M16

• People learn about the environment from five experiences
• Senses


  • Sight/visual
  • Hearing/auditory
  • Touch/tactile
  • Smell/olfactory
  • Taste/gustatory
  • Position and motion/kinesthetic
• Stereognosis


  A sense that allows a person to recognize the size, shape, and texture of an object
• Sensory reception


  Stimulation of sensory nerve fibers and the transmission of impulses to higher centers within the brain
• Normal sensation


  1. Reception: stimulation of a receptor

  2. Perception: integration and interpretation of stimuli

  3. Reaction: only the most important stimulus will elicit a reaction
• Sensory deficits


  Deficit in the normal function of sensory reception and perception
• Sensory deprivation


  Inadequate quality or quantity of stimulation
• Factors affecting sensory function

  • Age
  • Meaningful stimuli
  • Amount of stimuli
  • Social interaction
  • Environmental factors
  • Cultural factors
• The American Academy of Ophthalmology and the American Speech-Language-Hearing Association provide criteria for screening sensory problems
• Nursing Process: Assessment


  1. Through the patient's eyes

  2. Persons at risk

  3. Sensory alteration history

  4. Mental status

  5. Physical assessment

  6. Ability to perform self-care

  7. Health promotion habits

  8. Environmental hazards

  9. Communication methods

  10. Social support

  11. Use of assistive devices

  12. Other factors affecting perception
• Aphasia


  • Expressive (motor)
  • Receptive (sensory)
  • Global
• Nursing Diagnoses for patients with sensory alterations

  • Risk-prone health behavior
  • Impaired verbal communication
  • Risk for injury
  • Impaired physical mobility
  • Bathing self-care deficit
  • Situational low self-esteem
  • Risk for falls
  • Social isolation
• Implementation: Health promotion


  1. Screening

  2. Preventive measures

  3. Use of assistive devices

  4. Promoting meaningful stimuli

  5. Establishing safe environments

  6. Communication
• Implementation: Acute Care


  1. Orientation to the environment

  2. Communication

  3. Controlling sensory stimuli

  4. Safety measures
• Implementation: Restorative and continuing care

  1. Maintaining healthy lifestyles

  2. Understanding sensory loss

  3. Socialization

  4. Promoting self-care
• Sexuality is part of a person's personality and is important for overall health
• Many adults lack knowledge regarding sexuality
• Patients often share their feelings when the nurse addresses sexuality in a relaxed, matter-of-fact manner
• Religious teachings, cultural influences on gender roles, beliefs about sexual orientation, and social and environmental climates influence the value systems for both patients and care providers
• Sexuality


  Expression of an individual's sexuality is influenced by interaction among biological, sociological, psychological, spiritual, economic, political, religious, and cultural factors
• Sexual health


  A state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity
• Stages of sexual development


  • Infancy and early childhood
  • School-age years
  • Puberty/adolescence
  • Young adulthood
  • Middle adulthood
  • Older adulthood
• Sexual orientation


  Adolescents function with a powerful network of peers as they explore their sexual identity
• Contraception methods


  • Nonprescription: abstinence, barrier methods, spermicide, rhythm
  • Prescription: hormonal contraception, intrauterine device (IUD), diaphragm, cervical cap, sterilization (tubal ligation or vasectomy)
• About 20 million people in the United States are diagnosed each year with an STI each year; almost half of them are 15 to 24 years of age
• STIs are transmitted from infected individuals to partners during intimate sexual contact
• Types of STIs


  • Usually curable: syphilis, gonorrhea, chlamydia, trichomoniasis
  • Viral: human papillomavirus (HPV) and herpes simplex virus (HSV) type II, human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)
• Locating and treating people with STIs

  1. Some people do not know that they are infected because symptoms may be absent or may go unnoticed

  2. Common symptoms include discharge from the vagina, penis, or anus; pain during sex or when urinating; blisters or sores in the genital area; fever

  3. Any contact with another person's body fluid around the head or an open lesion on the skin, anus, or genitalia can transmit an STI
• Human immunodeficiency virus (HIV): primary routes of transmission include contaminated IV needles, anal intercourse, vaginal intercourse, oral-genital sex, and transfusion of blood, blood products
• Human papillomavirus infection (HPV): most common STI in United States; spread through direct contact with warts, semen, or other fluids
• Chlamydia (bacterial): causes infertility, pelvic inflammatory disease (PID), and neonatal complications
• Factors influencing sexuality


  • Sociocultural dimension of sexuality
  • Impact of pregnancy and menstruation on sexuality
  • Discussing sexual issues
• Sexual assessment and interventions need to be included in health care
• Nurses who have difficulty discussing topics related to sexuality need to explore their discomfort and develop a plan to address it
• Decisional Issues: Contraception


  Factors that influence effectiveness: method of contraception, understanding of the method
• Sexually Transmitted Infections (STIs)


  Infections that can be transmitted through sexual contact, including the anus, genitalia, or other body fluids
• STIs


  • Human immunodeficiency virus (HIV)
  • Human papillomavirus infection (HPV)
  • Chlamydia
• HIV transmission


  • Primary routes include contaminated IV needles, anal intercourse, vaginal intercourse, oral-genital sex, and transfusion of blood, blood products
• HPV infection


  • Most common STI in United States; spread through direct contact with warts, semen, or other fluids
• Chlamydia


  • Causes infertility, pelvic inflammatory disease (PID), and neonatal complications