Nursing 113 Exam 2
Sensory Reception
is the process of receiving data about the external or internal environment through the
senses.
The senses by which individuals maintain contact with the external environment
are:
vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), and touch (tactile).
Sterognosis
is the sense that perceives the solidity of objects and their size, shape, and texture.
Ex -- putting a paperclip in someone's hand when their eyes are closed and they are
able to tell you what it is.
Kinesthesia
refers to awareness of positioning of body parts and body movement; visceral pertains
to inner organs. The kinesthetic and visceral senses arise internally from muscles and
hollow organs, respectively, and are the body's basic orienting systems.
Proprioception
is the term used to describe the sense, usually at a subconscious level, of the
movements and position of the body and especially its limbs, independent of vision.
Proprioception is gained primarily
from input from sensory nerve terminals in muscles and tendons and the fibrous
capsules of joints combined with input from the vestibular apparatus.
Sensory perception
is the conscious process of selecting, organizing, and interpreting data from the senses
into meaningful information. Perception is influenced by the intensity, size, change, or
representation of stimuli, as well as by the past experiences, knowledge, and attitudes.
For a person to receive the necessary data to experience the world, FOUR
conditions must be met:
• A *stimulus*--an agent, act, or other influence capable of initiating a response by the
nervous system--must be present
• A receptor or sense organ must receive the stimulus and convert it to a nerve impulse.
• The nerve impulse must be conducted along a nervous pathway from the receptor or
sense organ to the brain.
• A particular area in the brain must receive and translate the impulse into a sensation.
To receive stimuli and respond appropriately
the brain must be alert and aroused. The *reticular activating system (RAS)*, a poorly
defined network that extends from the hypothalamus to the medulla, mediates arousal.
Sensoristasis
is the optimal arousal state of the RAS.
The RAS
selectively allows certain impulses to reach the cerebral cortex and be perceived. The
RAS serves to monitor and to regulate incoming sensory stimuli, thus maintaining,
enhancing, or inhibiting cortical arousal.
Somolence
is extreme drowsiness, but will respond normally to stimuli.
Locked-in Syndrome
,is a condition in which a patient is aware but cannot move or communicate verbally due
to complete paralysis (ex -- quadriplegic) of nearly all voluntary muscles in the body
except for the eyes (auditory and visual function preserved as well as emotion).
Asleep
can be aroused by normal stimuli (light touch, sound, etc.)
Stupor
Can be aroused by extreme and/or repeated stimuli
Coma
Cannot be aroused and does not respond to stimuli
Vegetative State
Cannot be aroused. Sleep-wake cycles, postures or withdraws to noxious stimuli,
occasional non-purposeful movement, random smiling or grimacing
Adaptation:
The body quickly adapts to constant stimuli. Repeated stimulus of a continuing noise,
such as city traffic, or a noxious odor eventually goes unnoticed. A stimulus MUST be
variable or irregular to evoke a response.
Factors contributing to severe sensory alteration include:
+sensory overload
+sensory deprivation
+sleep deprivation
+cultural care deprivation
Sensory Deprivation
results when a person experiences decreased sensory input or input that is
monotonous, unpatterned, or meaningless. With decreased sensory input, the RAS is
no longer able to project a normal level of activation to the brain. As a result, the
individual may hallucinate simply to maintain an optimal level of arousal.
Factors placing a patient at high risk for sensory deprivation include:
• An environment with decreased or monotonous stimuli (such as institutionalized
patients or those confined to a small living area at home, or bed rest, or in isolation).
• Impaired ability to receive environmental stimuli (patients with impaired vision or
hearing; with bandages or casts that interfere with vision, hearing, or tactile stimulation;
or with affective disorders who "close out" the environment).
•Inability to process environmental stimuli (patients with spinal cord injuries or brain
damage, those who are confused or disoriented, or are taking prescribed or recreational
drugs affecting the central nervous system).
Sensory Deprivation can lead to:
perceptual, cognitive, and emotional disturbances. *Perceptual responses* result from
inaccurate perception of sights, sounds, tastes, smells, and body position, coordination,
and equilibrium. These responses can range from mild distortions such as daydreams,
to gross distortions such as hallucinations. *Cognitive responses* involve the patient's
inability to control the direction of thought content. Typically, attention span and ability to
concentrate are decreased. *Emotional responses* typically are manifested by apathy,
anxiety, fear, anger, belligerence, panic, or depression. Rapid mood changes may also
occur.
Sensory Overload
, is the condition that results when a person experiences so much sensory stimuli that the
brain is unable to either respond meaningfully or ignore the stimuli. The person feels out
of control and may exhibit all of the manifestations observed in sensory deprivation. The
amount and quality of stimuli necessary to produce overload may differ greatly from one
individual to another and is influenced by factors such as age, culture, personality, and
lifestyle.
In some patients, especially those coming from a quiet environment with
unvarying stimuli --
the experience of being hospitalized quickly results in *sensory overload*. In such
patients, the brain is assaulted by the constant presence of strangers who not only
demand to be spoken to, but also touch and poke at the body; by the strange sights,
odors, sounds, and feels of the unfamiliar environment; by the constant presence of
pain or discomfort from dressings, intravenous (IV) lines, drainage tubes, or
endotracheal tubes; and by the ever-present worries about the meaning and course of
the illness.
In this case, nursing care focuses on
reducing the distressing stimuli and helping the patient to gain control over the
environment.
Sensory Deficit
is impaired or absent functioning in one or more senses. Examples of sensory deficits
includes impaired sight and hearing, altered taste, numbness and paralysis that result in
altered tactile perception, and impaired kinesthetic sense.
Defining characteristics of Sensory Deprivation:
•Physical behaviors: drowsiness, excessive yawning
•Escape behaviors: eating, exercising, sleeping, running away to escape the deprived
environment
•Changes in perception: unusual body sensations; preoccupation with somatic
complaints (dry mouth, palpitations, difficulty breathing, nausea); change in body image;
illusions and hallucinations
•Changes in cognitive behavior: decreased attention span, inability to concentrate,
decreased problem solving and task performance
•Changes in affective behavior: crying, increased irritability and annoyance over small
matters, confusion, panic, depression
Patients at risk of Sensory Deprivation:
•Institutionalized patients, especially those in long-term care settings
•Patients with communicable diseases (ex - AIDS)
•Patients confined to bed
•Patients with sensory alterations (ex - impaired vision or hearing, or patients with eye
patches or body casts)
•Patients from a different culture
•Patients with a disturbance of the nervous system
Nursing Interventions of Sensory Deprivation:
•*Visual stimulation*: colorful sheets, pajamas, robes
colorful uniform tops for the nurse
face-to-face human contact
clocks, calendars, wristwatches
Sensory Reception
is the process of receiving data about the external or internal environment through the
senses.
The senses by which individuals maintain contact with the external environment
are:
vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), and touch (tactile).
Sterognosis
is the sense that perceives the solidity of objects and their size, shape, and texture.
Ex -- putting a paperclip in someone's hand when their eyes are closed and they are
able to tell you what it is.
Kinesthesia
refers to awareness of positioning of body parts and body movement; visceral pertains
to inner organs. The kinesthetic and visceral senses arise internally from muscles and
hollow organs, respectively, and are the body's basic orienting systems.
Proprioception
is the term used to describe the sense, usually at a subconscious level, of the
movements and position of the body and especially its limbs, independent of vision.
Proprioception is gained primarily
from input from sensory nerve terminals in muscles and tendons and the fibrous
capsules of joints combined with input from the vestibular apparatus.
Sensory perception
is the conscious process of selecting, organizing, and interpreting data from the senses
into meaningful information. Perception is influenced by the intensity, size, change, or
representation of stimuli, as well as by the past experiences, knowledge, and attitudes.
For a person to receive the necessary data to experience the world, FOUR
conditions must be met:
• A *stimulus*--an agent, act, or other influence capable of initiating a response by the
nervous system--must be present
• A receptor or sense organ must receive the stimulus and convert it to a nerve impulse.
• The nerve impulse must be conducted along a nervous pathway from the receptor or
sense organ to the brain.
• A particular area in the brain must receive and translate the impulse into a sensation.
To receive stimuli and respond appropriately
the brain must be alert and aroused. The *reticular activating system (RAS)*, a poorly
defined network that extends from the hypothalamus to the medulla, mediates arousal.
Sensoristasis
is the optimal arousal state of the RAS.
The RAS
selectively allows certain impulses to reach the cerebral cortex and be perceived. The
RAS serves to monitor and to regulate incoming sensory stimuli, thus maintaining,
enhancing, or inhibiting cortical arousal.
Somolence
is extreme drowsiness, but will respond normally to stimuli.
Locked-in Syndrome
,is a condition in which a patient is aware but cannot move or communicate verbally due
to complete paralysis (ex -- quadriplegic) of nearly all voluntary muscles in the body
except for the eyes (auditory and visual function preserved as well as emotion).
Asleep
can be aroused by normal stimuli (light touch, sound, etc.)
Stupor
Can be aroused by extreme and/or repeated stimuli
Coma
Cannot be aroused and does not respond to stimuli
Vegetative State
Cannot be aroused. Sleep-wake cycles, postures or withdraws to noxious stimuli,
occasional non-purposeful movement, random smiling or grimacing
Adaptation:
The body quickly adapts to constant stimuli. Repeated stimulus of a continuing noise,
such as city traffic, or a noxious odor eventually goes unnoticed. A stimulus MUST be
variable or irregular to evoke a response.
Factors contributing to severe sensory alteration include:
+sensory overload
+sensory deprivation
+sleep deprivation
+cultural care deprivation
Sensory Deprivation
results when a person experiences decreased sensory input or input that is
monotonous, unpatterned, or meaningless. With decreased sensory input, the RAS is
no longer able to project a normal level of activation to the brain. As a result, the
individual may hallucinate simply to maintain an optimal level of arousal.
Factors placing a patient at high risk for sensory deprivation include:
• An environment with decreased or monotonous stimuli (such as institutionalized
patients or those confined to a small living area at home, or bed rest, or in isolation).
• Impaired ability to receive environmental stimuli (patients with impaired vision or
hearing; with bandages or casts that interfere with vision, hearing, or tactile stimulation;
or with affective disorders who "close out" the environment).
•Inability to process environmental stimuli (patients with spinal cord injuries or brain
damage, those who are confused or disoriented, or are taking prescribed or recreational
drugs affecting the central nervous system).
Sensory Deprivation can lead to:
perceptual, cognitive, and emotional disturbances. *Perceptual responses* result from
inaccurate perception of sights, sounds, tastes, smells, and body position, coordination,
and equilibrium. These responses can range from mild distortions such as daydreams,
to gross distortions such as hallucinations. *Cognitive responses* involve the patient's
inability to control the direction of thought content. Typically, attention span and ability to
concentrate are decreased. *Emotional responses* typically are manifested by apathy,
anxiety, fear, anger, belligerence, panic, or depression. Rapid mood changes may also
occur.
Sensory Overload
, is the condition that results when a person experiences so much sensory stimuli that the
brain is unable to either respond meaningfully or ignore the stimuli. The person feels out
of control and may exhibit all of the manifestations observed in sensory deprivation. The
amount and quality of stimuli necessary to produce overload may differ greatly from one
individual to another and is influenced by factors such as age, culture, personality, and
lifestyle.
In some patients, especially those coming from a quiet environment with
unvarying stimuli --
the experience of being hospitalized quickly results in *sensory overload*. In such
patients, the brain is assaulted by the constant presence of strangers who not only
demand to be spoken to, but also touch and poke at the body; by the strange sights,
odors, sounds, and feels of the unfamiliar environment; by the constant presence of
pain or discomfort from dressings, intravenous (IV) lines, drainage tubes, or
endotracheal tubes; and by the ever-present worries about the meaning and course of
the illness.
In this case, nursing care focuses on
reducing the distressing stimuli and helping the patient to gain control over the
environment.
Sensory Deficit
is impaired or absent functioning in one or more senses. Examples of sensory deficits
includes impaired sight and hearing, altered taste, numbness and paralysis that result in
altered tactile perception, and impaired kinesthetic sense.
Defining characteristics of Sensory Deprivation:
•Physical behaviors: drowsiness, excessive yawning
•Escape behaviors: eating, exercising, sleeping, running away to escape the deprived
environment
•Changes in perception: unusual body sensations; preoccupation with somatic
complaints (dry mouth, palpitations, difficulty breathing, nausea); change in body image;
illusions and hallucinations
•Changes in cognitive behavior: decreased attention span, inability to concentrate,
decreased problem solving and task performance
•Changes in affective behavior: crying, increased irritability and annoyance over small
matters, confusion, panic, depression
Patients at risk of Sensory Deprivation:
•Institutionalized patients, especially those in long-term care settings
•Patients with communicable diseases (ex - AIDS)
•Patients confined to bed
•Patients with sensory alterations (ex - impaired vision or hearing, or patients with eye
patches or body casts)
•Patients from a different culture
•Patients with a disturbance of the nervous system
Nursing Interventions of Sensory Deprivation:
•*Visual stimulation*: colorful sheets, pajamas, robes
colorful uniform tops for the nurse
face-to-face human contact
clocks, calendars, wristwatches
