1. 2 (T=5) تعریف کلی از حس و راههای حسی (T=10m) Sensory Alterations (T=10m) (...

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(T=5) حسی راههای حسو از کلی تعریف

(T=10m) Sensory Alterations

(T=10m) ( ICU psychosis بیماری یک )معرفی

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چیست؟ تجربه حسی به

دریافتحسی -1

گویند رادریافتحسی درونی یا بیرونی محیت از اطالعات دریافت فرایند

2- حسی ادراک

به حسها از تفسیراطالعات ،سازماندهیو انتخاب در هوشیارانه فرایند یکمیباشد دار معنی اطالعات

راههای حسو از کلی راههای تعریف حسو از کلی تعریف حسیحسی

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گیرنده توسط دریافتحسیمیگیرد انجام ها

پتانسیل تغییر اصلی علتگیرنده نفوذپذیری غشا

است امکان غشایی کهاز یونها کمابیش انتشار

تغییر نتیجه در و غشافراهم را غشایی پتانسیل

میکند

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NUR101FALL 2008LECTURE # 18K. BURGER

PPP By Sharon Niggemeier RN MS

انجام مغز در حسی درکمیشود

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A change in environment can lead to MORE or LESS normal stimuli.

When stimuli is different from what one is used to it leads to sensory alterations.

Hospitalized patients will experience sensory alterations due to different stimuli loads.

Can result in sensory overload or sensory deprivation

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Results from being unable to manage sensory stimuli: (too much stimuli)

Pain, dyspnea, anxiety (internal)Noise,, contact with many strangers

(external) Inability to disregard stimuli: for

example meds that stimulate the arousal mechanism, may prevent one from ignoring noise

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Unrealistic perceptions

disoriented, difficulty concentrating, muscleسردرگمی،tension

Reduced problem-solving ability

حواس پراکندگی

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Results from decreased sensory input or meaningless input: (too little stimuli)

Isolation/non-stimulating monotonous environment

Impaired ability to receive and/or send stimuli: vision, hearing deficits, speech deficits ( expressive or receptive aphasia)

Inability to cognitively process stimuli-confused, brain injury, meds affecting CNS

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Impaired reception, perception or both of the senses

Blindness, deafness, loss of taste, smell, touch

One sense may become more acute to compensate for deficit

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Drowsiness/sleeping/yawningDecreased attention, difficulty

concentrating, impaired memoryDisorientation, confusion, hallucinations

needs stimulus; body may produce hallucinations to maintain optimal arousal

Crying, annoyance over small matters, depression

Apathy, daydreaming, anger

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Sensory Overload Room close to nurse's station ICU or intermediate unit Bright lights Use of mechanical ventilator Use of ECG monitor Use of oxygen Use of IVs Other equipment Frequent treatments

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Sensory Deprivation

Private room Eyes bandaged Bed rest Sensory aid not available (hearing aid, glasses) Isolation precautions Few visitors

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Disturbed sensory perception

Social Isolation

Situational low self-esteem

Disturbed thought processes

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ای المسه سنگینی حتی دارم زیادی لمسحساسیت به من

سعی من میکند اذیت مرا پوستم روی لباسهایممیتوانم که مقدار هر را بدنم میکنم

غیر من به هم وزشنسیم حتی ولی دهم حرکت کماست ممکن

محرومیتحسی شدن دیوانه حال در میکنم فکر من بیمارستان در اینجا

یک به تبدیل میکنم نگاه که دیواری ساعت به هستممن به که میشود غمگین صورتی با چرخان خورشیدهراس شود نزدیک خیلی اینکه از من و شده نزدیک

دارم16

Client will:Demonstrate understanding by a verbal, written, or signed response (SENSORY DEFICIT)

Client will:Demonstrate relaxed body movements and facial expressions (SENSORY OVERLOAD)

Client will:Remain free from injury

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Prevent sensory alterationTeach self stimulation methods-

reading, etc. Provide stimulation – visual, auditory,

gustatory, tactileProvide reality orientation

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ICU psychosis syndrome

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ICU psychosis is ICU syndrome. ICU psychosis is also a form of delirium, or acute

mentale failure.How long does ICU psychosis last? it may last 24 hours or even up to two weeks with

fluctuations of the level of consciousness and behavior patterns.

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Sudden and unexpected nature of events

Pain

ICU environmen

Other factors .The loss of control over their lives that patients often feel in an ICU.

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Environmental Causes Sensory deprivation (being put in a room often without

windows, away from family, friends and all that is familiar) Sensory overload (being tethered to noisy machines day and

night) Sleep disturbance and deprivation Continuous light levels Stress Lack of orientation Medical monitoring

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Medical Causes

Pain (which may not be adequately controlled in an ICU)

Critical illness: The pathophysiology of the disease, illness or traumatic event - the stress on the body during an illness can cause a variety of symptoms.

Medication (drug) reaction or side effects: Infection creating fever and toxins in the body.

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Medical Causes

Metabolic disturbances: electrolyte imbalance, hypoxia (low blood oxygen levels), and elevated liver enzymes.

Heart failure (inadequate cardiac output)

Cumulative analgesia (the inability to feel pain while still conscious)

Dehydration

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extreme excitement anxiety restlessness hearing voices clouding of consciousness hallucinations nightmares paranoia disorientation agitation delusions abnormal behavior

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Pain control 、 analgesic drugs

Family support

Day-awake,night-asleep

Removing many wires and tubes

Constant and monotonus sounds

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Large clock,calendar and outside window visible to the patients to help with orientation

Personally familiar beside objects such as clock,radio or family photographs.

Use spectacles or hearing aids. Such as radio or television sets to provide meaningful sensory stimuli

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Fundamentals of nursing TAYLOR 2005

Guyton&hall . Medical physiology 11 TH edition 2006

Searching of elsevier and other databace

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