Sensory Flashcards
1
Q
Components of sensory experience
A
- Stimulus
- Reception - receiving stimuli by visual, auditory, olfactory, tactile and gustatory
- Kinesthetics - awareness of position and body movement (internal)
- Stereognosis - awareness of object size, shape and texture by touch without seeing it
- Visceral - organ changes
- Perception - conscious organization and translation into meaningful information
- Sensoristasis - optimum arousal for a person
2
Q
States of awareness
A
- Full consciousness - alert and oriented to time, place and person and understands verbal and written words
- Disoriented - not oriented to time, place and person
- Confused - reduced awareness; poor memory and misinterprets stimuli; impaired judgement
- Somnolent - extreme drowsiness but will respond to stimuli
- Semicomatose - responds to painful stimuli only
- Comatose - no purposeful response to stimuli; react to deep pain with atypical posturing
3
Q
Sensory alterations
A
- Sensory deprivation
- Sensory overload
- Sensory deficits
4
Q
Purpose
A
- Essential for survival and growth and development
- Gives meaning to events in environment
- Need to function safely
5
Q
Sensory deprivation
A
- Decrease or lack of meaningful stimuli
- Remaining stimuli is perceived in a distorted manner
- Causes alterations in perception, cognition and emotion
6
Q
Signs of sensory deprivation
A
- Excessive yawning, drowsiness and sleeping
- Decrease attention span and concentration
- Confusion or nocturnal confusion
- Impaired memory, periodic or general disorientation
- Decrease problem solving
- Preoccupation with somatic complaints
- Hallucinations or delusions
- Crying, annoyance of small things (irritability)
- Depression, apathy, emotional liability
7
Q
Sensory overload
A
- Unable to process or manage amount or intensity of stimuli
- Thoughts race, restlessness, overwhelmed, fatigue, can’t comprehend or internalize information
Factors contributing to sensory overload:
• Increased quantity or quality of internal stimuli (pain, dyspnea, anxiety)
• Increased quantity or quality of external stimuli (noise, intrusion, contact)
• Inability to disregard stimuli due to CNS disturbance (medication, disease)
8
Q
Signs of sensory overload
A
- Fatigue or sleeplessness
- Irritability, anxiety, restlessness
- Periodic or general disorientation
- Decreased problem solving
- Reduced task performance
- Increased muscle tension, scattered attention and racing thoughts
9
Q
Sensory deficits
A
- Impaired reception and/or perception of one or more sense
- Other senses may become more acute
- Sudden loss can lead to disorientation
- Gradual loss allows for adaptation
- Loss can lead to risk of deprivation and/or overload
10
Q
Uncompensated sensory loss
A
When a client does not us assistive devices as needed
• Either by choice, unavailability or unable to afford
11
Q
At risk for sensory deprivation
A
- Confined to no stimulating, monotonous environment
- Impaired vision or hearing
- Mobility restrictions
- Unable to process stimuli
- Emotional disorders
- Limited social contacts with friends and family
12
Q
At risk for sensory pverload
A
- Pain or discomfort
- Acutely ill and admitted to acute care facility
- Closely monitored in ICU and have intrusive tubes
- Decreased cognitive ability
13
Q
Actors affecting sensory function
A
- Growth and development
- Culture
- Stress
- Medications and illness
- Lifestyle and personality
14
Q
Assessing
A
- Nursing history - present sensory functioning, changes
- Mental status examination
- Physical examination - visual acuity, auditory acuity, olfactory and gustatory tests
- Client environment
- Social support network
15
Q
Diagnoses
A
- Altered sensory perception (of)
- Confusion (acute or chronic)
- Impaired memory
Related to: • Risk of injury • Impaired home maintenance • Risk for impaired skin integrity • Impaired verbal communication • Self care deficit • Social isolation or impaired social interaction • Risk of nutritional deficit • Anxiety • Loneliness • Powerlessness
