NURS 3000: Final (Burt)
Nursing Interventions for Various Sensory Impairments - Increase or Decrease Stimuli
-Explaining Care
-Visit More Often
-Orient
-Place TV, Radio, Calendar, Clock in Room
-Touch
-Elevate HOB
-Open/Close Door
-Turn Off TV
-Assist Out Of Bed, Ambulate
Normal Sensory Process Components - 1.) Reception (Nerve Cell Stimulation)
2.) Perception (Person is Aware of Stimuli)
3.) Reaction (Action)
Vibratory Sensations - Awareness of Vibrations, Use Tuning Fork, Place on Bony
Prominences, Joints
Kinesthetic Sensations - Aware of Position & Movement of Body Parts
Stereognosis Test - Can a patient identify an object through touch?
-Patient makes a fist around object & tries to identify it with their eyes closed.
Visceral Sensations - A stimulus that makes you aware of an organ.
-Ex: feeling full after eating.
How to Assess and Document LOC & Orientation? - "alert & oriented x 3"
-Oriented to Person, Place, Thing
, What patients are at risk for sensory disturbances? - -Risk for Injury
-Impaired Home Maintenance
-Risk for Impaired Skin Integrity
-Impaired Verbal Communication
-Social Isolation
What is sensory deprivation? - A decrease or lack of meaningful stimuli.
What are signs & symptoms of sensory deprivation? - -Excessive yawning
-Drowsiness
-Increased Amounts of Sleeping
-Impaired Memory
-Decrease of Attn Span
-Nocturnal Confusion
-Apathy
-Depression
-Crying
-Delusions
-Disoriented
What are causes of sensory deprivation? - -Restricting Environment
-Decreased Input for Senses
-Meaningless Stimuli
What is sensory overload? - When a person is unable to process or manage the amount
or intensity of sensory stimuli.
What are signs & symptoms of sensory overload? - -Fatigue
-Irritability
-Disorientation
Nursing Interventions for Various Sensory Impairments - Increase or Decrease Stimuli
-Explaining Care
-Visit More Often
-Orient
-Place TV, Radio, Calendar, Clock in Room
-Touch
-Elevate HOB
-Open/Close Door
-Turn Off TV
-Assist Out Of Bed, Ambulate
Normal Sensory Process Components - 1.) Reception (Nerve Cell Stimulation)
2.) Perception (Person is Aware of Stimuli)
3.) Reaction (Action)
Vibratory Sensations - Awareness of Vibrations, Use Tuning Fork, Place on Bony
Prominences, Joints
Kinesthetic Sensations - Aware of Position & Movement of Body Parts
Stereognosis Test - Can a patient identify an object through touch?
-Patient makes a fist around object & tries to identify it with their eyes closed.
Visceral Sensations - A stimulus that makes you aware of an organ.
-Ex: feeling full after eating.
How to Assess and Document LOC & Orientation? - "alert & oriented x 3"
-Oriented to Person, Place, Thing
, What patients are at risk for sensory disturbances? - -Risk for Injury
-Impaired Home Maintenance
-Risk for Impaired Skin Integrity
-Impaired Verbal Communication
-Social Isolation
What is sensory deprivation? - A decrease or lack of meaningful stimuli.
What are signs & symptoms of sensory deprivation? - -Excessive yawning
-Drowsiness
-Increased Amounts of Sleeping
-Impaired Memory
-Decrease of Attn Span
-Nocturnal Confusion
-Apathy
-Depression
-Crying
-Delusions
-Disoriented
What are causes of sensory deprivation? - -Restricting Environment
-Decreased Input for Senses
-Meaningless Stimuli
What is sensory overload? - When a person is unable to process or manage the amount
or intensity of sensory stimuli.
What are signs & symptoms of sensory overload? - -Fatigue
-Irritability
-Disorientation
