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NRSE 260 > Exam 2 > Flashcards

Exam 2 Flashcards

1
Q

What is mobility vs immobility?

A

mobility: person ability to move about freely
Immobility: inability to move freely
Bed Rest (3% loss of muscle a day)

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2
Q

What are factors that influence mobility?

A

developmental considerations

physical health
—> Muscular, skeletal, Nervous system problems
——> problems involving other body system

Mental Health
Lifestyle
Attitude and values
Fatigue + stress
external factors

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3
Q

Benefits of exercise?

A

controls weight

reduced risk of cardiovascular disease

reduced risk of type 2 diabetes and metabolic syndrome

reduced risk of some cancers (colon, breast, endometrial, lung)

strengthens bones and muscles (lower hip fx, improves arthritis)

improves mental health and mood

improves ability to do daily activities and prevents falls in older adults

increases chance of living longer

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4
Q

How does immobility affect the cardiovascular system?

A

orthostatic hypotension (drop of BP <20mmHg systolic or 10mmHg diastolic)

less fluid volume in circulatory system

increased cardiac workload

stasis of blood in legs

thrombus formation

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5
Q

How does immobility affect the respiratory system?

A

decreased respiratory movement resulting in decreased oxygenation and carbon dioxide exchange

stasis of secretions and decreased respiratory muscle

decreased ability to deep breath and cough

immobile patients are at high risk for developing pulmonary complications

—-> atelectasis: incomplete expansion or collapse of lung tissue
—–> hypostatic pneumonia

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6
Q

How does immobility affect Musculoskeletal system?

A

Muscle:
Lean body mass loss
muscle weakness/atrophy
decreased stability and balance

Skeletal:
disuse osteoporosis
pathological fractures
joint contracture
foot drop

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7
Q

How does immobility affect metabolic?

A

altered endocrine metabolism

decreased metabolic rate

negative nitrogen balance: weight loss, decreased muscle mass, and weakness

calcium reabsorption from bones

decreased urinary elimination of calcium resulting in hypercalcemia

alters protein, carbohydrate, fat metabolism

decreased protein resulting in loss of muscle

decreased appetite with altered nutritional intake

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8
Q

How does immobility affect the GI system?

A

decreased peristalsis

decreased fluid intake

constipation, then fecal impaction, then pseudodiarrhea

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9
Q

How does immobility affect urinary elimination?

A

urinary stasis

renal calculi from hypercalcemia

urinary tract infections from decreased fluid intake, poor perineal hygiene and indwelling urinary catheters

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10
Q

How does immobility affect the integumentary system?

A

pressure injury
—> caused by increased pressure on skin, aggravated by metabolic changes
—> inflammation
—-> decreased circulation to tissue causing ischemia

older adults at greater risk

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11
Q

What effects does immobility have on psychsocial?

A

emotional and behavioral responses
—–> hostility, giddiness, fear, anxiety, passivity

sensory alterations:
—> altered sleep patterns

changes in coping:
—> depression, sadness, dejection

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12
Q

What are complications of immobility?

A

Thrombophlebitis, Deep Vein thrombosis:
—> inflammation of the vein (usually in lower extremities) that result in clot formation

Manifestations: pain, edema, warmth, and erythema at site

Assess: measure calf and thighs daily

Nursing actions: notify MD, elevate leg, avoid pressure, do not massage, anticipate giving anticogaulents

Pulmonary Embolism:
occlusion of blood flow to one or more pulmonary arteries by clot: often orgininates in venous system of lower leg

Manifestations: SOB, chest pain, hemopysis, decreased BP and rapid pulse

Nursing Action: notify MD, position pt in high fowlers, obtain SpO2, prepare to obtain blood gases, monitor frequent VS, prepare to give thrombolytic or anticogulants

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13
Q

How to Assess Pressure Injury?

A

Skin: breakdown, warmth, change in color, skin turgor, observe bony prominences, bradden scale, observe for incontience

PAY ATTENTION TO:
skin beneath and around devices or compression stocking

bony prominences (heel, sacrum, occiput)

skin to skin areas ( penis, back of knee, inner thigh, butt)

all areas where patients lack sensations to feel pain/ had breakdown previously

if patient is getting epidural/spinal cord medication

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14
Q

How to access respiratory system?

A

chest wall movement +rate,

ausculatate (crackles, wheeze, diminished sounds)

assess cough

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15
Q

How to assess Cardiovascular system?

A

orthostatic blood pressure (lying, sitting to standing 1 + 3 minutes)

pulse

s/s dizziness

palpate apical and peripheral pulses

auscultate heart sounds

assess edema

check skin for s/s DVT

measure calf and thigh

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16
Q

How to assess elimination?

A

assess intake and output

bladder for distention

urine color + amount

clarity

frequency

auscultate bowel sounds

observe feces for color, amount, frequency and consistency

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17
Q

How to assess metabolic?

A

height + weight + skinfolds

intake and output

food intake

urinary + bowel elimination

wound healing

ausculutate bowel sounds

skin turgor

review labs (electrolytes, serum total protein, and BUN)

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18
Q

How to assess musculoskeletal system?

A

ROM capability

muscle tone + mass

observe for contractures

gait

alignment

endurance

monitor nutritional status of calcium

monitor use of assistive devices to assist ADLs

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19
Q

How to assess pyschosocial?

A

emotional status

mental status

behavior + decision making

mobility

sleep-wake pattern

coping skill

ADL

family support

social activites

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20
Q

What are variable that lead to back injury in health care workers?

A

uncoordinated lift

manual lifting and transferring of patients without assistive device

lifting when fatigued or after recent back injury recovery

repetitive movements such as lifting, transferring, and repositioning patient

standing for long period of time

tranferring patient

repetative task

transferring/repositioning uncooperative or confused patient

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21
Q

What are proper body mechanics?

A

use of proper body movement in daily activites

prevention and correction of problems associated with posture

enhancement of coordination and endurance

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22
Q

Good principles of body mechanics:

A

maintain a wide, stable base with feet

put bed at correct height (waist level when providing care; hip level when moving patient)

try to keep patient as close to you body as possible to minimize reaching

use big muscles rather than small muscles (legs not back)

know limits and seek assistance

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23
Q

Walkers:

A

WWAL: walker with affected leg

patient holds the handgrips on the upper bars takes a step moves walker forward and take another step

nurse on weak side

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24
Q

Canes:

A

COAL: cane opposite affected leg

keep cane on stronger side of body

support body weight on both legs

place cane forward 6-10 inches

move weaker leg forward with cane

advance stronger leg past cane

nurse on weak side

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25
Q

Crutches:

A

measuring for crutches
—> 2-3 fingers width- prevents nerve damage b/w axillae + rest pad

hand grips should be even with hip line

elbows flexed 30 degrees

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26
Q

Crutch Gait:

A

two point gait: partial wt. bearing both feet, move crutches while moving opposite leg (move RC and LF move together, then LC and RF together)

three point gait: bear wt. on one foot, using both crutches, move both crutch and injured leg together, then move injured leg

four point gait: bear wt. both legs (move RC then LF then LC then RF)

swing to gait: swing to crutch

swing through gait: swing past crutches

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27
Q

Health promotion:

A

prevention of work related musculoskeletal injury

promote activites and exercise

improve bone health in patients with osteoporosis

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28
Q

Implementation in acute care: metabolic

A

provide high-protein, high calories diet with vitamin B and C supplement

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29
Q

Implementation in acute care: Respiratory

A

repostion every 1-2 hours

cough and deep breaths every 1-2 hours

incentive spirometer while awake

yawn

provide chest physiotherapy

suction if unable to expectorate secretions

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30
Q

Implementation: cardiovascular

A

progress from bed to chair to ambulate

change postion as often as possible

reducing orthostatic hypotension (move pt gradually)

reducing cardiac workload: avoid valsalva maneuver)

give stool softner

preventing thrombus formation

sequential compression devices (anti-embolism hose stocking, leg exercise)

isometric exercise to increase activity tolerance

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31
Q

Safety Guidelines for Nursing Skill:

A

comunicate clearly with members of health care system

assess and incorporate the patient priorites of care and preferences

use best evidence when making decisions about pt care

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32
Q

Implementation: psychosocial

A

orient to time, person, place

develop schedule of therapies

alert roommate

involve in daily care, provide stimuli

hygiene

refer to psych, spiritual, social worker if not coping well

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33
Q

Implementation: integumentary

A

repositon every 1-2 hours; if mobile have them turn every 15 minutes

use corrective devices and therpeutic bed

provide skin care

monitor nutritonal intake

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34
Q

Implmentation: Elimination

A

provide adequate hydration

serve diet rich in fiber, fruit, veggie, fluid

stool softener, laxative, enema

perineal care

assess for paralytic ileus

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35
Q

Implemenation: Musculoskeletal

A

prevent muscle atrophy and joint contractures

change patient position every 2 hours

passive ROM

CPM (continuous passive motion)

Active ROM

cluster care to promote a proper sleep- wake cycle

physical therapy

assist with ambulation

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36
Q

Equipment and assistive devices:

A

gait belt

stand-assist and repositioning aid

lateral assist devices

friction- reducing sheets

mechanical lateral assist device

transfer chair

powered stand assist and repositoning lift

powered full body lift

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37
Q

Moving patients:

A

safety is first priority

ask pt to help as much as possible

determine if pt comprehends what is expected

determine patient comfort level

determine if you need assistance in moving patient

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38
Q

Positioning patient:

A

pillows

mattresses

adjustable bed

bed side rails

trapeze bar

additional equipment

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39
Q

Gait belt:

A

helps prevent falls

use when unsteady or poor balance

helps move patient with walking, moving from bed to chair or from sitting to standing

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40
Q

Polyuria

A

greater than 2000 mL/ day

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41
Q

Oliguria

A

less than 400 mL/day

42
Q

Anuria:

A

total suppression of urine less than 150 mL/per day

43
Q

Dysuria

A

painful urination

44
Q

Nocturia

A

needing to use bathroom during the night

45
Q

Postvoid retention:

A

holding urine after voiding

46
Q

What Urine Volume is a cause of concern?

A

less than 30 mL/hr for more than 2 hours

47
Q

What are developmental concerns with urination?

A

Children: voluntary control 18-24 months; toilet training 2-3 years, enuresis

Prostate enlargement: 40 years old urinary frequency, hesitation, retention, incontience, and UTI

Pregnancy: less space with growing fetus, increase circulatory volume, increase renal output, relaxation of sphinctor, greater risk of UTI

Childbirth: gravity weakens pelvic floor, risk of prolapse of bladder, stress incontience: kegel exercise

post menopausel: decreased tone due to low estrogen levels, urgency, stress incontience, UTI

Older adults: loss of muscle tone in bladder: frequency, ineffective emptying, residual urine, nocturia, neuromuscular problem

48
Q

Other factors in urinary eliminination:

A

conditions: acute and chronic disorders: poor abdominal and pelvic muscle tone, spinal cord issue, pregnancy (kidney disease)

Immobility: incontience can occur as result of impaired mobility due to difficult transferring to bathroom

surgical procedure:
anesthesia + opioid analgesics result in decreased urine output
abdominal surgery creating obstructive edema and inflammation

pain:
suppresion of urge to urinate
obstruction in ureter
arthritis or painful joints lead to immbility and delayed urination

Psychofactors:
emotional stress and anxiety
having to use public toilets or bedpans
lack of privacy during hospital stay
not having enough time to urinate

Fluid intake and output:

Medication:
diuretic: prevent reabsorption of water + certain electrolytes
antihistamine + anticholinergic: urinary retention
analesics + tranqulilzers: suppress CNS, dimish effectiveness of reflex
medcation can cause change in urine color
Nephrotoxic meds ( chemo)

49
Q

What are disease associated with renal problems:

A

congential urinary tract abnormalites

polycystic kidney disease

urinary tract infection

urinary calculi

hypertension

diabetes

gout

connective tissue disorders

50
Q

What is urinary rentention?

A

an accumulation of urine due to inability of bladder to empty

51
Q

Safety Guideline for urinary elimination:

A

Follow principles of surgical and medical asepsis as indicted

identify patient at risk for latex allergies

52
Q

Incontinence prevention and treatment:

A

frequent check for incontience episodes

turning and repositoning schedule

no rinse skin cleansers are preferable to soap and water

avoid excessive fricition or scrubbing

low air loss/pressure distrubution mattress

change cloth pads frequently

limit disposable brief

moisture barrier creams

skin protectant spray

53
Q

continuing + restorative care: urinary elimination

A

behavioral therapy

pelvic floor muscle training (kegals)

bladder retraining: increase uriniation intervals till no incontinence episodes

toileting schedule (q-2-3 hours or before and after meals)

intermittent catherterization (drain 300-400 mL of urine on schedule)

skin care

foods and fluids: avoid artifitcal sweetner, spicy foods, citrus products, caffeine)

increase fluid intake during daytime and decrease fluid intake prior to bedtime

54
Q

types of urinary incontinence;

A

Overflow: bladder is full and urine leaks, drippling of urine, due to blockage of urethra

Urge/urgency: overactive bladder urgency (“gotta go”) brain telling bladder is full, overactive detrusor muscle with increased bladder pressure

Stress: weak pelvic muscles let urine escape with increased abdominal pressure associated with effort or exertion, sneezing, or coughing, pregnancy, bending, walking

55
Q

Urinary Tract Infections: Risk factors

A

Risk factors:
sexually active women
women who use diaphragm for contraception
postmenopausal women,
individuals with diabetes,
uncircumcised patients,
use of indwelling catheters,
older adults

56
Q

Urinary Tract Infections: Signs + symptoms

A

frequency,
urgency,
nocturia,
burning and pain (dysuria)
irritation of the bladder (cysitis)
hematuria
flank pain
suprapubic tenderness
fever
foul smelling cloudy urine

57
Q

Urinary tract infections: Older adults

A

increased confusion
recent falls
new onset incontience
anorexia
fever
tacycardia
hypotension

58
Q

Urinary diversions:

A

are created to reroute urine
can be temporary or permanent
continent or incontinent

Types:
ureterostomy (ileal conduit)

nephrostomy

indiana pouch

neobladder

59
Q

Assessment: Nursing history: urinary elimination

A

fluid intake amount

pattern of urination (frequency and times of day, normal volume with voiding, history of recent change)

symptoms of urinary alterations

factors affecting ability to urinate normally: medical conditions, medications

past history of problem

adequacy of self care behaviors

urinary diversion

60
Q

Physical examination: Urinary elimination

A

bladder if indicted + urethral meatus: assessment of skin integrity and hydration; exam of urine

Kidney: tenderness, auscultate to detect renal artery bruit

bladder: palpate, percussion, bedside scanner
—> external genitalia, urethral meatus: identify infection, inflammation, discharge, lesion

catheter insertion: for inflammation or breakdown

perineal skin

skin exposed to moisture

61
Q

Assessment of Urine:

A

intake and output

characteristic of urine:
color
clarity
odor
pH
specific gravity
constituents
UTI: + nitrates, leukocyte esterase (WBC) bacteria

62
Q

Urine specimen:

A

urinalysis: random nonsterile specimen

clean catch midstream for culture and sensitivity (C&S)

catheter: sterile urine specimen for C&S

timed urine specimen

point of care testing

63
Q

Promoting Normal Micturition:

A

maintaining normal voiding habits

strengthening muscle tone (kegel exercise)

assisting with toileting

privacy important

close door and bedside curtain

mask sounds with running water

ask family to leave room

respond quickly to assistance

maintaining adequate fluid intake: helps flush solutes or particles that collect in urinary system and decrease bladder irritability

promoting complete bladder emptying: sitting for women and standing for me

preventing infection: increase fluid intake, perineal hygiene and voiding at regular intervals

64
Q

Measure Urine Output:

A

ask patient to void into bedpan, urinal, specimen container in bed or bathroom

put on gloves: pour urine into appropraite measuring device

place calibrated container on flat surface and read at eye level

note amount of urine voided and record on appropriate form

discard urine in toilet unless specimen is needed, if specimen is required pour urine into appropriate specimen container

65
Q

Types of catheters:

A

Foley ( baloon) catheter: indwelling catheter

Straight catheter: without ballon are used for clean intermittent catheterization

triple lumen (three-way): used to instill medications or continous bladder irrigation

coude (curved) catheter: semirigid curved tip for prostate enlargement

66
Q

Urinary diversions: care

A

changing pouch:
gently cleanse the skin surrounding the stoma
measure stoma and cut opening in pouch
remove the adhesive backing and apply pouch
press firmly into place over stoma
observe appearance of stoma and surrounding skin
change every 4-6 days

continent diversion: catheretize 4-6 times a day

67
Q

Routine catheter care:

A

use soap and water at insertion site

routine perineal care with soap and water at least q 8 hours and after defectation

empty drainage bag when half full or depending on orders

68
Q

Catheter drainage system:

A

always hang bag below bladder on bedframe

bag should never touch floor

assess for cloting or kinks in tube

69
Q

Variables that influence bowel elimination:

A

developmental considerations (Age)

food and fluid

psychological factors

pathologic conditions

surgery + anesthesia

diagnostic test: colonoscopy, endoscopy

lifestyle

physical activity

personal habits

pain

pregnancy

medications

70
Q

Constipation:

A

a symptom, not disease

infrequent stool and/or hard, dry small stools that are difficult to eliminate

71
Q

Diarrhea

A

increase in number of stools and passage of liquid, unformed feces

72
Q

Flatulence

A

accumulation of gas in intestines causing walls to stretch

73
Q

Impaction

A

results from unrelieved constipation; a collection of hardened feces wedged in rectum that person cannot expel

74
Q

incontinence

A

inability to control passage of feces and gas into anus

75
Q

Hemorrhoids

A

dilated, engorged veins in lining of rectum

76
Q

Nursing History: Bowel Elimination

A

What patient describes as normal vs abnormal is often different and conditions that tend to promote normal elimination

identifying normal and abnormal patterns, habits, and that patient perception of normal and abnormal with regard to bowel eliminiation allows you to accurately determine a patient problem

recent changes in type, color, smell of stool: black tarry stool could be a sign of internal bleeding in GI tract or just from iron supplement

77
Q

Bowel elimination assessment:

A

elimination pattern

stool characteristic

routines

bowel diversion

appetite changes

diet history

daily fluid intake

surgery/illness

medications

emotional state

exercise

pain/discomfort

social history

mobility and dexterity

78
Q

Physical assessment of anus + rectum

A

Inspection + palpation:
lesion, ulcers, fissure (linear break on margin of anus), inflammation, external hemorrhoids

ask the patient to bear down as though having a bowel movement: assess for appearance of internal hemorrhoids or fissures and fecal masses

inspect perineal area for skin irritation secondary to diarrhea or fecal incontinence

78
Q

Physical Assessment of abdomen:

A

sequence for abdominal assessment proceeds from inspection, auscultation, percussion to palpate

Inspection: observe contour, any masses, scars, or distention

Auscultation: listen for bowel sounds in all quadrants
—-> note frequency, character, audible clicks, flatus
—–> describe bowel sounds as hypoactive, hyperactive, absent or infrequent

percussion + palpation: performed by advanced practice professionals

79
Q

Laboratory Test: Bowel elimination

A

H/H (hemoglobin + hematocrit) for anemia

LFTs (liver function test) serum amylase and serum lipase used to assess for hepatobiliary disease and pancreatitis

fecal specimens

80
Q

Diagnostic examinations: Bowel elimination

A

Direct Visualization: endoscopy, colonoscopy, esophagogastroduodenoscopy
wireless capsule endoscopy

indirect visualization:
upper gastrointestinal (UGI)
small bowel series
barium enema
admominal ultrasound
magnetic resonance imaging (MRI)
abdominal CT scan

bowel preparation

patient teaching: report abdominal pain, fever, chills or bleeding

81
Q

Fecal occult blood test:

A

guaiac fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) vit c can affect results

82
Q

Stool collection:

A

Medical aseptic technique is imperative

hand hygiene before + after glove use, is essential

wear disposable gloves

do not contaminate outside of container with stool

obtain stool and package, label, transport according to agency policy

Patient Guidelines:
void first so that urine is not in stool sample

defecate into container rather than toilet bowl

do not place toilet tissue in bed pan or specimen container

avoid contact with soaps, detergents, disinfectants as these may affect test results

notify nurse when specimen is avaiable

83
Q

Digital removal of stool:

A

use if enemas fail to remove impaction

last resort in managing severe constipation

can cause stimulation of vagus nerve

84
Q

Restorative Bowel Care:

A

promotion of regular exercise (150 minutes of exercise each week, if immoble promote ambulation as soon as possible)

management of patient with fecal incontinence or diarrhea

—> fecal collector for short term use
—> maintenance of skin integrity
—-> liquid stool contains digestive enzymes that can cause rapid skin breakdown. Irritation for repeat wiping or frequent ostomy pouch changes can irritate skin
—>good skin care: cleansing with a no rinse cleanser: apply a barrier ointment
—rehydration

management of patient with constipation:
increase fiber diet, hydration, exercise, avoid opioids

85
Q

Bed Pan positioning:

A

prevent muscle strain and discomfort

elevate head of bed 30-45 degrees

sitting positon increases downward pressure to rectum

wear gloves when handling bedpans

when patient are immobile or it is unsafe to allow them to raise hip, they remain flat and roll onto bedpan

86
Q

Enemas:

A

cleansing enemas:
- normal saline: safest (isotonic)

  • warm tap water: hypotonic and exerts osmotic pressure lower than fluid in intersitital spaces: cause water intoxication
  • hypertonic: (fleets) pulls fluid out of interstitial spaces: used for patient who cant tolerate large volumes of fluids
  • soapsuds: intestinal irritation stimulates peristalsis (caution with pregnant + elderly)

oil retention: lubricate and soften stool

other types of enema:
- carminative (relieve gas distention) kayexalate (treat high serum K+ levels)

87
Q

Administration of enema:

A

sterile technique is unnecessary

wear gloves

explain procedure, positioning, precautions to avoid discomfort, length of time necessary to retain solution before defecation

unsafe to give enema on toilet

88
Q

Bowel training:

A

Goal: eliminate a soft, formed stool at regular intervals without laxative

when achieved continue to offer assistance with toileting at successful time

Factors within patient control:
- timing ( 1 hour after meal)
- positioning (upright, use toilet or bedside commode over bedpan)
- privacy
- nutrition (fluid + fiber)
-exercise (2 1/2 hours per week)

89
Q

Nasogastric tube: (NG)

A

categories of nasogastric (NG) tube:
- fine or small bore medication administration and enteral feeding
- large bore (12 french and above) for gastric decompression or removal of gastric secretions

Maintaining Patency of NG Tube:
- flush with normal saline or warm water
- if an NG tube does not drain properly after flushing, reposition it by advancing or withdrawing it slightly (any change in tube postion requires you to verify its placement in patient GI tract)

90
Q

Colostomy Care:

A

Care for ostomies:
- use mild soap and water to cleanse skin, then dry it gently and completely
- custom cut to stoma size, 1/8 larger than stoma
- empty pouch when 1/3-1/2 full
- change pouch 3-7 days
- apply paste if necessary

Assess:
stoma (pink or red) skin ( no breakdown)
- note size, which should stabilize within 6-8 weeks
- keep skin around stoma site clean and dry

measure patient fluid intake + output (ileostomies higher risk for dehydration)

Psychological consideration:
self esteem, body image, sexuality

emotional support

promote self care
- encourage patient to care for and look at ostomy

91
Q

Ileostomy vs colostomy: location, effluent

A

Colostomy: end of colon (depending on where in the colon)
should be more formed

Ileostomy: end of ileum
will be liquid (watch for undigested foods/ medications

92
Q

Communicating with unconscious patient:

A

be careful what is said in patient presence; hearing is last sense that is lost

assume that patient can hear you and talk in normal tone of voice

speak to patient before touching

keep enviromental noise at a low level

93
Q

Communicating with patient that is confused:

A

maintain patient safety

use frequent face to face contact to communicate the social process

speak calmly, simply, directly to patient

orient and reorient the patient to environment

orient the patient to time, place, person

offer explanations for care

reinforce reality if patient is delusional

94
Q

Caring for hearing - impaired patient:

A

teach measures to prevent hearing problems

orient patient to presence before speaking

decrease background noises before speaking

check patient hearing aid

postion yourself so that light is on your face

talk directly to patient while facing him/her

use pantomime or sign language as appropriate

write any ideas you cannot convey in another manner

95
Q

Caring for visually impaired patient:

A

orient patient to room arrangement and furnishing

assist with ambulation by walking slightly ahead of patient

stay in patient field of vision if he or she has partial vision

provide diversion using other sense

indicate conversation has ended when leaving room

teach patient self care behaviors to maintain vision and prevent blindness

acknowledge your presence in patient room

speak in normal tone of voice

explain the reason for touching the patient before doing so

keep call light within reach

orient the patient to sound in enviroment

96
Q

Sensory Deprivation:

A

environment with decreased or monotonous stimuli
- nursing home
- patient living alone at home

impaired ability to recieve enviromental stimuli

inability to process environmental stimuli

97
Q

Preventing sensory alterations:

A

control patient discomfort whenever possible

offer care that provides rest and comfort

be aware of need for sensory aids and prostheses

use social activities to stimulate sense and mind

enlist aid of family member to participate in or encourage activites

encourage physical activity and exercise

provide stimulation for as many sense as possible

98
Q

Assessment of sensory experience:

A

through patient eye…

sensory alteration history

physical assessment

health promotion habit

communciation methods

use of assistive device

person at risk

mental status

ability to perform self care

enviromental hazards

social support

other factors affecting perception

99
Q

Factors affecting sensory stimulation:

A

Developmental consideration

culture

personality and lifestyle

stress and illness

medications

social interaction

enviromental

illness

100
Q

Effect of sensory deprivation:

A

Perceptual Disturbance:
inaccurate perceptions in sights, sounds taste, smell, body positon, coordination, equilibrium

cognitive disturbance:
problems with concentration, attention span, memory, problem solving, task performance

emotional disturbance:
manifested in apathy, anxiety, fear, anger, belliegerence, panic, depression

101
Q

Sensory Overload:

A

The patient experiences so much sensory stimuli that the brain is unable to respond meaningfully or ignore stimuli.

The patient feels out of control and exhibits manifestations observed in sensory deprivation.

Nursing care focuses on reducing distressing stimuli and helping the patient gain control over the environment.

Noise above 80 dB can cause damage if exposed too long

Sources of noise into categories: Staff conversation (65%), roommates (54%), alarms (42%), intercoms (39%), and pagers (38%) were the most common sources of noise disruption reported by patients

NRSE 260 (5 decks)

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