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NURS 105 > Chapter 49 Sensory Alterations COPY > Flashcards

Chapter 49 Sensory Alterations COPY Flashcards

1
Q

5 Senses =

A 
Visual
Auditory
Tactile (touch)
Olfactory
Gustatory (taste)
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2
Q

Kinesthetic sense =

A

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

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3
Q

Stereognosis =

A

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

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4
Q

Meaningful stimuli allow

A

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

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5
Q

Normal sensation:

A

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

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6
Q

Sensory Alterations:

A

Sensory Deficits
Sensory Deprivation
Sensory Overload

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7
Q

Sensory Deficits:

A

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

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8
Q

Sensory Deprivation: 3 types

A
  1. Reduced sensory input (cognitive)
  2. Elimination of patterns or meaning from input (affective)
  3. Restrictive environments that produce monotony and boredom (perceptual)
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9
Q

Sensory stimulation must be of sufficient…

A

quality and quantity

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10
Q

Effects of sensory deprivation:

A

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

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11
Q

Sensory Overload =

A

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

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12
Q

Overload is

A

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

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13
Q

Common sensory deficits:

A 
Visual Deficits
Hearing
Balance
Taste
Neurological
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14
Q

Factors Influencing Sensory Function:

A 
Age
Meaningful Stimuli
Amount of Stimuli
Social Interaction
Environmental Factors
Cultural Factors
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15
Q

Infants and children are at risk due to

A

genetic, prenatal, and postnatal conditions

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16
Q

Hearing changes begin at age

A

30

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17
Q

Glustatory and Olfactory changes begin at age

A

50

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18
Q

Proprioceptive changes common after age

A

60

-increased difficulty with balance, spatial orientation, and coordination

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19
Q

Meaningful stimuli reduce the incidence of

A

sensory deprivation

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

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20
Q

Amount of Stimuli: excessive stimuli can cause

A

overload

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

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21
Q

Social Interaction:

A

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

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22
Q

Environmental factors:

A

A person’s occupation places put them at risk

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

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23
Q

Cultural Factors:

A

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

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24
Q

Assessment:

A 
Health promotion practices
Nursing history = look at risks
Review factors
Extent of lifestyle and self-care alterations
Patient's expectations
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25
Q

Persons at Risk:

A

Older adults - do not automatically assume

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26
Q

Otolarynogologist =

A

Doctors who treat serious hearing problems

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27
Q

During history it is useful to assess the patient’s

A

self rating for a sensory deficit

28
Q

Assessment also includes:

A 
Mental Status
Physical Assessment - 5 senses 
Ability to Perform Self-Care 
Health Promotion Habits
Environmental Hazards
Communication Methods
Social Support
Use of Assistive Devices
29
Q

HHIE-S =

A

Hearing Handicap Inventory for the Elderly

30
Q

MMSE =

A

Mini-Mental State Examination

31
Q

IADL:

A

Instrumental Activities of Daily Living

Ex. reading bills, writing checks, driving

32
Q

Common hazards include:

A 
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
33
Q

Look for safety hazards, this includes:

A

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?

34
Q

Patients with aphasia have varied degrees of

A

inability to speak, interpret, or understand language

35
Q

Expressive aphasia:

A

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

36
Q

Receptive aphasia:

A

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

37
Q

Global aphasia:

A

inability to understand language or communicate orally

38
Q

Some antibiotics are ototoxic which means it

A

permanently damages the auditory nerve

39
Q

Opioid analgesics, sedatives, and antidepressant medications often alter

A

perception of stimuli

40
Q

Nursing Diagnosis :

A 
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
41
Q

Goals and Outcomes:

A
  • 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.
42
Q

Health Promotion:

A 
Screening
Preventive Safety
Use of Assistive Devices
Promoting Meaningful Stimulation
Establishing Safe Env.
Communication
43
Q

Four recommended interventions for screening children for preventing blindness =

A
  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
44
Q

Refracted error =

A

common visual problem

Ex. near sightedness

45
Q

Trauma is a common cause of

A

blindness in children

46
Q

Promoting meaningful stimulation: Vision

A

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
47
Q

Promoting meaningful stimulation: Hearing

A
  • 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
48
Q

Conductive hearing loss=

A

excessive cerumen occluding the ear canal

49
Q

Promoting meaningful stimulation: Taste and Smell

A
  • Good oral hygiene
  • Differently textured food
  • Aromas - brewed coffee, garlic, baked breads
  • Avoid mixing foods
  • Cologne, deodorizer, flowers, etc.
50
Q

Promoting meaningful stimulation: Touch

A
  • Touch therapy

- Hair brushing, back rub, touching arms/shoulders

51
Q

Hyperesthesia:

A

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

52
Q

Environment: Adaptions for Visual Loss -Driving

A 
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
53
Q

Environment: Adaptions for Reduced Hearing

A

-Change env. sounds to amplified or lower pitched

54
Q

Environment: Adaptions for Reduced Olfaction

A
  • Use smoke detectors
  • checking ash trays
  • check food dates and appearance
55
Q

Environment: Adaptions to Reduced Tactile Sensation

A
  • use caution when using water bottles or heating pads

- Temp on home water heater, no higher than 120 F/ 48.8 C

56
Q

Acute Care:

A

Orientation to the Environment
Communication
Controlling Sensory Stimuli
Safety Measures

57
Q

Acute Care: Orientation to the Environment

A

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

58
Q

Patients confined to bed are at risk for

A

sensory deprivation

59
Q

The most common language disorders are

A

stroke and aphasia

60
Q

Reduce sensory overload by

A

organizing patient’s plan of care

  • rest periods
  • doing dressings, vitals, and bathing all at once reduces fatigue
61
Q

Safety measures: 3 suggestions for a sighted guide=

A
  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
62
Q

A sighted guide =

A

gives patients with visual issues confidence and ensures safe mobility

63
Q

Restorative and Continuing Care:

A

Maintaing healthy lifestyles
Understanding sensory loss
Socialization
Promoting Self Care

64
Q

The ability to perform self-care is essential for

A

self esteem

65
Q

Evaluation:

A

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

66
Q

If outcomes are not met, ask patient these questions:

A

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?

NURS 105 (10 decks)

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