Chap 44: Taylor

Chap 44: Taylor
Sensory Functioning
I. The Sensory Experience
A. Components and Conditions
-Two Components
RECEPTION and PERCEPTION
>sensory reception: the process of receiving data
about the external or internal environment
through the senses (stereognosis, kinesthesia,
visceral, proprioception)
>sensory perception: is the conscious process of
selecting, organizing, and interpreting data from
the senses into meaningful info

For a person to receive the necessary data to experience the world, FOUR conditions must be met:
1. a STIMULUS- an agent, act, or other influence
capable of initiating a response by the nervous
system- must be present
2. A receptor or sense organ must receive the stimulus
and convert it to a nerve impulse
3. The nerve impulse must be conducted along a
NERVOUS PATHWAY from the receptor or sense
organ to the BRAIN
4. A particular area in the brain must receive and
translate the impulse into a sensation
B. Arousal Mechanism
-to receive stimuli and respond appropriate the
brain must be alert and aroused
-The RAS - mediates arousal
>sensoristasis: nerve impulses from all the
sensory tracts reach RAS, which then selectively
allows certain impulses to reach the cerebral
cortex and be perceived
>adaptation (stimulus must be irregular)
-our response to a stimulus goes to our RAS and
then our RAS tells us whether we are awake
alert or in a coma.
-SEE BOX 44-1 (Delirium/Dementia)
II. Disturbed Sensory Perception
-severe sensory alterations can occur in ICU
A. Sensory Deprivation
-results when a person experiences decreased
sensory input or input that is monotonous,
unpatterned, or meaningless
-may hallucinate
-high risk: an environment w/ decreased or
monotonous stimuli, impaired ability to
receive environmental stimuli, inability to
process environmental stimuli
-can lead to:
>perceptual responses (daydreams)
>cognitive responses (decreased attention span
decreased ability to concentrate, memory probs
>emotional responses (apathy, rapid mood
changes, panic, depression)

B. Sensory Overload
-person feels out of control
-strange sights, odors, sounds @hospital
-nrg care focuses on reducing distressing stimuli
and helping pt gain control over environment
C. Sensory Deficits
-impaired or absent functioning in one or more
senses

SEE Box 44-2 pg 1580


II. Factors Affecting Sensory Stimulation
A. Developmental Considerations
-newborns need lot of stimulus
-NICU babies need less stimulus
-children need play
-older adult: see pg 1582
B. Culture: touch or no touch?
C. Personality/ Lifestyle
D. Stress and Illness (less stimulus)
E. Meds
-can alert or depress the CNS
-some can impair sensory functioning (taste)

IV. The NURSING PROCESS
A. Assessing
-the pt and the environment
1. Identify at-risk pts: aging, diseases, social, work
LOUD NOISES: ear plugs
2. Assess the sensory experience: stimulation,
reception, and transmission, perception,
reaction
Have there been any changes in stimulation?
high risk> bed rest, isolation pts, ICU, elderly
Corrective devices: glasses
is the pt confused? CNS impaired?
observe for boredom, inactivity, day dreaming,
^ sleeping, anxiety, panic, illusions
3. Physical Assessement: Eyes/EARS
4. Asses self-care abilities> orient to surroundings
B. DX
-Disturbed Sensory Perception (problem)
-Risk for Injury, Anxiety (etiology)
C. Outcome Id/ Planning
-optimal sensory stimulation is priority
-the pt will:
>live in a developmentally stimulating
and safe environment
>exhibit a level of arousal that enables the
brain to receive and meaningfully organize
patterns of the senses
>maintain orientation to time, place, person
>verbalize acceptance of deficit
D. Implementing
-SAFETY
1. Preventing Disturbed Sensory Perception and
Stimulating the Senses
>prevention with pt's help
>rest/comfort
>be aware of the need for sensory aids or
prostheses
>encourage physical activity/exercise
>stimulate all senses
>social activities
>enlist help of fam
2. Teaching about Sensory Experiences
>explain procedures
>teach how to stimulate senses
>SEE TEACHING TIPS pg 1591
>SEE TABLE 44-1
Meeting the Needs of Pts w/ Reduced Vision

prevention: avoid rubbing eyes, avoid
eye strain, vision tests, etc

communicating with pt:
>acknowledge your presence
>speak in NORMAL tone
>orient person
>call light within reach
>indicate conversation has ended

Pts with reduced hearing:
-PREVENT: avoid excessive noise, avoid excessive
cleaning

-Communicating:
-decrease background noise
-make sure hearing aid is working
-make sure pt can read your lips
-write


Communicating w/ a Confused Pt:

-use frequent face to face contact
-speak calmly, simply, directly
-orient and reorient
-time, place, person
-use objects from pts past

Communicating w/ Unconscious Pt

-be careful what you say
-use normal tone
-speak to person before touching
-keep noise at low level