Chapter 44 - Sensory Functioning

Question 1

Sensory Stimulation

Answer 1

Reception

Perception

Arousal Mechanism

Question 2

Conditions of the Sensory Experience

Answer 2

Stimulus

Receptor

Nerve impulse

Sensation

Question 3

Reception

Answer 3

Process of receiving data through the senses (Visual, Auditory, Olfactory, Gustatory, and Tactile)
Stereognosis
Kinesthesia
Visceral

Question 4

Perception

Answer 4

Conscious process of selecting, organizing, and interpreting data from the senses into meaningful information

Question 5

Arousal-The Reticular Activating System

Answer 5

Sensoristasis-Optimal arousal state

RAS mediates arousal

Receives all the input from the sensory nerves and selectively allows certain impulses to reach the cerebral cortex and be perceived

Adaptation

Question 6

States of Arousal/Awareness

Answer 6

Conscious states
Delirium
Dementia
Confusion
Awake and aware
Somnolence
Chronic vegetative state
Unconscious states
Asleep
Lethargic
Stupor
Coma
Glasgow Coma Scale (eye opening, motor response, verbal response) 
Max points is 15, < 7 defines coma

Question 7

Factors Affecting States of Awareness

Answer 7

Inadequate blood flow
Altered nutrition and metabolism
Fluid and electrolyte imbalances 
Infectious processes 
Inadequate sleep and rest
Inability to organize incoming stimuli 
Dementia 
Sensory alterations and sensory deficits

Question 8

Sensory Deprivation

Answer 8

↓ environmental stimuli

Impaired ability to receive environmental stimuli

Inability to process environmental stimuli

Question 9

Manifestations of Sensory Deprivation

Answer 9

Physical behaviors
Escape behaviors
Changes in perception
Changes in cognitive behaviors
Changes in affective behaviors

Question 10

Effects of Sensory Deprivation

Answer 10

Perceptual responses
Cognitive responses
Emotional responses

Question 11

Nursing Interventions for Sensory

Answer 11

Deprivation 
Visual stimulation             
Auditory stimulation
Gustatory stimulation
Olfactory stimulation
Tactile stimulation
Cognitive input
Emotional input
Cultural considerations

Question 12

Sensory Overload

Answer 12

↑ internal stimuli

↑ external stimuli

Inability perceptually to disregard or selectively ignore some stimuli

Question 13

Manifestations of Sensory Overload

Answer 13

Similar to those observed in sensory deprivation

Elderly and CVA patients often experience confusion or agitation

Question 14

Nursing Interventions for Sensory Overload

Answer 14

Provide consistent pattern of stimulation
Speak calmly / simple explanation
Establish a schedule for routine care
Identify distressing stimuli
Reduce and eliminate stimuli (be careful not to cause sensory deprivation)
Provide periods of rest
Cultural considerations

Question 15

Sensory Deficits

Answer 15

Impaired or absent functioning in one or more senses

May be reversed or permanent

Nursing Interventions

Question 16

Nursing Diagnoses Examples

Answer 16

Disturbed Sensory/Perception:
Sensory Deprivation / Overload
Acute Confusion
Chronic Confusion
Impaired Verbal Communication
Delayed Growth and Development 
Self-Care Deficit 
Disturbed Sleep Pattern
Impaired Social Interaction

Question 17

Expected Outcome Examples

Answer 17

Optimal sensory stimulation AEB:
Maintain orientation X3
Respond appropriately to verbal and non-verbal sensory stimuli
Exhibit a level of arousal that enables patient to receive and respond to stimuli
Report feeling safe and in control of environment
Demonstrate appropriate self-care behaviors
Verbalize acceptance of sensory deficit

Question 18

Communicating with a Confused patient

Answer 18

Orient frequently
Speak calmly, simply, directly
Frequent face to face contact
Allow adequate time to process
Emphasize patient strength
Reminiscence
Reinforce reality

Question 19

Communicating with an Unconscious Patient

Answer 19

Be careful what is said in their presence
Assume the person can hear you
Speak to the person before touching
Keep surrounding noises down to a minimum