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Number one goal is always
prevent injury
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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)
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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
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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
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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
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Sensory Deprivation clinical manifestations
- Cry over small things
- Hallucinations or Delusions
- Periodic Disorientation
- General Confusion
- Impaired Memory
- Excessive Yawning
- Decreased attention span
- difficulty concentrating
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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
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Factors that affects sensory function
- Development Stage
- Culture
- Stress
- Medication and Illness
- Lifestyle and Personality
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What is sensory overload
occurs when a person is unable to process or manage the amount or intensity of sensory stimuli
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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)
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Short Sensory Overload..
- causes thoughts to race in many directions
- causes restlessness and anxiety
- person feels overwhelmed/out of control
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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
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Sensory Perception
Conscious organization and translation of the data into meaningful info
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Sensory reception
- process of receiving stimuli
- External vs Internal
- External=visual, auditory, olfactory, gustation and tactile
- Internal= kinesthetic and visceral
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The 4 aspects of Sensory Process
- Stimulus
- Receptor
- Impulse Conduction
- Perception
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Perception
Awareness and interpretation of the stimuli {brain}
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Impulse Conduction
Impulse Travels from nerve to spinal cord or brain
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Receptor
Nerve cell that converts the stimulus to a nerve impulse
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Stimulus
Agent that stimulates a nerve
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RAS
Reticular Activating System
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What does RAS do
- Mediates arousal mechanism
- 2 components
- Reticular Excitatory Area (REA
- Reticular Inhibitory Area (RIA)
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RIA
Reticular Inhibitory Area
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REA
Reticular Excitatory Area
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Communicating Effectively
- Convey Respect
- Enhance Self-Esteem
- Ensure exchange of correct info
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impaired vision
- orient to environmant
- keep pathways clear
- organize belongings
- keep call light in reach
- assist with ambulation
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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
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impaired olfactory
- teach about the dangers of cleaning with chemicals
- teach about food poisoning
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impaired tactile
- risk for burns
- risk for pressure ulcers
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the confused client
- most commonly elderly
- Elderly at risk because
- chronic medical probs, medsm undertreated pain
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Acute vs Chronic Confusion
Abrupt Onset (if cause is treated confusion stops)
Gradual onset, Irreversible Syptoms
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