Quiz 3 sensory alterations Flashcards
What is vertigo?
Sensation of dizziness or spinning.
- Chronic disease of the inner ear characterized by recurrent episodes of vertigo; progressive sensorineural hearing loss, which may be bilateral; and tinnitus.
Assessing cognitive function
- review the appropriate developmental expectations for each age-group.
- Symptoms of cognitive impairment such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require you to further assess patients for underlying causes.
Mini-Mental State Exam-2 (MMSE-2), the Mini-Cog, and the Clock Drawing Test
Three common conditions affecting cognition
delirium, dementia, and depression.
during a cognitive and psychosocial assessment, you will gain information that indicates a patient’s ability to follow a recommended treatment plan. When assessing a patient’s medication history, have the patient describe when he or she takes the medication at home and the dosage. If a patient has slow responses or reaction time when performing physical activities, it is necessary to consider these limitations when teaching new psychomotor skills. During your assessment, carefully consider a patient’s learning needs and capability to learn.
Visual sensory deficit safety concerns
Factors influencing sensory function:
Age- varies
Meaningful stimuli- not positive aspect in environment
Amount of stimulant - avoid sensory overload
Social interaction- check for presence of support
Environmental factors- note occupational risks
Cultural factors- note cultural disparities
Steps in the nursing process
ADPIE
Assess:
pain included, subjective and objective information
communication methods, social support, use of assistive devices, others factors affecting perception
Diganosis
apply with patients of sensory alterations include: risk for injury, self care deficit, risk for falls, impaired verbal communication, impaired socialization, impaired mobility
Planning
(goals+outcomes) partner with the patient, incorporate what you know about the patients sensory problems, (setting priorities) type and extent of sensory alteration, safety, patient preferences, teamwork and collaboration
Interventions:
Health promotion: Screening, Preventive measures – avoid trauma, Use of assistive devices, Promoting meaningful stimulation, SAFETY MEASURES
Evaluation
Use critical thinking and compare with baselines, observe the patient, ask the patient to explain or demonstrate self-care skills, continue the existing plan of care, make modifications, or end the use of interventions.
SMART goals
- Specific: Be sure an outcome addresses only one patient behavior or response.
- Measurable: Use a term in an outcome statement that allows for observation as to whether a change takes place in a patient’s status.
- Attainable: Mutually set an outcome that a patient agrees to meet.
- Realistic: Set an outcome that a patient can meet based upon his or her physiological, emotional, economic, and sociocultural resources
- Time: Include when an outcome is to be met.
Impaired skin integrity intervention
- Impaired skin integrity in the form of a (pressure injury) and the best nursing interventions: skin care, special bed surface, and a turning schedule.
- Impaired Tissue Integrity, initiate care more frequently to keep skin surfaces clean and dry and eliminate factors such as moisture or drainage.
NANDA approved nursing diagnosis
Ineffective coping/t recent life events AEB pt c/o increased stress and new onset tension headaches after starting nursing school.
. Gentamycin nursing assessment
Antibiotics are considered ototoxic and permanently damage the auditory nerve, whereas chloramphenicol sometimes irritates the optic nerve. Opioid analgesics, sedatives, and antidepressant medications often alter the perception of stimuli. Conduct a thorough pain assessment when you suspect that pain is causing perceptual problems.
