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54 Cards in this Set
- Front
- Back
3 components of sensory experience
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Sensory reception, perception, reaction
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Stereognosis
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is the ability to perceive and recognize the form of an object using cues from texture, size, spatial properties, and temperature. Stereognosis tests determine whether or not the parietal lobe of the brain is intact. Typically, these tests involved having the patient identify common objects (eg. keys, comb, safety pins) placed in their hand without any visual cues.
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4 requirements for sensory experience
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Stimuli capable of initiating a response by nervous system
Receptor or sense organ to receive stimuliys and convert it to nerve impulse Nerve pathway to conduct impulse to brain Area of brain must be able to receive and translate impulse into sensation |
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Reticular Activating System (RAS)
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is an area of the brain responsible for regulating arousal and sleep-wake transitions.
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Patients at risk for sensory deprivation
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Institutionalized patients, patients confined to bed, patients with sensory alterations, depressed patients, patients with communicable diseases, patients with nervous system disease, patients from a different culture.
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Patients at risk for sensory overload
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Acutely ill or chronically ill patients, patients in pain, patients with invasive monitoring or treatment equipment, hospitalized patients (esp, ICU), patients with nervous system disturbances.
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Factors affecting sensory stimulation
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Age/developmental status, amount/presence or absence of meaningful stimuli, social interaction, environmental factors, culture
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States of consciousness
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Normal
Delirium Dementia Confusion Somnolence/Lethargy Chronic vegetative state |
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States of unconsciousness
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Asleep
Stuporous Comatose |
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cognition involves
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Cerebral functioning - process of conscious thought, reality orientation, problem solving, judgement comprehension.
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Components of Assesing sensory and perceptual function
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Nursing history, mental status, physical examination, identify patients at risk, patient's environment, patient's social support system.
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Acute confusion
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Nursing diagnostic label - Abrupt onset of global, transient changes and disturbances in attention, cognition level, level of consciousness or sleep-wake cycle. Aka delirium
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Chronic confusion
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Irreversible, long-standing or progressive deterioration of intellect and personality with memory, behavioral changes. Aka dementia
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Impaired memory
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inability to recall information, behavioral skills
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Expected outcomes related to sensory/perception
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Patient will -
Live in developmentally stimulating/safe environment Exhibit appropriate level of arousal demonstrate intact functioning of the senses maintain orientation to person, place, time respond appropriately to sensory stimuli |
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Nursing interventions related to sensory/perception
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Adjusting environmental stimuli
managing acute sensory deficits Use of sensory aids |
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Sensoristasis
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Sensoristasis is the term used to describe when a person is in optimal arousal.
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Enables a person to be aware of position and movement of body parts
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kinesthetic senses
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Senses that enable a person to taste
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Gustatory sense
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Senses that enable a person to hear
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Auditory
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Senses that enable a person to smell
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Olfactory
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Recognition of an object's size shape and texture
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Stereognosis
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Senses of touch
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tactile
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Numbness and tingling of affected area, stumbling gait
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peripheral neuropathy
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results from vestibular dysfunction, vertigo
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Disequilibrium
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Decreased accomodation of the lens to see near objects clearly
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presbyopia
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Blurring of reading matter distortion or loss of central vision and vertical lines
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Macular degeneration
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Caused by clot, hemorrhage, or emboli to the brain
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stroke
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Opaque areas of the lense that cause glaring and blurred vision
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cataract
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decrease in salivary production, leading to thicker mucus and dry mouth
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Xerostomia
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Decreased tear production that results in itching and burning
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Dry eyes
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Progressive hearing disorder in older adults
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Presbycusis
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Earwax, causes conduction deafness
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cerumen
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Blood vessel changes of the retina, decreased vision, and macular edema
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Diabetic retinopathy
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Increase in intraocular pressure presses against optic nerve resulting in peripheral visual loss, halo effect surrounding lights, difficulty adjusting to darkness
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glaucoma
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List 3 types of sensory deprivation and give an example of each
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Sensory input deprivation - hearing or vision loss
Elimination of patterns of meaning from input - when in a strange environment Restrictive environments that produce monotony and boredom |
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Cognitive effects of sensory deprivation
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Reduced capacity to learn, inability to think or problem-solve, poor task performance, disorientation, bizare thinking, increased need for socialization, altered mechanisms of attention
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Affective effects of sensory deprivation
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boredom, restlessness, increased anxiety, emotional liability, panic, increased need for physical stimulation
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Perceptual effects of sensory deprivation
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changes in visual/motor coordination, reduced color perception, less tactile accuracy, reduced ability to perceive shape and size, changes in spatial and time judgement
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Sensory overload
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When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli
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Identify the 6 factors that influence the capacity to receive or perceive stimuli
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age, presence of meaningful stimuli, amount of stimuli, social interaction, environmental factors, cultural factors
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Groups at high risk for sensory alterations
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Older adults, those living in confinement, acutely ill patients (especially ICU)
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When assessing for changes in a client's mental status, the nurse needs to evaluate the following 3 areas-
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Physical appearance and behavior (motor activity, posture, facial expression, hygiene)
Cognitive ability (LOC, abstract reasoning, calculation, attention, judgement, ability to converse, memory function) Emotional stability (agitation, euphoria, irritability, hopelessness, wide mood swings, hallucinations, illusions, delusions) |
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Some behaviors associated with visual sensory deficits in a young child include
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Self-stimulation including eye-rubbing, body rocking, sniffing/smelling, arm-twirling; hitching (using legs to propel while in a sitting position) instead of crawling.
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Some behaviors associated with visual sensory deficits in an adult include
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Poor coordination, squinting, underreaching or overreaching for objects, persistent repositioning of objects, impaired night vision, falls
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Some behaviors associated with tactile sensory deficits in children include
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inability to perform developmental tasks related to grasping objects or drawing, repeated injury from handling harmful objects (hot, sharp, etc)
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Some behaviors associated with tactile sensory deficits in an adult include
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Clumsiness, over or under-reaction to painful stimulus, failure to respond when touched, avoidance of touch. Sensation of pins & needles, numbness. Unable to identify object placed in hand.
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A motor-based inability to name common objects or to express simple ideas in words or writing
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Expressive aphasia
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Sensory-based inability to understand written or spoken language
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Receptive aphasia
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List several nursing diagnoses for a client with impaired sensory alterations
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Impaired adjustment
impaired verbal communication risk for injury impaired physical mobility self-care deficit situational low self-esteem disturbed sensory perception social isolation disturbed thought processes |
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The most common visual problem is -
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refractive error such as nearsightedness
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Children at risk for hearing impairment are -
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Those with a: family history, prenatal infection, low birth weight, chronic ear infections, down syndrome
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An oversensitivity to tactile simuli
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hyperesthesia
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4 general approaches to maximize sensory function
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Orientation to environment - use name tags, address client by name, explain transfers
Communication - work with clients limitations to maximize ability to communicate Control sensory stimuli - attempt to minimize overstimulation, provide adequate stimulation. Safety Measures - help with ambulation, frequent repositioning. |