Final Funds Notes
Fundamentals Final Notes
Sensory perception
The ability to receive and interpret sensory impressions through
sight (visual), hearing (auditory), touch (tactile), smell
(olfactory), taste (gustatory) and movement or position
(kinesthetic)
For clients who Sit and face the clients
have hearing loss Avoid covering your mouth while speaking
Encourage the use of hearing devices
Speak slowly and clearly
Minimize background noise
Write what clients can't understand
Lower vocal pitch before increasing volume
For clients who Call clients by name before approaching to avoid startling them
have vision loss Identify yourself
Stay withing client's visual field if they have a partial loss
Give specific info about the location of items or areas of the
building
Explain interventions before touching them
Before leaving inform clients of your departure
Describe arrangements of food items on tray using clock
For clients who Greet clients call them by their name
have aphasia Make sure only one person speaks at a time
Speak clearly and slowly using short sentences and simple words
a disorder that results
from damage to portions Do not shout
of the brain that are Pause between statements to allow time for clients to understand
responsible for language.
Check for comprehension
Tell clients when you do not understand them
Ask questions that require simple answers
Reinforce verbal with nonverbal communication
Allow plenty of time for clients to respond
For clients who Call clients by name and identify yourself
are disoriented Maintain eye contact
Use brief, simple sentences
Ask only one quest at a time
Allow plenty of time for client to respond
Give directions one step at a time
Avoid lengthy conversation
Provide for adequate sleep and pain mgmt
Encourage clients to verbalize feelings about sensoriperceptual
loss
, Orient client to time, person, and situation: Keep clock in room,
post calendars, or write date where it is visible
Provide and use assistive devices
Provide care clients cannot do on their own
Stages of infection 1. Incubation: Interval between entrance of pathogen into body and
appearance of first symptoms
2. Prodromal: Interval from onset of nonspecific signs and
symptoms (malaise, low-grade fever, fatigue) to more specific
symptoms. (During this time microorganisms grow and multiply,
and patients may be capable of spreading disease to others.) For
example, herpes simplex begins with itching and tingling at the
site before the lesion appears.
3. Illness stage: Interval when patient manifests signs and symptoms
specific to type of infection. For example, strep throat is
manifested by sore throat, pain, and swelling; mumps is
manifested by high fever and parotid gland swelling.
4. Convalescence: Interval when acute symptoms of infection
disappear. (Length of recovery depends on severity of infection
and patient’s host resistance; recovery may take several days to
months.)
Rn: a nurse should access each client for the risks of infection specific to
the client, the disease or injury, and environment.
Inadequate hand hygiene is a risk factor for the spread of infection
Expected findings: Fever, Chills, increased pulse & RR, malaise,
fatigue, Nausea, vomiting, abdominal cramping, enlarged lymph
nodes.
Risk for injury in home environment
Visual Remove throw rugs to prevent tripping hazards
Keep walking pathways clear
Ensure that the stairways are well lit with secure handrails
Instruct client to use magnifying glass when reading
, Paint the edges of steps or replace steps with ramps
Auditory Use flashlights vs. a warning sound for alarms and doorbells
Olfactory Make sure smoke and carbon monoxide detectors are functioning to
sense odors and odorless gasses.
Remove sources of unpleasant odors (bedpans, soiled dressings)
Gustatory Read expiration dates on food packages to avoid consuming
contaminated or spoiled food products.
Promote good oral hygiene
Tactile Protect and inspect body parts that lack sensation from injury (burns,
pressure injuries, frostbite)
Avoid the use of hot water bottles
Lable faucets “hot” & “cold” with words or colors
Set hot water heaters to avoid excessively hot water 48.8 ° C (120°F)
is generally acceptable
Encourage the use of prescribed assistive devices
Sensory Deprivation Provide meaningful stimulation
Provide large-print materials or electronic players for audio
books
Amplify phones
Provide pleasant aromas
Increase touch (if acceptable) with back rubs, hand holding,
ROM exercise, and hair care
Ensure client has vision & hearing assistive devices
Communicate frequently with the client.
Encourage family to bring flowers, sculptures, pictures, pets (if
allowed)
Provide objects with various textures. Encourage to engage in
activities
Sensory Overload Minimize overall stimuli:
Provide private room
Reduce lights and noise. Offer the client ear plugs and dark
glasses if needed
Provide orientation cues (calendars, clocks)
Limit visitors
Reduce unpleasant odors
Assist with stress reduction
Ensure pain is adequately managed
Schedule sleep to minimize interruptions
Presbyopia Age-related loss of the eyes ability to focus on close objects due to decreased
elasticity of the lens
Fundamentals Final Notes
Sensory perception
The ability to receive and interpret sensory impressions through
sight (visual), hearing (auditory), touch (tactile), smell
(olfactory), taste (gustatory) and movement or position
(kinesthetic)
For clients who Sit and face the clients
have hearing loss Avoid covering your mouth while speaking
Encourage the use of hearing devices
Speak slowly and clearly
Minimize background noise
Write what clients can't understand
Lower vocal pitch before increasing volume
For clients who Call clients by name before approaching to avoid startling them
have vision loss Identify yourself
Stay withing client's visual field if they have a partial loss
Give specific info about the location of items or areas of the
building
Explain interventions before touching them
Before leaving inform clients of your departure
Describe arrangements of food items on tray using clock
For clients who Greet clients call them by their name
have aphasia Make sure only one person speaks at a time
Speak clearly and slowly using short sentences and simple words
a disorder that results
from damage to portions Do not shout
of the brain that are Pause between statements to allow time for clients to understand
responsible for language.
Check for comprehension
Tell clients when you do not understand them
Ask questions that require simple answers
Reinforce verbal with nonverbal communication
Allow plenty of time for clients to respond
For clients who Call clients by name and identify yourself
are disoriented Maintain eye contact
Use brief, simple sentences
Ask only one quest at a time
Allow plenty of time for client to respond
Give directions one step at a time
Avoid lengthy conversation
Provide for adequate sleep and pain mgmt
Encourage clients to verbalize feelings about sensoriperceptual
loss
, Orient client to time, person, and situation: Keep clock in room,
post calendars, or write date where it is visible
Provide and use assistive devices
Provide care clients cannot do on their own
Stages of infection 1. Incubation: Interval between entrance of pathogen into body and
appearance of first symptoms
2. Prodromal: Interval from onset of nonspecific signs and
symptoms (malaise, low-grade fever, fatigue) to more specific
symptoms. (During this time microorganisms grow and multiply,
and patients may be capable of spreading disease to others.) For
example, herpes simplex begins with itching and tingling at the
site before the lesion appears.
3. Illness stage: Interval when patient manifests signs and symptoms
specific to type of infection. For example, strep throat is
manifested by sore throat, pain, and swelling; mumps is
manifested by high fever and parotid gland swelling.
4. Convalescence: Interval when acute symptoms of infection
disappear. (Length of recovery depends on severity of infection
and patient’s host resistance; recovery may take several days to
months.)
Rn: a nurse should access each client for the risks of infection specific to
the client, the disease or injury, and environment.
Inadequate hand hygiene is a risk factor for the spread of infection
Expected findings: Fever, Chills, increased pulse & RR, malaise,
fatigue, Nausea, vomiting, abdominal cramping, enlarged lymph
nodes.
Risk for injury in home environment
Visual Remove throw rugs to prevent tripping hazards
Keep walking pathways clear
Ensure that the stairways are well lit with secure handrails
Instruct client to use magnifying glass when reading
, Paint the edges of steps or replace steps with ramps
Auditory Use flashlights vs. a warning sound for alarms and doorbells
Olfactory Make sure smoke and carbon monoxide detectors are functioning to
sense odors and odorless gasses.
Remove sources of unpleasant odors (bedpans, soiled dressings)
Gustatory Read expiration dates on food packages to avoid consuming
contaminated or spoiled food products.
Promote good oral hygiene
Tactile Protect and inspect body parts that lack sensation from injury (burns,
pressure injuries, frostbite)
Avoid the use of hot water bottles
Lable faucets “hot” & “cold” with words or colors
Set hot water heaters to avoid excessively hot water 48.8 ° C (120°F)
is generally acceptable
Encourage the use of prescribed assistive devices
Sensory Deprivation Provide meaningful stimulation
Provide large-print materials or electronic players for audio
books
Amplify phones
Provide pleasant aromas
Increase touch (if acceptable) with back rubs, hand holding,
ROM exercise, and hair care
Ensure client has vision & hearing assistive devices
Communicate frequently with the client.
Encourage family to bring flowers, sculptures, pictures, pets (if
allowed)
Provide objects with various textures. Encourage to engage in
activities
Sensory Overload Minimize overall stimuli:
Provide private room
Reduce lights and noise. Offer the client ear plugs and dark
glasses if needed
Provide orientation cues (calendars, clocks)
Limit visitors
Reduce unpleasant odors
Assist with stress reduction
Ensure pain is adequately managed
Schedule sleep to minimize interruptions
Presbyopia Age-related loss of the eyes ability to focus on close objects due to decreased
elasticity of the lens
