SENSORY

Question 1

Interventions for various sensory impairments

Answer 1

1. increase stimuli/meaning by explaining care
2. decrease stimuli
3. visit more and orient often
4. place tv, radio, calendar or clock in room
5. give familiar objects
6. touch pt
7. elevate HOB
8. open door
9. assist OOB & w amb.

Question 2

Normal sensory process components

Answer 2

1. reception (nerve cells receiving stimulus)
2. perception (person becomes aware of stimulus)
3. reaction (action taken to respond to stimulus)

Question 3

visceral sensations

Answer 3

stimuli that makes you aware of an organ

i.e.
full stomach

Question 4

kinesthetic sensations

Answer 4

awareness of position and movement of body parts

Question 5

vibratory sensations

Answer 5

using tuning fork on bony prominences to make sure pt can detect vibrations and know when those vibrations stop

Question 6

stereognosis sensation

Answer 6

putting an object in the pt’s hand and having them identify it w their eyes closed

ability to perceive and understand an object through touch

Question 7

Orientation

Answer 7

alert, oriented (x3) to person, place, and time

understands verbal and written words

“alert & oriented x 3”

Question 8

Pts at high risk for various sensory disturbances

Answer 8

1. risk for injury
2. impaired home maintenance
3. risk for impaired skin integrity
4. impaired verbal communication
5. social isolation

Question 9

Definition of sensory deprivation

Answer 9

decrease or lack of meaningful stimuli

Question 10

S/S of sensory deprivation

Answer 10

1. excessive yawning
2. drowsiness
3. increased amt of sleeping
4. decreased attention span
5. impaired memory
6. disorientation
7. nocturnal confusion
8. delusions
9. crying
10. apathy
11. depression

Question 11

causes of sensory deprivation

Answer 11

1. restricting environment
2. decreased input from impaired senses
3. meaningless stimuli

Question 12

definition of sensory overload

Answer 12

person unable to manage/process the amt or intensity of sensory stimuli

Question 13

S/S of sensory overload

Answer 13

1. fatigue
2. irritability
3. anxiety
4. disorientation
5. muscle tension

Question 14

causes of sensory overload

Answer 14

1. too much stimuli
2. meaningless stimuli
3. repetitions/unchanging stimuli

Question 15

interventions for sensory overload

Answer 15

1. decrease stimuli & interruptions
2. organize care efficiently
3. close door
4. turn off tv
5. decrease odors & noise levels
6. restrict visitors/calls
7. provide comfort

Question 16

interventions for sensory deprivation

Answer 16

1. increase stimuli/meaning
2. explain care
3. visit more
4. place tv, radio, clock, or calendar in room (familiar objects)
5. touch more
6. elevate HOB

Question 17

NANDA Dx R/T sensory needs

Answer 17

1. acute confusion
2. chronic confusion
3. impaired memory