Sensory Alterations
A nurse developing interventions for a client with visual alterations. What should the nurse consider?
1. Teach the client to use the call light for assistance – safety
2. Maintain adequate lighting
3. Keep the floor clear of obstacles
4. Keep something at the bedside for nausea/vomiting
The nurse is determining the best nursing diagnosis for a patient with difficulty keeping a sleeping pattern while in the hospital. What would be the best nursing diagnosis for this patient?
1. Sleep-related fatigue
2. Impaired sleep pattern
3. Altered dream pattern
4. Sheep counting-itis
2. Impaired sleep pattern
Impaired sleep pattern is the only actual ICNP nursing diagnosis.
A nurse is asking about a client's home environment; which of the following statements would be appropriate for the home environment of a patient with visual alterations?
1. I have several rugs in my home, my feet get so cold.
2. I like to rearrange the furniture frequently to keep things interesting.
3. I keep my home well-lit to ensure I can see.
4. I have a cane to help me walk, but most of the time, I brace myself on the walls and furniture.
3. I keep my home well-lit to ensure I can see.
This naturally occurring 24-hour clock regulates our sleep/wake cycle. It is heavily influenced by the environment, seasonal changes, light, and age.
What are Circadian Rhythms?
A nurse will be educating a client with a hearing deficit on at hoe would care. What can the nurse do to promote patient understanding?
1. Face the client directly when speaking
2. Minimize background noise.
3. Ensure there is adequate lighting.
4. Provide written material.
Establishing a regular sleep pattern is essential to overcoming sleep disorders and can include regular bedtime and wakeup time, reading, avoiding caffeine and smoking, and drinking this liquid.
What is warm milk?
An elderly patient is admitted to the hospital after experiencing a sudden change in mental status at his independent living facility; as the night shift nurses begin rounds, they notice the patient is using his fingers to "feed" soup to his IV pole. This patient is experiencing
This sleep disorder is characterized by the inability to fall asleep and remain asleep. This can result in unrefreshing sleep, daytime sleepiness, difficulty concentrating, and irritability.
What is insomnia?
A client reports that they are experiencing sensory overload in the hospital, and they are not sleeping well. What can the nurse direct the UAP to do in order to improve sensory overload?
1. Play music for the patient at loud levels.
2. Perform patient care tasks one at a time, allowing more interaction with the patient.
3. Allow multiple visitors at a time to ensure the patient is able to maintain social relationships.
4. Use appropriate lighting while performing patient tasks, and ensure that the light is tolerable for the patient.
4. Use appropriate lighting while performing patient tasks, and ensure that the light is tolerable for the patient.
This sleep disorder has no cure and usually manifests between 15-30 years of age. Patients often experience significant daytime sleepiness, fragmented nighttime sleep, and vivid hallucinations. Additionally, the most dangerous aspect of this disorder is sudden sleep attacks that can occur at any time during the day!
What is Narcolepsy?
A client is experiencing complications from sensory deprivation. The client is both blind and has progressive hearing loss, what would the nurse be concerned with from a psychosocial perspective?
What is Social Isolation?
This sleep disorder is characterized by frequent short breathing pauses during sleep. More than five pauses longer than 10 seconds are considered abnormal and should be evaluated by a sleep specialist. The priority for patients experiencing this condition is respiratory status.
What is Sleep Apnea?
This electrolyte imbalance can result in tactile sensory alteration in the fingers, toes, and lips.
What is Hypocalcemia?
Low calcium levels in the blood, also known as calcium deficiency or hypocalcemia, can cause tingling in the fingers, toes, and lips. This tingling is also known as paresthesia.
The Reticular Activating System (RAS) in the brainstem is thought to mediate the arousal mechanism and is inhibited during this sleep phase.
What is NREM?
NREM is 75-85% of sleep
◦Stage 1: light sleep, awakens easily
◦Stage 2: requires more intense stimuli to awaken
◦Stage 3: the deepest stage where HR & RR drop 20-30% below normal waking hours. This stage restores energy & releases important growth hormones.