Sensory Flashcards
meaningless or under stimulation of the nervous system
Sensory deprivation
excessive stimulation
Unable to process or manage the amount of intense sensory stimuli
Sensory overload
medical condition usually of older adults- loss of vision in center of visual field-retina.
(risk factors)
Macular degeneration
Damage to the macula, the central portion of the retina. Risk factors- excessive sunlight exposure and smoking
a disturbance in the circulation of the aqueous fluid- increase in intraocular pressure
May lose peripheral vision
Glaucoma
opacity/clouding of the lens of the eye causing blurred vision , sensitivity to glare, and reduced visual acuity/image distortion
Cataracts
Central vision lost is…
Macular degeneration
(nearsightedness)- unable to
see distant objects (ME)
Myopia
unable to see close objects
Hyperopia-(farsightedness)-
farsightedness in older adults- loss of ability to see close objects as a result of aging. (Normal developmental change).
Presbyopia
sensory overload signs
pain/anxiety/dyspnea
irritability/anxiety/ inability to concentrate
when hearing loss is due to problems with the ear canal, ear drum, or middle ear and its little bones
Conductive hearing loss
HARDENING of the bones of the middle ear; chronic progressive
otoSCLEROSIS
Damage to the NERVE of the inner ear (MOST COMMON)
SENSORINEURAL HEARING LOSS – (nerve deafness)
Why?
- aging
progressive loss of hearing
d/t aging- deeper voices are better
PRESBYCUSIS
You notice that Mr. Wong, who has cataracts, is sitting closer to the television than usual. The nurse would interpret the etiologic basis of his sensory problem is an alteration in which of the following?
a. Environmental stimuli
b. Sensory reception
c. Nerve impulse conduction
d. Impulse translation
b. Cataracts are interfering with the patient’s ability to receive visual stimuli—altered sensory reception. The nature of incoming stimuli
damage to endings of nerve in the inner ear “ringing of the ears”
Tinnitus
HOH
hard of hearing
A nurse is assessing a patient in a long-term care facility. The nurse notes that the patient is at risk for sensory deprivation due to limited activity related to severe rheumatoid arthritis. Which interventions would the nurse recommend based on this finding? Select all that apply.
a. Use a lower tone when communicating with the patient.
b.Provide interaction with children and pets.
c.Decrease environmental noise.
d.Ensure that the patient shares meals with other patients.
e.Discourage the use of sedatives.
f.Provide adequate lighting and clear pathways of clutter.
b, d, e. For a patient who has sensory deprivation, the nurse should provide interaction with children and pets, ensure that the patient shares meals with other patients, and discourage the use of sedatives. Using a lower tone of voice is appropriate for a patient who has a hearing deficit. Decreasing environmental noise is an intervention for sensory overload. Providing adequate lighting and removing clutter is an intervention for a vision deficit.
Which patient would the nurse assess as being at greatest risk for sensory deprivation?
a. An elderly man confined to bed at home after a stroke
b. An adolescent in an oncology unit working on homework supplied by friends
c. A woman in labor
d. A toddler in a playroom awaiting same-day surgery
a. The patient confined to bed rest at home is at risk for greatly reduced environmental stimuli. All of the other patients are in environments where environmental stimuli are at least adequate.
is a decreased sense of smell, or a decreased ability to detect odors through your nose
(happy)
Hyposmia
anSomia
the loss of the sense of smell, either total or partial. It may be caused by head injury, infection, or blockage of the nose.
Interventions: what actions the nurse is going to take for smell + taste?
Taste- tell the patient what the food is, and they may have memory of what the food tasted like.
Ask client to describe what they taste
Use seasonings
Bring the food closer to their nose- promote aromatic stimuli-coffee, flowers, aromatherapy, etc.
Tactile Impairment
hypersensitivity to touch
Of the four items listed below, which nursing intervention would be best to prevent sensory alterations for a man with a severe hearing deficit who reads lips well?
a. Turn the radio or television volume up very loud and close the door to his room.
b. Prevent embarrassment and emotional discomfort as much as possible.
c. Provide daily opportunity for him to participate in a social hour with six or eight people.
d. Encourage daily participation in exercise and physical activity
c. Although all the options listed are appropriate, providing daily opportunities for this patient to participate in a social hour builds on his strength of being able to lip-read and provides sufficient sensory stimulation to prevent sensory deprivation resulting from his hearing loss, thereby meeting his needs.
HRF Injury is a problem. T or F .
Not a problem. wont have
“As manifested by”
Kinesthetic impairment
high risk for falls.
_________- non-responsive
___________-altered mental state. Decrease in responsiveness in which a person is only arousable with vigorous stimuli
Comatose
Stuporous
Assess level of orientation:
“Oriented x 3’’
- Time- What time of year is it? What is the year? “It is summer, year—-“
2.Person-What is your name? Who am I? “My name is Mary,” “You are my nurse”
3.Place- Where are you? “I am in the hospital,” “I am in Lockport.”
Nursing Interventions for the Confused Client
Reorient frequently , state your name, day, date, time. Provide clocks, calendars. Provide visual clues to time. Use personal belongings.
Use simple communication decrease anxiety keep the patient safe and provide continuity of care.
Limit choices
Promote feelings of security.
Use alternative therapies.
Level of Consciousness (LOC) * 4 levels*
second one is in the bible
1.Alert.
2. Drowsy/ lethargic
3. Stuporous-altered mental state. Decrease in responsiveness in which a person is only arousable with vigorous stimuli
4. Comatose- non-responsive
what are the four components of sensory experience ?
stimulus, reception , perception and arousal.
Role of RAS
reticular activating system controls conscious and alertness. keeps us awake , attentive and observant
Conduction vs nerve deafness
Conductive deafness occurs when ossicular conduction is lost but bone conduction is preserved and is more sensitive in order to compensate.
-Any disease affecting the outer or middle ear will produce a conductive deafness.
Nerve deafness
Caused by injury of the acoustic nerve and auditory nerve in the Brain.
What areas of the body have greatest number of tactile receptors?
hands and face
lost of olfactory neurons decrease the ability to perceive ________
smell
_______ is usually as indicator cerebral functions.
think of sheets in clicinal ( the back)
LOC
hearing aids can help sensorineural.
T or F
F. it cannot.
______________ brings sound and information about one’s position and movement in space into the brain.
Cranial nerve VIII
inability to smell
anosmia
________ plays role in taste, memory, mood and safety. (where in brain)
Olfaction
_____ rare inability to detect flavor at all.
begins with A
Ageusia
________ loss of ability to understand or express speech, caused by brain damage.
aphasia
