Normalcy: Altered Sensory Input

Normalcy: Altered Sensory Input Concept: Sensory Perception Definitions: - Answer--Sensation: the ability to perceive stimulation through one's sensory organs such as the nose, ears, and eyes. This stimulation can be internal, external and includes feelings of pain temperature and light; includes the 5 senses (vision, hearing, taste, smell, touch). Perception: the process by which we receive, organize and interpret sensation. Sensory Perception: the ability to receive sensory input and through various physiological processes in the body, translate the stimulus or data into meaningful information. Concept: Sensory Perception - Risk Factors - Answer--Individual Risk Factors - medications, lifestyle choices, medical conditions, occupation Elderly - decline in sensory/perceptual functions with aging --Vision - systemic (dm, htn), primary eye disorders (cataracts, glaucoma, macular degeneration; decreased ability to focus on near objects (presbyopia) --Hearing - age related hearing loss (presbycusis) typically r/t sensorineural (changes in nerve pathways from inner ear to brain) a decrease in the ability to process sound --Olfactory and Gustatory - decrease in the olfactory cells and in the olfactory cilia receptors that send signals to the brain. Taste declines r/t decrease in olfactory cells and potential chewing problems and tooth loss; decrease in number of taste cells. --Tactile Perception - tactile thresholds increase (perceptibility to the sense of touch). Potential for injury from heat and cold. Concept: Sensory Perception Nursing Management - Answer--History and Physical Exam --Vision: changes, exam, EOM, Snellen interior eye --Hearing: difficulty hearing, tinnitus, ear pain, exam, hearing test --Taste: check smell, medications, exam - tongue, oral --Smell: history, medications, uri/sinus, polyps, inspection nose, breathing --Touch: neuro r/t touch/balance - Romberg, monofilament, sharp/dull, location Diagnostic Tests: vision, hearing - auditory brainstem response (brain activity with sound) Clinical Management --Primary - protect eyes and ears, silver nitrate gtt newborn, oral care, chronic condition management - dm, heart disease --Secondary - screening tests - vision, hearing --Collaborative Interventions - surgery, pharmacotherapy, adaptive methods - dogs, braille, sign language Assessment of Eye - Answer--History External assessment Visual fields, & eye movement Eye position- exophthalmos, enophthalmos Eye lids and lashes Blink response Conjunctivae, sclera Light reflex- accommodation v. light reflex Fundus - Answer--Fundus is normally orange-red color- darker on darker complexion Normal look to blood vessels Optic Disc where blood vessels converge is yellowish to pale pink with well defined margins Macula responsible for central vision- always temporal to optic disc Age Related Changes - Answer--Smaller pupils, do not dilate easily- night vision a problem Lens less elastic- near object difficult to see Lens becomes opaque- color perception Decreased depth perception, peripheral Eyes recessed in socket- tissue folds on lids Decreased strength of muscles of eye movement Conjunctivitis - Answer--Conjunctiva covers inner lid and external eye Inflammation from bacteria or virus Extremely contagious- "Pink Eye" Redness and itching, gritty sensation Tearing and discharge Inflamed preauricular nodes Treated with antibiotic drops and pills Nursing Issues With Eye Infections - Answer--Pain