Exam Week 12 part 2

Card Set Information

Exam Week 12 part 2
2013-11-10 22:03:40
Nursing 103

Sensory Perception
Show Answers:

  1. Number one goal is always
    prevent injury
  2. Clients at risk for having sensory overload
    • Have pain or discomfort
    • Acutely Ill (admitted to N.H, Hosp)
    • being closely monitored in ICU
    • have decreased cognitive ability (head injury)
  3. Clients at risk for Sensory deprivation
    • clients that are confined to nonstimulating/ monotonous environment
    • having impaired vision or hearing
    • have mobility restrictions (quadriplegia)
    • unable to process stimuli (brain damage or meds that affect CNS)
    • Emotional disorder, depression causing withdraw
    • have limited social interaction
  4. Essential components in Assessing Clients Sensory Perception Function
    • Nursing History
    • Mental Status Examination
    • Physical Examination
    • Identify Clients at risk
    • Clients Environment
    • Clients Social Support Network
  5. What is Sensory Deprivation?
    • Decrease of or lack of meaningful stimuli
    • the balance of Reticular Activating System is disturbed. RAS is unable to maintain normal stimulation
    • Person becomes more acutely aware of remaining stimuli and receives in distorted manner
  6. Sensory Deprivation clinical manifestations
    • Cry over small things
    • Hallucinations or Delusions
    • Periodic Disorientation
    • General Confusion
    • Impaired Memory
    • Excessive Yawning
    • Decreased attention span
    • difficulty concentrating
  7. Sensory Overload
    Clinical manifestations
    • 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
  8. Factors that affects sensory function
    • Development Stage
    • Culture
    • Stress
    • Medication and Illness
    • Lifestyle and Personality
  9. What is sensory overload
    occurs when a person is unable to process or manage the amount or intensity of sensory stimuli
  10. 3 factors that contribute to sensory overload
    • increased quantity/quality of internal stimuli (PAIN, dyspnea, or anxiety)
    • increased quantity/quality of external stimuli ( noisy health care setting, intrusive dx studies, contact with many strangers)
    • Inability to disregard stimuli selectively (result of nervous system disturbance, medications that stimulate arousal mechanism)
  11. Short Sensory Overload..
    • causes thoughts to race in many directions
    • causes restlessness and anxiety
    • person feels overwhelmed/out of control
  12. Sensoristasis
    • the state in which a person is in Optimal Arousal
    • beyond this comfort zone people must adapt to the increase or decrease in sensory stimulation
  13. Sensory Perception
    Conscious organization and translation of the data into meaningful info
  14. Sensory reception
    • process of receiving stimuli
    • External vs Internal
    • External=visual, auditory, olfactory, gustation and tactile
    • Internal= kinesthetic and visceral
  15. The 4 aspects of Sensory Process
    • Stimulus
    • Receptor
    • Impulse Conduction
    • Perception
  16. Perception
    Awareness and interpretation of the stimuli {brain}
  17. Impulse Conduction
    Impulse Travels from nerve to spinal cord or brain
  18. Receptor
    Nerve cell that converts the stimulus to a nerve impulse
  19. Stimulus
    Agent that stimulates a nerve
  20. RAS
    Reticular Activating System
  21. What does RAS do
    • Mediates arousal mechanism
    • 2 components
    •   Reticular Excitatory Area (REA
    •   Reticular Inhibitory Area (RIA)
  22. RIA
    Reticular Inhibitory Area
  23. REA
    Reticular Excitatory Area
  24. Communicating Effectively
    • Convey Respect
    • Enhance Self-Esteem
    • Ensure exchange of correct info
  25. impaired vision
    • orient to environmant
    • keep pathways clear
    • organize belongings
    • keep call light in reach
    • assist with ambulation
  26. impaired hearing
    • assess frequently
    • teach to check IV tubing for kinks, EKG leads
    • Face client when talking
    • DO NOT YELL at deaf clients
    • decrease extraneous noise
  27. impaired olfactory
    • teach about the dangers of cleaning with chemicals
    • teach about food poisoning
  28. impaired tactile
    • risk for burns
    • risk for pressure ulcers
  29. the confused client
    • most commonly elderly
    • Elderly at risk because
    •     chronic medical probs, medsm undertreated pain
  30. Acute vs Chronic Confusion
    Abrupt Onset (if cause is treated confusion stops)

    Gradual onset, Irreversible Syptoms