Normalcy:
Altered Sensory Input
Concept: Sensory Perception
Definitions: - Answer--Sensation: the ability to perceive stimulation through one's
... [Show More] 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 [Show Less]