptions for Reduced Olfaction

Answer 54

- Use smoke detectors - checking ash trays - check food dates and appearance

Question 55

Environment: Adaptions to Reduced Tactile Sensation

Answer 55

- use caution when using water bottles or heating pads | - Temp on home water heater, no higher than 120 F/ 48.8 C

Question 56

Acute Care:

Answer 56

Orientation to the Environment Communication Controlling Sensory Stimuli Safety Measures

Question 57

Acute Care: Orientation to the Environment

Answer 57

-Provide reorientation: name tags are visible, addressing patient by name, explaining patient where they are, cues for time or location

Question 58

Patients confined to bed are at risk for

Answer 58

sensory deprivation

Question 59

The most common language disorders are

Answer 59

stroke and aphasia

Question 60

Reduce sensory overload by

Answer 60

organizing patient's plan of care - rest periods - doing dressings, vitals, and bathing all at once reduces fatigue

Question 61

Safety measures: 3 suggestions for a sighted guide=

Answer 61

1. Ask the patient if they want a sighted guide. Instruct patient to grasp your arm just above the elbow 2. Go one-half step ahead and slightly to the side of the person. The shoulder of the person need to be directly behind your shoulder, If patient is frail, place their hand on your forearm. 3. Relax and walk at a comfy pace. Warn patient when you approach doorways or narrow spaces

Question 62

A sighted guide =

Answer 62

gives patients with visual issues confidence and ensures safe mobility

Question 63

Restorative and Continuing Care:

Answer 63

Maintaing healthy lifestyles Understanding sensory loss Socialization Promoting Self Care

Question 64

The ability to perform self-care is essential for

Answer 64

self esteem

Question 65

Evaluation:

Answer 65

Reassess signs and symptoms of sensory alteration Determine the patient's ability to remain functional within the home or health care environment Ask patient to demonstrate new skills Ask if expectations are met

Question 66

If outcomes are not met, ask patient these questions:

Answer 66

How often do you wear your hearing aids/corrective lens? Are you able to participate in a small group discussion? Are you able to read the newspaper without squinting?