Prefinals - Sensory Perception Flashcards
Is the process of receiving stimuli or data
Sensory reception
External stimuli are:
Visual (sight)
Auditory (sound)
Olfactory (smell)
Tactile (touch)
Gustatory (taste)
Refers to the awareness of the position and movement of body parts
Kinesthetic
The ability to perceive and understand an object through touch by its size, shape, and texture
Stereognosis
Refers to any large organ within the body
Visceral
Involves the conscious organization and translation of the data or stimuli into meaningful information
Sensory perception
Four aspects of the sensory process:
Stimulus
Receptor
Impulse conduction
Perception
An agent or act that stimulates a nerve receptor
Stimulus
A nerve cell that converts stimulus into a nerve impulse
Receptor
The pathway where the nerve impulse travels along nerve pathways
Impulse conduction
This takes place in the brain, where specialized brain cells interpret the nature and quality of the sensory stimuli
Perception
For the individual to receive and interpret stimuli, the brain must be alert, this is managed by this mechanism in the brain
Arousal Mechanism
Is thought to mediate the arousal mechanism. This is found in the brainstem
Reticular Activating System
2 components of the RAS:
Reticular excitatory area
Reticular inhibitory area
Is the term used to describe the state in which an individual is in optimal arousal
Sensoristasis
Is the ability to perceive internal and external stimuli, and to respond appropriately through thought and action
Awareness
States of awareness:
Full Consciousness
Disoriented
Confused
Somnolent
Semicomatose
Coma
Alert, oriented to time, place, person, understands verbal and written words
Full Consciousness
Not oriented to time, place, or person
Disoriented
Reduced awareness, easily bewildered, poor memory, misinterprets stimuli, impaired judgment
Confused
Extreme drowsiness but will respond to stimuli
Somnolent
Can be aroused by extreme or repeated stimuli
Semicomatose
Will not respond to verbal stimuli
Coma
Factors Affecting Sensory Function:
Developmental Stage
Culture
Stress
Medications and Illness
Lifestyle and Personality
Sensory Alterations
Is a lack of culturally assistive, supportive, or facilitative acts
Culture Deprivation or Culture Care Deprivation
Is generally thought of as a decrease in or lack of meaningful stimuli
Sensory Deprivation
Responses to Sensory Deprivation:
Excessive yawning, drowsiness, sleeping
Decreased attention span, difficulty concentrating, decreased problem-solving ability
Impaired memory
Periodic disorientation, general or nocturnal confusion
Preoccupation with somatic complaints, such as palpitations
Hallucinations or delusions
Crying, annoyance over small matters, depression
Apathy, emotional lability
Clients with sensory deprivation are those that:
Are confined in a nonstimulating or monotonous environment in the home or healthcare agency
Have impaired vision or hearing
Have mobility restrictions such as quadriplegia or paraplegia with bedrest, traction apparatus
Are unable to process stimuli, like clients who have brain damage or taking medications that affect the central nervous system
Have emotional disorders and withdraw within themselves
Have limited social contact with family and friends
Generally occurs when an individual is unable to process or manage the amount or intensity of sensory stimuli
Sensory overload
3 factors that contribute to sensory overload:
Increased quality or quantity of internal stimuli, such as pain, dyspnea, or anxiety
Increased quality or quantity of external stimuli, such as noisy healthcare settings, intrusive diagnostic studies, or contact with many strangers
Inability to disregard stimuli selectively
Responses to Sensory Overload:
Complaints of fatigue, sleeplessness
Irritability, anxiety, restlessness
Periodic or general disorientation
Reduced problem-solving ability and task performance
Increased muscle tension
Scattered attention and racing thoughts
Clients with sensory overload are those that:
Have pain or discomfort
Are acutely ill and have been admitted to an acute care facility
Are being closely monitored in an intensive care unit and have intrusive tubes such as IVs, catheters, or nasogastric or endotracheal tubes
Have decreased cognitive ability
Is impaired reception, perception, or both of one or more of the senses. This can include things like blindness and deafness.
Sensory Deficits
How the body responds to the loss of sensory function. Things like using the left ear when there is hearing loss in the right ear.
Compensatory behavior
Nursing assessment of sensory-perceptual functioning includes six components:
Nursing history
Mental status examination
Physical examination
Identification of clients at risk
Client’s environment
Client’s social support network
The nurse assesses the client’s current sensory perceptions, usual functioning, sensory deficits, and potential problems
Nursing History
This includes data on mental status, including level of consciousness, orientation, memory, and attention span
Mental Status Examination
This assessment determines whether the senses are impaired. This can include testing for vision, hearing, smelling, tasting, feeling, and kinesthetic senses.
Physical Examination
A nurse should assess this for quality, quantity, and types of stimuli.
Client Environment
Nonstimulating environments include:
Severely restrict physical activity
Limit social contact with family and friends
The degree of isolation an individual feels is significantly influenced by the quality and quantity of support from family members and friends.
Social Support Network
For social support network, a nurse should assess:
Who visits and when
If the client lives alone
Any signs indicating social deprivation (withdrawal from contact with others to avoid dependence on others or embarrassment, negative self-image, reports lack of meaningful communication with others, absence of opportunities to discuss fears or concerns that facilitate coping mechanisms)
Is the leading cause of blindness in adults older than 65
Age-related Macular Degeneration
Are opacities of the lens. Development is slow and painless and may be unilateral or bilateral. They are the leading cause of blindness in the world.
Cataracts
Is associated with optic nerve damage due to an increase in intraocular pressure and leads to vision loss. It is the 2nd most common cause of blindness in the US
Glaucoma
Is a microvascular disease of the eye, occurring in both type 1 and type 2 diabetes.
Diabetic Retinopathy
Otherwise known as acute confusion. It has an abrupt onset and a cause, that when treated, reverses the confusion.
Delirium
Is often called chronic confusion. It has symptoms that are gradual and irreversible
Dementia
Is considered the golden standard in identifying clients with delirium
Confusion Assessment Method
Is a screening tool in which family members are interviewed to maximize the detection of delirium in clients
Family CAM or FAM-CAM
