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WEEK 3 NOTES

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WEEK 3 STUDY GUIDE
The Concept of Sensory Perception (p. 1381-1404)
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Sensory perception
o Is protective, such as a mother sensing that the bath water is too hot as she sees the steam rise
from the water. It is also complex, allowing individuals to master activities that require the use
of multiple senses at once, such as driving a car.
Alterations in sensory perception affect:
o Self-care, mobility, safety, independence, communication, and relationships with others
Normal Sensory Perception
o Sensory process involves 2 components:
 Reception
 Perception
o Sensory reception
 Process of receiving stimuli or data
 Either:
o External
 Visual
 Auditory
 Olfactory
 Tactile
 Gustatory
o Internal
 Gustatory
 Kinesthetic
 Awareness of the position and movement of body parts
 Stereognosis
 Ability to perceive and understand an object through
touch by its size, shape and texture
 Visceral
 Any large organ in the body
 Ex: full stomach
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To be aware of the surroundings, 4 sensory processes must be present:
 Stimulus
o Agent or act that stimulates a nerve receptor
 Receptor
o Nerve cell acts as a receptor by converting the stimulus to a nerve
impulse. Most receptors are specific, that is, sensitive to only one type of
stimulus, such as visual, auditory, or touch.
 Impulse conduction
o The impulse travels along nerve pathways to the spinal cord or directly to
the brain.
o EX: auditory impulses travel to the organ of Corti in the inner ear. From
there, the impulses travel along the eighth cranial nerve to the temporal
lobe of the brain
 Perception
o Awareness and interpretation of stimuli, takes place in the brain.
o Cognition
 Process by which an individual learns, stores, retrieves, and uses information
o Awareness
 Ability to perceive environmental stimuli and body reactions and to respond
appropriately through thought and action
o Alterations of Sensory Perception
 Alterations and Manifestations
 Vertigo
o Feeling of rotation or imbalance
o Acute or chronic
o May/may not accompanied by nausea
o Difficulty with balance and nystagmus
o Caused by:
 Strokes
 Brain tumors
 Head trauma
 Viruses
 Idiopathic
 Color Blindness
o One or more pigments are missing within the cones in the retina
o Most common variant (red/green)
 Impaired sense of smell
o Commonly assoc. with respiratory illness
o Normal aging process
o Medication side effects
o Tobacco smoking
o Radiation
o Parkinsons, MS
 Taste disturbances
o Normal aging process
o Medication side effect
o Smoking
o Infection
o Gum disease
o Genetic Considerations and Risk Factors
 Illness
 Atherosclerosis, hypertension, strokes, uncontrolled diabetes, maternal
diabetes, repeated otitis media infections
o Health Promotion
 Test each senses
 With older adults – provide information about risk factors and encourage patients to
engage in activities that would slow or halt this process.
o Modifiable Risk Factors
 Regular eye exams
 Controlling chronic diseases
 Avoiding hot temperatures (tactile)
 Smoking
 Constricts BV’s that supply eyes and optic nerve
 Unprotected UV exposure
 Medication
 Narcotics and sedatives
 Antidepressants
 Stress
 Isolation
 Touch is important
 Injuries
 All eye injuries are emergency
o Screenings
 Hearing
 Newborns are screened
 School-aged children get periodic screenings at school
 Adults screened every 10 years until 50.
 50+ is every 3 years
 Vision
 Children between 3 and 5 get screening once
 Adults should get one at the age of 40
 Taste, Smell, Touch
 No recommended screening guidelines
o Nursing Assessment
 Observation and Patient Interview
 Mental Status Examination
 Sensory alterations can cause changes in mental status, and an altered mental
status can cause changes in sensory perception
 Identification of Patients at Risk
 The patient may be at higher risk of developing sensory alterations if he or she
has altered mobility, has multiple comorbidities, is older, is involved in contact
sports, or smokes.
 Patient’s Environment
 Inadequate environmental stimulation may place the patient at risk for sensory
deprivation; excessive stimulation may increase the risk for sensory overload.
 Patient’s Social Support Network
 The degree of isolation an individual feels is significantly influ enced by the
quality and quantity of support from family mem bers and friends.
 Physical Examination
 Visual acuity, using a Snellen chart or other reading material such as a
newspaper, and visual fields, using picture charts for those with limited reading
or language proficiency
 Hearing acuity, by observing the patient’s conversation with others and by
performing the whisper test and the Weber and Rinne tuning fork tests
 Olfactory sense, by identifying specific aromas
 Gustatory sense, by identifying three tastes such as lemon, salt, and sugar
 Tactile sense, by testing light touch, sharp and dull sensation, twopoint
discrimination, hot and cold sensation, vibration sense, position sense, and
stereognosis
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Eye and Vision Assessment
 Try with and without corrective lenses
o Snellen or E chart for distance vision
o Rosenbaum chart for near vision
 Cardinal fields of vision:
o Tests extraocular eye movements
o Nurses should ask the patient to follow a pen or their finger while
keeping the head stationary. Nurses move the pen or their finger through
the six fields one at a time, returning to the central starting point before
proceeding to the next field
 Internal structures of the eye are assessed by opthamnoscope by physician
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Ear and Hearing Assessment (p. 1395)
 Inspect external ear
 Otoscope to inspect external auditory canal and tympanic membrane
o Tympanic membrane should be shiny, translucent and gray in color
o Should reflect a well defined cone or light – any deviation from this may
indicate an infection or fluid behind the eardrum
 Whisper test to evaluate level of hearing (any deviation is noted bilateral or
unilateral)
 Weber Test
o Tuning fork test – prefer to use 512-1024Hz (corresponds to normal
speech)
o Placed on midline vertex of the patients head and asked if both ears hear
sound the same
 Rinne Test
o Place vibrating tuning fork on patient’s mastoid bone and ask the patient
to indicate when sound is no longer heard.
 With young kids, clapping or other means to create noise are used
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Taste, Smell, and Tactile Assessment
 Using smell cards or familiar smells
 There are many different ways to test for tactile function using sharp, dull,
warm, and cold objects as well as: temperature, vibratory, deep pressure pain,
and position sense (if sensory lost is found)
o Goal is checking for symmetry
o Graphesthesia
 Ability to recognize a letter that is written on the skin
o Two point discrimination is performed by asking a patient to close the
eyes and report whether one or two points of contact are felt on the skin.
o Independent Interventions
 Independent interventions focus on education, injury prevention, and wellness
promotion.
 Patient teaching is essential especially in regards to safety
 Preventing Sensory Overload
 Patients with risk of being overstimulated
o Nurse aims to reduce number and types of environmental stimuli
o Earplugs, sunglasses, quiet period etc..
 Preventing Sensory Deprivation
 Newspapers, music, books, television – visual and auditory
 Soft fabrics – tactile stimulation
 Fresh flowers can stimulate the olfactory sense
 Arrangements for people to visit regularly
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Managing Acute Sensory Deficits
 Sensory Aids
o Used for those with hearing and visual deficits
o Service dogs
 Promoting the Use of Other Senses
o For some, when one sense is lost, one or more of the intact senses are
heightened to compensate.
 Communicating Effectively
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Promoting Effective Coping
 Impaired Vision
o Vision impairment shows greater disability in ADL’s
o Nurses watch for increased depression
o Nurses should teach patients and their families the importance of
organizing the patients living environment
 Impaired Hearing
o For safety, patients should obtain devices that either amplify sounds or
responds to sounds with flashing lights
o Closed captioning
 Impaired Olfactory Sense
o Taught the dangers of cleaning with chemicals like ammonia
o Needs to keep gas running appliances in good working order
o Food poisoning is of concern (watch expirations)
 Impaired Tactile Sense
o Patients not aware of hot temperatures and pressure ulcers
 Use thermometer and change positions frequently
o Collaborative Therapies
 Vision
 Optometrist
o Eye exams and prescribe corrective lenses
 Ophthalmologist
o More severe disorders requiring surgery and more advanced treatment
 Optician
o Trained to help fit glasses and frames
 Physical Therapist or Occupational Therapist
 Hearing
 Audiologist
o Provides hearing exams and prescriptions for hearing aids
o Diagnose and treat balance disorders
o Provide hearing or speech rehabilitation
 Otolaryngologist
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o Physician that diagnose and treat ear, nose, and throat disorders
o Patients with smell or taste disorders
Hearing instrument specialist
o Trained to fit patients with hearing aids
Physical Therapist or Occupational Therapist
American Sign Language classes
Neurologist
o If sight or hearing loss is related to loss of nerve conduction
o Surgery
 Common with sight disorders
 Also with hearing and smell/taste disorders
o Pharmacologic Therapy
 Vision
 Can be prevented/controlled/or reversed with proper treatment
 Medication is important when treating glaucoma and macular degeneration
 Hearing
 Impacted cerumen – gentle removal with ear wax softener
 Infected ear - antibiotics
 Olfactory
 Generally treated by treating underlying cause of impairment – not always fixed
o Lifespan Considerations
 Everyone will experience temporary sensory alterations in their lifetime
 Sensory Perception in Infants
 Vision
o Newborns are unable to focus on objects that are more than 8-10 inches
away
o Cannot move their eyes between 2 images
o During first 3 months – infants eyes start to work together and able to
track objects
o As vision matures – so does depth perception and color
o By 2 years – normal adult vision
o Amblyopia
 Lazy eye that can’t be corrected using lenses
 Treatment during first 2-4 years of life
o Comprehensive eye exam by 6 months
 Hearing
o Hearing and vision should be checked as to avoid developmental and
learning delays
o Otoacoustic emissions test
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 Earphone and microphone plays sound in babys ear
 If normal, the microphone will detect an echo
o Auditory Brainstem Response
 Electrodes that detect nerve response after sounds are played
Touch
o Pain response
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Sensory Perception in Children and Adolescents
 Vision
o Risk of injury
o Vision screenings (comprehensive is not necessary)
 Hearing
o Recurrent severe otitis media can cause fluid buildup in the inner or
middle ear – risk of hearing loss
o Risk of injury
o Avoiding loud noises
o Monitoring cerumen buildup
o Immunizations! Mumps contribute to hearing loss
 Touch
o Superficial Tactile Sensation Test
 Stroke the skin on lower leg or arm while childs eyes are closed
 Children can point to where was touched
o Superficial Pain Sensation Test
 Touch sharp and non-sharp items to childs extremities
 Children can distinguish between sharp and dull pain
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Sensory Perception in Pregnant Women
 Tinnitus and vertigo more common
 Most revert back to normal after delivery
 Heightened sense of smell associated with nausea and vomiting
 Cravings for weird combinations of foods
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Sensory Perception in Older Adults
 Often lose some sensitivity in their hearing and vision as they age
 Fewer taste buds – sensitivity to taste decreases
 Loss of nerve endings in the nose reduces sense of smell over time
 Higher risk of hearing disorders
o Presbycusus
 Age-related loss of high frequency of sounds
o Tinnitus
o Glaucoma
o AMD
o Cataracts
Eyes, Ears, Nose, Mouth & Throat (D’Amico p. 237-292)
Tissue Integrity (p. 1565-1568)
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Integumentary System
o Skin, hair, nails, sebaceous, sweat, and mammary glands.
o Nurses aim to maintain skin integrity and promote wound healing
Tissue Integrity
o Includes: integumentary, mucous membrane, corneal, or subcutaneous tissues not
interrupted by wounds
Normal Tissue Integrity
o Functions of skin:
 Protection from microorganisms and trauma
 Nerves enable perception of touch, pain, pressure, heat, and cold
 Regulating temperature
 Dilation of BV’s and secretion of sweat
 Under control of the CNS
 Supplements body’s intake of vitamin D by synthesizing D through UV light
Physiology Review
o Epidermis
 Epithelial cells
 4 or 5 layers depending on location
 Stratum corneum
o Outermost layer
o Thickest layer
o Keratin
 Fibrous, water
repellent protein
that serves to
protect
 Stratum lucidum
o Areas of thick skin
(palms, soles)
o Keratinocytes
 Dead/flattened cells
 Produce keratin until they die
 Stratum granulosum
o 2/3 cells thick
o Contain glycolipid
 Slows water loss
o Keratinization begins here
 Stratum spinosum
o Several layers thick
o Abundant cells that arise from the bone marrow
o Mitosis happens here, though more abundant in basale
 Stratum basale
o Contains keratinocytes and melanocytes
o Melanin shields the keratinocytes and protects nerve endings in
dermis from UV light
o Dermis
 Made of flexible CT
 Richly supplied with BV’s, nerve fibers, and lymphatic vessels
 Hair follicles, sebaceous glands, sweat glands
 Papillary layer
 Ridges that indent overlying epidermis
 Capillaries
 Receptors for pain and touch
 Reticular layer
 BV’s
 Sweat and sebaceous glands
 Deep pressure receptors
 Bundles of collagen fibers
o Hypodermis
 Known as subcutaneous tissue
 Loose CT
 Stores ½ fat cells in body
 Insulator and cushion
 Energy storage
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Cultural Considerations
o The darker your skin, the more melanin -> the more protection from UV
o Assessing darker skin tones for oxygenation, look at:
 Buccal mucosa, lips, tongue, nail beds, palms and soles
o Pallor in dark skin
 Yellow/brown tinge or ashen gray
o Cyanosis
 Nail beds, lips, buccal mucosa
o Darker skinned patients may have yellow tinge naturally to eyes
 Check the palms and soles
o Darker skin and checking for risk of pressure ulcers
 Light pressure to skin and observation for an area that is darker than the surrounding
skin or that is taught/shiny/or indurated.
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Alterations and Manifestations of Tissue Integrity
o Melasma
 Too much melanin produced in darker skinned patients where UV exposure occurs
Oral Health (p. 452-457)
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Normal Oral Health
o Anatomy
 Hard palate
 Hard surface for the tongue to bring food further into mouth
 Soft palate
 Primarily muscle
 Uvula
 Tonsils
 Lymphatic tissue
 Dorsum of tongue
 Upper surface
 Teeth
 Set in gingival (gums)
 3 parts to teeth:
o Crown
 Uppermost – covered with enamel
o Pulp
 Center of tooth – BV’s and nerves
o Root
 Lowest – embedded in jaw
o Age
 Teeth appear 5-8mos
 By 2yr have all 20 deciduous teeth
 6-7yr start losing deciduous teeth
 Get 33 permanent teeth
 25yr have all teeth including wisdom
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Alterations of Oral Health
o Dental caries and Periodontal disease
 Most common
 Dental caries
 Teeth are exposed to bacteria that use sugars and starches to produce acids
that weaken the enamel.
 To reverse the process: minerals (potassium, calcium, fluoride)
 Both associated with plaque and tartar deposits
 Plaque
o Invisible soft film that adheres to the enamel surface
o Consists of bacteria, saliva, epithelial cells, and leukocytes
o When plaque goes unchecked, tartar is formed
 Visible, hard deposit of plaque and dead bacteria that forms at
gum lines
 Eventually disrupts bone tissue
 Periodontal disease
 Characterized by gingivitis
o Red/swollen gingival, bleeding, receding gums, pockets between teeth
and gums
 Pyorrhea
o Advanced disease
o Teeth are loose and pus is evident
 Lifespan Considerations
Baby bottle syndrome
Carbs demineralize enamel causing
decay
Decay of all upper teeth and
lower posterior teeth
Burning mouth syndrome
Estrogen deficiency (menopause)
Unpleasant tingling sensation
in the mouth; sometimes
changes in taste perception
Cheilosis
Bacteria, fungus infections,
nutritional deficiencies
Glossitis
Allergic response
Lips cracking
Granulomas
Hormones of pregnancy
Hairy leukoplakia
Early sign of HIV infection
Parotitis
Mumps causing inflammation
Benign tumor-like growths on
gums
Fuzzy white patch on the
tongue
Swelling of one or both of the
parotid glands or other
salivary glands
Reddened or excoriated mucosa
Friction against soft tissue
Mouth mucous membranes
irritated with some bleeding
Sordes
Debilitating diseases with
protracted low fever
Stomatitis
Trauma, allergy, vitamin deficiency,
infection
Crusts on teeth and lips
Inflammation of the tongue;
tongue can change color or
look smooth
Inflammation of the oral
mucous membranes
Educate parents about the
risks. Suggest substitutes to
soothe the child, such as
pacifiers.
Use over-the-counter
medicated creams or
lozenges or prescribed oral
medications.
Address the cause of the
condition; lubricate lips; use
antimicrobial ointment.
Encourage regular oral
hygiene, recognizing the
difficulty of cleaning the
tongue.
Refer to a dentist for ruling
out other causes.
Refer for clinical testing to
confirm diagnosis.
Encourage regular oral
hygiene, even though
brushing and flossing can be
difficult.
Check for ill-fitting dentures,
dental bridges, or other
irritants.
Remove crusts, and apply
ointments to keep lips
lubricated; keep teeth clean.
Respond to the cause of
inflammation; encourage
regular effective oral hygiene.
o Preschoolers and School-Age Children
 Deciduous teeth guide entrance of permanent teeth
 Establish good oral health early
 Fluoride to prevent caries
 Taught how to brush
 Limit refined sugars
 Parental supervision to ensure brushing is done
 When permanent teeth appear – regular checkups
o Adolescents and Adults
 Smokers made aware
o Pregnant Women
 Increased progesterone – increase in gingivitis, levels of saliva, or granulomas on
gums
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Stomach acids on teeth
Periodontal disease increases due to hormones affecting gingival tissue and increases
reaction to bacterial plaue
 More bleeding, redness and swelling
o Older Adults
 Risk of caries and periodontal disease due to maintenance of oral hygiene and not
able to visit dentist regularly
 Lack of fluoridated water and preventative dentistry in their younger years
contribute to more problems at this age
 Loss of teeth mainly due to periodontal disease
 Dexterity and dementia are problems
 Xerostomia
 Severe dry mouth
 Drink more water
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Nursing Management
o Observation and Patient Interview
 Observe teeth and gums
 Halitosis
 Bad breath
o Physical Examination
 Lips: Are they a normal color and without breaks in the surface?
 Tongue: Is it pink, smooth, and muscular?
 Mucosa (the lining of the mouth): Is it moist, without surface breaks, and of
appropriate color?
 Teeth: Do they show evidence of food collecting on them? Are particles caught
between them?
 Gums: Are they of even color without being swollen?
 Throat: Is it a healthy color, similar to the tongue? Does it have a coating over it? Is
the surface smooth or bumpy and swollen?
 Tonsils (if present): Are they a similar color and not swollen? Do they have an
exudate?
 Patient’s breath: Does the patient’s breath have any unusual or foul odor?
o Identifying Patients at Risk
 Those that are seriously ill, confused, comatose, depressed, illiterate, or dehydrated
 Those with NG tubes and Oxygen – more likely to develop dry mucous membranes
 Patients with oral or jaw surgery
 Those with: inadequate nutrition, lack of money and/or insurance for dental,
excessive refined sugars, family history of periodontal disease
 Older adults seeking salty and sweet items due to loss of taste buds
 Decreased saliva production in older adults
 Dry mouth due to: poor fluid intake heavy smoking, alcohol use, high salt intake,
anxiety, and many medications.
 Medications/treatments that cause dry mouth:
 Diuretics
 Laxatives
 Tranquilizers
 Some chemo drugs
 Anticonvulsant drug Phenytoin (Dilantin) causes gingival hyperplasia
 Patients with radiation to head and neck
o Promoting Oral Hygiene
 Teach or actually brush their teeth
 Referrals to dentist or oral surgeon
 Teach cleaning of dentures at least 1x day