NSG 101 Exam 4 Study: Sensory Perception and Restraints

4 components of the senses

• Stimulus

• Reception

• Perception

• Arousal Mechanism

Stimulus

aka sensation. -anything that triggers a nerve receptor.- can be internal or external (doorbell rings, bubbles in stomach, smell smoke). -sight, smell, taste, touch, sound, pain, proprioception. -will vary based on personal experiences (depends on reception and how the brain processes it)

Reception

• Process of receiving stimuli from nerve endings.

• Nerve impulse is sent along sensory neurons to the brain (CNS)- receive sound, smell, etc.

• Adaptation

• Specialized receptors

Adaptation

• some receptors keep “firing” until the stimulus is removed.

• some receptors “adapt” (stop sending signal) and the response declines

Specialized receptors

• Mechanoreceptors (skin, hair follicles)= touch.

• Hair cells (cochlea-inside ear)= sound, pressure, position changes

• Thermoreceptors (skin)= temperature

• Proprioceptors (skin, muscles, joints)

• Photoreceptors (eye) -Rods: light vs dark -Cones: color

• Chemoreceptors (tongue)= taste buds

• Olfactory receptors (nasal cavity)= smell

Perception

-interpreting our sensory input. -ability to give meaning to impulses. -not all stimuli “get through” -brain discards stimuli it deems unimportant.

-specialized areas of the brain handle different sensory impulses:

Occipital lobes

(part of perception). vision.

Temporal lobes

(part of perception). sound.

Somatosensory area

(part of perception). touch.

Arousal Mechanism

aka paying attention. composed of consciousness and alertness. -mediated by reticular activating system (RAS). -anesthesia, sedatives, opioids, darkness, and quiet can depress the RAS.

Newborns

• Visual= tracking and light vs. dark, but no acuity

• Hearing= hear low frequencies best

• Taste= prefer sweet

• Smell= know smell of mother’s breast milk vs. strangers

• Tactile= face, hands, and soles are most sensitive

Infants

• Visual= lights, color, and contrast

• Hearing= can discriminate sounds and voices of familiar people

• Tactile= enjoy cuddling, feeding, touch

Children and Adolescents

• Visual= improved acuity, full depth perceptions

• Hearing= fully developed, frequent ear infections in young children

• Psychomotor= steady on feet, learning motor skills (bicycle, bouncing ball, etc.)

Adults

• Senses peak unless impaired by disease state or injury

Older adults

• Experience decline in sensory ability

Myopia

nearsightedness (distant objects blurry, closer objects clear)

Hyperopia

farsightedness (distant objects clear, closer objects blurry)

Presbyopia

age related farsightedness

Astigmatism

distortion of images

Cataracts

clouding of lens

Glaucoma

increased pressure, damage to the optic nerve

Macular degeneration

central vision loss (inability to see in front of you)

Strabismus

misalignment of eyes (don’t look in same direction)

Retinopathy

damage to nerves often from uncontrolled DM ll (diabetic retinopathy is the leading cause of blindness in adults)

Conduction deafness

loss of soundwave transmission (infection. ruptured membrane, etc.)

Sensorineural hearing loss

damage to CN Vlll or hair cells (ototoxic meds, viruses, heredity)

Presbycusis

age related hearing loss

Central deafness

damage to temporal lobe

Tinnitus

ringing in ears (trauma, infection, etc)

Otitis media

ear infection

Impacted cerumen

ear wax

Otosclerosis

hardening of bones in ear

Nursing interventions for sensory overload

• reduce unnecessary light

• empty commodes, bedpans

• minimize noise

• remove meal trays

• keep wounds covered

• avoid perfume

• promote sleep

Nursing interventions for visual deficits

• verbally alert pt to your presence

• adequate lighting

• prevention (DM education, risk factors)

• corrective lens

• large print/ braille materials

• audio material

• tell where you are

Nursing interventions for hearing deficits

• education/prevention (protecting your ears)

• minimize background noise

• enunciation

• speak directly to pt

• sign language

• hearing aids

Restraints

devices used to prevent patients from harming themselves or others when alternative interventions are not effective

Types of chemical restraints

• Benzodiazepines (diazepam, midazolam)

• Antipsychotics (haloperidol)

• Neuromuscular blocking agents/ Paralytics (rocuronium)

  • any patient on a paralytic has to be sedated.

Restraint Guidelines

~Restraint-free environment is standard of care. ~Violates fundamental rights of autonomy and dignity. ~Justified to prevent injury of patient and staff. ~Documentation by more than 1 witness. ~Discontinue at earliest possible time. ~Can NEVER be standing orders. ~Treating physician must be consulted ASAP if ordered by another provider. ~Must be evaluated within 1 hr. of initiation by the provider. ~q 15 min assessment. ~Removed q hour and assessed for injury.