Final Fundamentals Exam

Sensory experience is

Vital to survival

Sensory reception

Process of receiving data about external/internal environment through senses

External Environment Sensory

• Light

• Noise

• Visitor

Internal Environment Sensory

• IV line

• Pain

• Implanted device

Sensory Receptions

• Visual

• Auditory

• Olfactory

• Gustatory

• Tactile

• Stereognosis

• Kinesthesia

• Proprioception

Visual Reception

Sight

Auditory Reception

Hearing

Olfactory Reception

Smell

Gustatory Reception

Taste

Tactile Reception

Touch

Stereognosis Reception

Recognizing 3D objects

Kinesthesia Reception

Position and movement of the body

Proprioception Reception

Body’s awareness

Sensory Perception

Conscious process of selecting, organizing, and interpreting data from senses into meaningful information

Sensory Process

• stimulus initiates response

• Receptor/sense receive stimulus

• Conducted to brain

• Brain receives and translates

Reticular Activating System (RAS)

Monitors/regulates incoming sensory stimuli (maintaining/enhancing, inhibiting cortical arousal)

Sensoristasis

Optimal arousal state of RAS

RAS extends from

Hypothalamus → medulla and mediates arousal

Types of conscious states

• Delirium

• Demetria

• Confusion

• Minimally/Normal consciousness

• Somnolence

• Locked-In syndrome

Types of Unconscious States

• Asleep

• Stupor

• Coma

• Vegetative State

Sensory Deprivation

Decreased sensory input (insufficient quality/quality of stimuli)

Examples of sensory deprivation

• long term care

• Assisted living

• Prison

Nursing intervention w/ sensory deprivation

• provide visual, auditory, gustatory, olfactory, and tactile stimuli

• Ask for cognitive/emotional input

Sensory Overload

Excessive sensory stimuli (pt feels out of control)

Example of sensory overload

• hospital unit

• Concerts

• Crowded/noisy/congested streets

Nursing interventions w/ sensory overload

• Schedules

• Simple explanations

• Reduce/eliminate stimuli

• Provide consistent/predictable stimuli to help develop sense of control

Sensory Deficit

An impaired or absent function in one or more senses

Examples of sensory deficits

Visual deficit from welding or gustatory deficit = decreased taste sensation

Sensory Processing Disorder

Difficulty in the way, the brain organizes and uses sensory information, causing problems interacting effectively in every day environment

Why sensory processing disorder happens

1. Nervous system = not detect/receive sensory info

2. Brain may not process sensory

3. Disorganized brain cells inaccurate messages

Sensory changed in aging

• Decreased vision (cataracts/glaucoma)

• Decreased hearing (presbyeusis, tinnitus)

• Changes in smell/taste (cant detect sweets)

• Changes in peripheral sensation (diabetic neuropathy, phantom limb pain)

Communication techniques w/ confused patients

• face to face

• Speak calmly, simply, directly

• Orient/reorient pt to environment

• Ensure pt room board is current/correct

• Communicate expectations

• Verbally reinforced patient strength

• Reinforce reality and use object objects from patient’s past

Vision Education to Pt

• don’t rub eyes

• Avoid UV light

• Visit doctor if vision changes

• Protect eyes from object

• Don’t clean eyes with soiled materials

Hearing Education to Pt

• avoid excess noise

• No excessive car cleaning

• Don’t put objects in ears

Nurse Assessment/Diagnosis

• Assess: stimulation reception, vision, auditorium gustatory

• Diagnosis: impaired vision/hearing/taste/tactile perception/kinesthetic functioning

Taste Education to Pt

• oral care 3x day

• Adjust diet to taste

• Enhance taste w/ spices

Smell Education to Pt

Avoid strong perfume/cologne

Touch Education to Pt

Provide texture and touch

Stress

Condition in which the human system responds to changes in its normal balance state

Stressors

Anything that is perceived as challenging, threatening, or demanding that triggers a stress reaction

Types of stressors

• Internal

• External

• Physiological

• Psychological

Internal Stressors Example

• Illness

• Fear

External Stressors Example

• Noise

• Cold weather

Physiological Stressors Example & Symptoms

• Infection

• Chemical

• Hypoxia

• Tachycardia/Nausea/Diarrhea

Physiological Stressors Example & Examples

• Economic

• Accidents

• Can cause illnesses

Stressors are..

Highly individualized

Adaption

Change that takes place in response to a stressor

Stress affects..

Health illness continuum (bad for sick/injured pt)

Local Adaptation Syndrome (LAS)

Localized response of the body to stress (short term, specific body part)

LAS Type 1:

Reflex pain response (CNS, rapid/autonomic, protective to prevent injury)

LAS Type 2:

Inflammatory Response (local response to injury/infection, prevents infection spread, promotes wound healing)

Stage 1 of General Adaptation Syndrome

Fight or Flight (hypertension, ^mental awareness, ^RR, muscle tension)

Effects of Stress

• Changes in appetite, activity, sleep

• Change in elimination patterns

• ^ pulse, ^RR, ^ BP

• Feeling anxious, nervous, threatened

• Blaming others

• Feeling inattentive

Stage 2 of General Adaptation Syndrome

Resistance body mounts a response and copes w/ stressors

Stage 3 of General Adaptation Syndrome

Exhaustion (when adaptive response can no longer provide a defense, Exhaustion or Death)

Stress in Older Population

Known risk for elderly (doesn’t lower as you age)

Causes of stress in elderly

• Health related

• Surgical procedures

• Loss of spouse

• Retirement

• Chronic pain

• Loss of independence

• Low physical/mental capabilities

Anxiety

vague, uneasy feeling of dread/discomfort, known source, apprehension (anticipating danger)

Levels of Anxiety

• Mild

• Moderate

• Severe

• Panic

Mild Anxiety

^ alertness/perception/ability to focus

Moderate Anxiety

Narrowed perceptual fuel, focusing on immediate concerns

Severe Anxiety

All behavior is geared towards getting relief

Panic

Loss of control, experience dread and terror

Defense Mechanisms

Unconscious reactions to stress to protect self-esteem and lower stress (mild-moderate)

Repression

Unconsciously pushing unpleasant feelings out

Regression

Younger age behavior (sucking thumb)

Denial

Lack if recognition obvious to others

Projection

Putting own feelings onto other

Supression

Intentionally pushing unpleasant feelings out

Rationalization

Making excuses to explain situation

Compensation

Making up for mistakes through extreme efforts, gift giving, hard work

Coping mechanisms (anxiety)

• Crying

• Deep breathing

• Smoking

• Drinking

• Physical activity

• Sleeping

• Laughing

Coping mechanisms are…

Emotional expressions, not distortions of reality, so they are coping

Stress Management Techniques

• Relaxation (deep breathing, muscle relaxation, autogenic training)

• Mindfulness (mediation, intentional presence and focus)

• Anticipatory Guidance (preparing person for unfamiliar/painful event, teach about procedures)

• Guided Imagery (creates mental image, concentrates on it to lessen pain)

Effects of Stress

• Long Term: danger to physical/emotional health

• Family Stress: caregiver burden, stress family/significant others

• Crisis: usual methods of coping become ineffective

State Legislation

• scope of practice (nurse practice act)

• Education requirements

• Disciplinary authority of board of nursing

Federal legislation

• Medicare/Medicaid provisions related to reimbursement for nursing services

Board of nursing

• Delegation

• Licensing

• Medication administration

• Unprofessional conduct

Healthcare institution

Clinical procedures and policies

Accreditation

Quality education from accredited nursing program

Licensure

Ensure entry-level competence

Credentialing includes

• accreditation

• Certification

• Licensure

Crime

Punishable by state (rape, fraud, theft, etc.)

Felony

Punishable by imprisonment (>1yr)

Misdemeanor

Less serious, fine or imprisonment (<1yr)

Tort

Civil action (fine)

Intentional tort

• Assault/battery

• Defamation of character

• Invasion of privacy

• False imprisonment

• Fraud

Unintentional Tort

• Negligence

• Malpractice

What four elements must liability involve to be proven

• Duty

• Breach of duty (nurse didn’t do her duty)

• Causation (did it cause pt harm?

• Damages (did harm cause damage?)

safeguards in nursing practice

• Respect, legal boundaries of nursing practice/no institutional practices and policies

• Respect, patient rights

• Practice good communication skills

• Be competent in your practice

• Document everything

You should never document..

• How you felt

• What you think/wish happened

• Unapproved abbreviations

We should always look over documentation to

Find anything out of the ordinary or may harm someone (risk)

Documentation should consist of..

• facts

• Names/person involved

• Witnesses names

• Date and time

• place of incident

• Equipment involved

• Pertinent characteristics of person involved

• Action taken

Nursing is the #1 most..

Trusted profession

Ethics

Principles of write or wrong (begins an early childhood)

Nursing Ethics

Subset of ethics (bioethics) practice/analysis nurses used to make and evaluate clinical judgment

Ethics include

• foundation for morality/moral behavior

• Involve critical thought and action

• Metaethics, normative ethics applied (practical) ethics

Law

• Standard of rule of conduct

• Enforced by government

• Protect rights of public

Autonomy (self-determination)

Respect the rights of patients or their surrogates to make healthcare decisions

Nonmaleficence

Avoid causing harm