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Chapter 47: Mobility and Immobility

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Chapter 47: Mobility and Immobility. Bonnie M. Wivell, MS, RN, CNS. The Nature of Movement. Coordination between the musculoskeletal system and the nervous system. Alignment and Balance The positioning of the joints, tendons, ligaments and muscles while standing, sitting, and lying - PowerPoint PPT Presentation
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Chapter 47: Chapter 47: Mobility and Mobility and Immobility Immobility Bonnie M. Wivell, MS, RN, Bonnie M. Wivell, MS, RN, CNS CNS
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Page 1: Chapter 47: Mobility and Immobility

Chapter 47: Mobility Chapter 47: Mobility and Immobilityand Immobility

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

Page 2: Chapter 47: Mobility and Immobility

The Nature of MovementThe Nature of Movement

Coordination between the Coordination between the musculoskeletal system and the musculoskeletal system and the nervous system.nervous system.

Alignment and BalanceAlignment and Balance– The positioning of the joints, tendons, The positioning of the joints, tendons,

ligaments and muscles while standing, ligaments and muscles while standing, sitting, and lyingsitting, and lying

Gravity and FrictionGravity and Friction– Gravity is the force of weight downwardGravity is the force of weight downward– Friction is force that opposes movementFriction is force that opposes movement

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Physiology and Regulation Physiology and Regulation of Movementof Movement

Long bones contribute to heightLong bones contribute to height Short bones occur in clusters Short bones occur in clusters Flat bones provide structural contourFlat bones provide structural contour Irregular bones make up the vertebral Irregular bones make up the vertebral

column and some bones of the skullcolumn and some bones of the skull Functions of MSKFunctions of MSK

– Protects vital organsProtects vital organs– Aids in calcium regulationAids in calcium regulation– Production and storage of bloodProduction and storage of blood

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JointsJoints Synostotic = bones joined by bones; no Synostotic = bones joined by bones; no

movement; example: skullmovement; example: skull Cartilaginous = cartilage unites bony Cartilaginous = cartilage unites bony

components; allows for growth while components; allows for growth while providing stability; example: 1providing stability; example: 1stst sternocostal sternocostal jointjoint

Fibrous = ligament or membrane unites two Fibrous = ligament or membrane unites two bony surfaces; limited movement; Example: bony surfaces; limited movement; Example: tib/fibtib/fib

Synovial = A true joint; freely movable; Synovial = A true joint; freely movable; – PivotalPivotal– Ball and socketBall and socket– Hinge Hinge

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Ligaments/Tendons/Ligaments/Tendons/CartilageCartilage

Ligaments = white, shin, flexible Ligaments = white, shin, flexible bands of fibrous tissue binding joints bands of fibrous tissue binding joints together and connecting bones and together and connecting bones and cartilagescartilages

Tendons = white, glistening, fibrous Tendons = white, glistening, fibrous bands of tissue that connect muscle bands of tissue that connect muscle to bone; strong, flexibleto bone; strong, flexible

Cartilage = nonvascular, supporting Cartilage = nonvascular, supporting connective tissueconnective tissue

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Skeletal MuscleSkeletal Muscle Ability of muscles to contract and relax are Ability of muscles to contract and relax are

the working elements of movementthe working elements of movement Muscles are made of fibers that contract Muscles are made of fibers that contract

when stimulated by an electrochemical when stimulated by an electrochemical impulse that travels from the nerve to the impulse that travels from the nerve to the musclemuscle

Muscles associated with posture converge Muscles associated with posture converge at a common tendonat a common tendon– Lower extremities, Trunk, Neck, BackLower extremities, Trunk, Neck, Back

Coordination and regulation of different Coordination and regulation of different muscle groups depend on muscle tone muscle groups depend on muscle tone (normal state of balanced muscle tension)(normal state of balanced muscle tension)

Muscle tone helps maintain functional Muscle tone helps maintain functional positions such as sitting or standingpositions such as sitting or standing

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The Nervous SystemThe Nervous System The motor strip is the major voluntary motor The motor strip is the major voluntary motor

area and is located in the cerebral cortexarea and is located in the cerebral cortex A majority of motor fibers descend from the A majority of motor fibers descend from the

motor strip and cross at the level of the motor strip and cross at the level of the medullamedulla

Motor fibers from right motor strip control Motor fibers from right motor strip control voluntary movement on left side of body and voluntary movement on left side of body and motor fibers on left control movement on motor fibers on left control movement on right side of bodyright side of body

Impulses descend from motor strip to Impulses descend from motor strip to spinal spinal cordcord

Impulse exits the spinal cord through efferent Impulse exits the spinal cord through efferent motor nerves and travels through the nervesmotor nerves and travels through the nerves

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The Nervous System Cont’d.The Nervous System Cont’d.

Neurotransmitters or chemicals transfer Neurotransmitters or chemicals transfer electric impulses from the nerve to the muscleelectric impulses from the nerve to the muscle

Neurotransmitters stimulate the muscles Neurotransmitters stimulate the muscles causing movementcausing movement

Movement is impaired by disorders that alterMovement is impaired by disorders that alter– Neurotransmitter productionNeurotransmitter production– Transfer of impulses from the nerve to the muscleTransfer of impulses from the nerve to the muscle– Activation of muscle activityActivation of muscle activity

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Pathological Influences on Pathological Influences on MobilityMobility

Postural abnormalities: congenital or Postural abnormalities: congenital or acquired postural abnormalities affect the acquired postural abnormalities affect the efficiency of the MSK system as well as efficiency of the MSK system as well as body alignment, balance, and appearancebody alignment, balance, and appearance– Can cause pain, impair alignment or mobilityCan cause pain, impair alignment or mobility

Impaired muscle development: patients Impaired muscle development: patients with muscular dystrophy experience with muscular dystrophy experience progressive, symmetrical weakness and progressive, symmetrical weakness and wasting of skeletal muscle groups, with wasting of skeletal muscle groups, with increasing disability and deformityincreasing disability and deformity

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Pathological Influences on Pathological Influences on MobilityMobility

Damage to the Central Nervous System: Damage to the Central Nervous System: damage to any component of the CNS that damage to any component of the CNS that regulates voluntary movement results in regulates voluntary movement results in impaired body alignment, balance, and impaired body alignment, balance, and mobilitymobility– Complete transection of the spinal cord results in Complete transection of the spinal cord results in

a bilateral loss of voluntary motor control below a bilateral loss of voluntary motor control below the level of traumathe level of trauma

– Damage to the cerebellum causes problems with Damage to the cerebellum causes problems with balance and motor impairment is directly related balance and motor impairment is directly related to amount and location of destructionto amount and location of destruction

Trauma to the Musculoskeletal System: Trauma to the Musculoskeletal System: direct trauma results in bruises, contusions, direct trauma results in bruises, contusions, sprains, and fracturessprains, and fractures

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Mobility and ImmobilityMobility and Immobility

MobilityMobility refers to a person’s ability to refers to a person’s ability to move about freely and move about freely and immobilityimmobility refers refers to the inability to do soto the inability to do so

The effects of muscular deconditioning The effects of muscular deconditioning associated with lack of physical activity associated with lack of physical activity are often apparent in a matter of daysare often apparent in a matter of days

Disuse atrophy describes the tendency of Disuse atrophy describes the tendency of cells and tissue to reduce in size and cells and tissue to reduce in size and function in response to prolonged function in response to prolonged inactivity resulting from bed rest, trauma, inactivity resulting from bed rest, trauma, casting, or local nerve damagecasting, or local nerve damage

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The Effects of ImmobilityThe Effects of Immobility Metabolic changesMetabolic changes

– Negative nitrogen balanceNegative nitrogen balance– Calcium resorption (loss)Calcium resorption (loss)

GI changesGI changes– Constipation Constipation → Impaction → Mechanical → Impaction → Mechanical

ObstructionObstruction Respiratory changesRespiratory changes

– Atelectasis Atelectasis → Pneumonia→ Pneumonia Cardiovascular changesCardiovascular changes

– Orthostatic hypotensionOrthostatic hypotension– Increased cardiac workloadIncreased cardiac workload– Thrombus formation (Virchow’s triad)Thrombus formation (Virchow’s triad)

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The Effects of Immobility The Effects of Immobility Cont’d.Cont’d.

Musculoskeletal changesMusculoskeletal changes– ↑ ↑ protein breakdown → ↓ lean body massprotein breakdown → ↓ lean body mass– OsteoporosisOsteoporosis– Joint contractures Joint contractures

Foot dropFoot drop Changes in urinary eliminationChanges in urinary elimination

– Urinary stasisUrinary stasis– Renal calculiRenal calculi

Integumentary changesIntegumentary changes– Pressure ulcersPressure ulcers

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Older AdultsOlder Adults Immobility can lead to….Immobility can lead to….

– Loss of mobility and functional declineLoss of mobility and functional decline– Weakness, fatigue, and increased risk for Weakness, fatigue, and increased risk for

fallsfalls– Shallow breathing resulting in pneumoniaShallow breathing resulting in pneumonia– Inadequate turning/repositioning results in Inadequate turning/repositioning results in

skin breakdown and pressure ulcersskin breakdown and pressure ulcers– Anorexia and insufficient assistance with Anorexia and insufficient assistance with

eating leads to malnutritioneating leads to malnutrition– Multiple interruptions and noise impair Multiple interruptions and noise impair

sleep, causing fatigue, depression, and sleep, causing fatigue, depression, and confusion.confusion.

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MobilityMobility ROM = amount of movement at a jointROM = amount of movement at a joint

– Active/PassiveActive/Passive– See pages 1232 – 1236See pages 1232 – 1236

Gait = style of walkingGait = style of walking Exercise and activity tolerance: age and Exercise and activity tolerance: age and

illness can affect thisillness can affect this Body Alignment Body Alignment

– Standing/Sitting/LyingStanding/Sitting/Lying Patients with impaired mobility, decreased sensation, Patients with impaired mobility, decreased sensation,

impaired circulation, and lack of voluntary muscle impaired circulation, and lack of voluntary muscle control are at risk for damage to the MSK system control are at risk for damage to the MSK system when lying downwhen lying down

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Range of MotionRange of Motion

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Safe Patient HandlingSafe Patient Handling

Protecting the Patient and Health Protecting the Patient and Health Care workerCare worker– Manually lifting and transferring clients Manually lifting and transferring clients

contributes to the high incidence of work-contributes to the high incidence of work-related MSK problems and back injuryrelated MSK problems and back injury

– Lift teams/lift equipmentLift teams/lift equipment– Ergonomics trainingErgonomics training

Plan ahead based on patient Plan ahead based on patient assessmentassessment

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Assistive Devices for Patient Assistive Devices for Patient MovementMovement

All devices must be appropriate for All devices must be appropriate for patientpatient– Weight limitWeight limit– Reason for DeviceReason for Device– Measured to patientMeasured to patient

CanesCanes WalkersWalkers Wheel chairsWheel chairs CrutchesCrutches

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Gait BeltGait Belt

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Wearing a Gait BeltWearing a Gait Belt

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Using a Gait BeltUsing a Gait Belt

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Ambulating With a WalkerAmbulating With a Walker

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AssessmentAssessment

MetabolicMetabolic– I&OI&O– Lab valuesLab values– Height and weightHeight and weight– Nutritional intakeNutritional intake

RespiratoryRespiratory– Auscultate lungsAuscultate lungs

CVCV– Pulses/Cap refillPulses/Cap refill– Edema/DVTEdema/DVT

MSKMSK– Muscle tone/strengthMuscle tone/strength– ContracturesContractures

IntegumentIntegument– BreakdownBreakdown– Color changesColor changes

EliminationElimination– I&OI&O– Bowel soundsBowel sounds– Frequency and Frequency and

consistency of stoolconsistency of stool– Dietary intakeDietary intake

PsychosocialPsychosocial– AnxietyAnxiety– DepressionDepression– Sleep deprivationSleep deprivation

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PlanPlan

Goals and outcomes individualizedGoals and outcomes individualized Set prioritiesSet priorities Collaborative care: team approachCollaborative care: team approach

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InterventionsInterventions Health promotionHealth promotion

– EducationEducation– PreventionPrevention– Early detectionEarly detection

Prevention of work-related MSK injuriesPrevention of work-related MSK injuries– Use of ergonomicsUse of ergonomics

ExerciseExercise Bone healthBone health

– ScreeningScreening– Maintain independence with ADLsMaintain independence with ADLs– Assistive ambulatory devicesAssistive ambulatory devices

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Interventions Cont’d.Interventions Cont’d.

MetabolicMetabolic– High-protein, high-calorie dietHigh-protein, high-calorie diet– Vitamin B for skin integrity and wound healingVitamin B for skin integrity and wound healing– Vitamin C for replacing protein storesVitamin C for replacing protein stores– TPNTPN– Enteral feedingsEnteral feedings

RespiratoryRespiratory– Turn, cough, and deep breathe (TCDB)Turn, cough, and deep breathe (TCDB)– Chest physiotherapy (CPT)Chest physiotherapy (CPT)– 2000 mL of fluid daily if not contraindicated2000 mL of fluid daily if not contraindicated

Page 36: Chapter 47: Mobility and Immobility

Interventions Cont’d.Interventions Cont’d.

CVCV– Mobilize ASAP, dangle or sit in chair at Mobilize ASAP, dangle or sit in chair at

minimumminimum– Isometric ExerciseIsometric Exercise– Discourage use of valsalva maneuverDiscourage use of valsalva maneuver– DVT prophylaxisDVT prophylaxis

TEDS – apply properly, remove at least bidTEDS – apply properly, remove at least bid Avoid crossing legs, sitting for prolonged Avoid crossing legs, sitting for prolonged

periods of time, wearing constrictive clothing, periods of time, wearing constrictive clothing, putting pillows under the knees, and putting pillows under the knees, and massaging legsmassaging legs

MedsMeds

Page 37: Chapter 47: Mobility and Immobility

Interventions Cont’d.Interventions Cont’d.

MSKMSK– ROMROM– CPM in orthopedicsCPM in orthopedics

IntegumentIntegument– Screen for risk (Braden Scale)Screen for risk (Braden Scale)– PreventionPrevention– Position changesPosition changes

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Interventions Cont’d.Interventions Cont’d.

EliminationElimination– Adequate hydrationAdequate hydration– If incontinent, provide frequent skin careIf incontinent, provide frequent skin care– Catheterize prnCatheterize prn– Foods high in fiberFoods high in fiber– Stool softners/cathartics prnStool softners/cathartics prn

PsychosocialPsychosocial– Schedule care to prevent interruption of sleepSchedule care to prevent interruption of sleep– Depression screening (GDS)Depression screening (GDS)– Provide stimulation and re-orient prnProvide stimulation and re-orient prn– Involve clients in own care as much as possibleInvolve clients in own care as much as possible

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PositioningPositioning

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Semi Fowler’s PositionSemi Fowler’s Position

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Sim’s or Left Lateral PositionSim’s or Left Lateral Position

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Now let’s write a nursing Now let’s write a nursing care plan regarding care plan regarding

immobilityimmobility

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Chapter 48: Skin Chapter 48: Skin Integrity and Wound Integrity and Wound

CareCare

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SkinSkin

Two layersTwo layers– Epidermis = has several layersEpidermis = has several layers

Stratum corneum = thin, outermost layerStratum corneum = thin, outermost layer– Allows for evaporation of water from skinAllows for evaporation of water from skin– Permits absorption of topical medsPermits absorption of topical meds

Basal layerBasal layer

– Dermis = provides strength, support and Dermis = provides strength, support and protection of underlying muscles, bones, protection of underlying muscles, bones, and organsand organs

Page 51: Chapter 47: Mobility and Immobility

Pressure UlcersPressure Ulcers

Impaired skin integrity (damage Impaired skin integrity (damage to the skin) related to unrelieved, to the skin) related to unrelieved, prolonged pressure and/or prolonged pressure and/or shearing/frictionshearing/friction

AKA: Pressure sore, decubitus AKA: Pressure sore, decubitus ulcer, bedsoreulcer, bedsore

Localized injury to the skin or Localized injury to the skin or other underlying tissue, usually other underlying tissue, usually over a body prominenceover a body prominence

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PathogenesisPathogenesis

Pressure IntensityPressure Intensity– Tissue ischemia can occur due to Tissue ischemia can occur due to

capillary occlusion for a prolonged capillary occlusion for a prolonged period of timeperiod of time

– Patient’s with decreased sensation Patient’s with decreased sensation cannot respond to discomfort associated cannot respond to discomfort associated with ischemia hence tissue death resultswith ischemia hence tissue death results

– Blanching = occurs when normal red Blanching = occurs when normal red tones of the light skinned client is absent tones of the light skinned client is absent (doesn’t occur in darkly pigmented skin)(doesn’t occur in darkly pigmented skin)

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Pathogenesis Cont’d.Pathogenesis Cont’d. Pressure DurationPressure Duration

– Low pressure over a prolonged time periodLow pressure over a prolonged time period– High-intensity pressure over shot periodHigh-intensity pressure over shot period

Tissue ToleranceTissue Tolerance– Depends on integrity of the tissue and the Depends on integrity of the tissue and the

supporting structuressupporting structures– Shear, friction and moisture make skin more Shear, friction and moisture make skin more

susceptible to damage from pressuresusceptible to damage from pressure– Ability of underlying skin structures to assist Ability of underlying skin structures to assist

with redistribution of pressurewith redistribution of pressure Affected by poor nutrition, increased aging, and low Affected by poor nutrition, increased aging, and low

BPBP

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Risk FactorsRisk Factors

Impaired sensory Impaired sensory perceptionperception

Impaired mobilityImpaired mobility Alteration in LOCAlteration in LOC ShearShear FrictionFriction MoistureMoisture

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Classification of Pressure Classification of Pressure UlcersUlcers

Stage I:Stage I: Intact skin with non-blanchable Intact skin with non-blanchable redness of a localized arearedness of a localized area

Stage II:Stage II: Partial-thickness skin loss involving Partial-thickness skin loss involving epidermis, dermis or both; superficial epidermis, dermis or both; superficial abrasion, blister, or shallow craterabrasion, blister, or shallow crater

Stage III:Stage III: Full-thickness tissue loss; Full-thickness tissue loss; subcutaneous fat may be visible, slough may subcutaneous fat may be visible, slough may be present; may include undermining and be present; may include undermining and tunnelingtunneling

Stage IV:Stage IV: Full-thickness tissue loss with Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or exposed bone, tendon, or muscle; slough or eschar may be present on some parts; often eschar may be present on some parts; often includes undermining and tunnelingincludes undermining and tunneling

UnstageableUnstageable if bed is full of slough or eschar if bed is full of slough or eschar

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STAGE I ULCER- GREATER STAGE I ULCER- GREATER TROCHANTERTROCHANTER

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STAGE II ULCER – ISCHEAL TUBEROSITYSTAGE II ULCER – ISCHEAL TUBEROSITY

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STAGE IIISTAGE III

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STAGE IV ISCHEAL TUBEROSITY AND STAGE IV ISCHEAL TUBEROSITY AND SACRUMSACRUM

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DefinitionsDefinitions

Granulation tissue = red moist tissue Granulation tissue = red moist tissue composed of new blood vessels; indicates composed of new blood vessels; indicates healinghealing

Slough = stringy substance attached to wound Slough = stringy substance attached to wound bed; needs removed before wound can healbed; needs removed before wound can heal

Eschar = black or brown necrotic tissue; must Eschar = black or brown necrotic tissue; must be removed before wound can healbe removed before wound can heal

Exudate = Exudate = TType (consistency), ype (consistency), AAmount, mount, CColor, olor, and and OOdor of wound drainage; part of your dor of wound drainage; part of your assessmentassessment

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Process of Wound HealingProcess of Wound Healing Primary intention = edges are well Primary intention = edges are well

approximated or closed; risk of approximated or closed; risk of infection low; heals quickly; minimal infection low; heals quickly; minimal scar formationscar formation– Example: surgical woundExample: surgical wound

Secondary intention = wound is left Secondary intention = wound is left open until becomes filled with scar open until becomes filled with scar tissue; chance of infection is great; tissue; chance of infection is great; longer healing timelonger healing time– Example: burn, pressure ulcer, severe Example: burn, pressure ulcer, severe

lacerationlaceration

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Complications of Wound Complications of Wound HealingHealing

Hemorrhage/hematomaHemorrhage/hematoma InfectionInfection

– Second most common health care associated Second most common health care associated infectioninfection

Dehiscence = partial or total separation of Dehiscence = partial or total separation of wound layerswound layers

Evisceration = protrusion of visceral Evisceration = protrusion of visceral organs through wound openingorgans through wound opening

Fistulas = abnormal passage between two Fistulas = abnormal passage between two organs or between organs and the outside organs or between organs and the outside of the bodyof the body

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Prediction and Prevention of Prediction and Prevention of Pressure UlcersPressure Ulcers

Risk AssessmentRisk Assessment– Braden Scale (see slide in chapter 47)Braden Scale (see slide in chapter 47)– PreventionPrevention

Factors influencing pressure ulcer Factors influencing pressure ulcer formation and wound healingformation and wound healing– NutritionNutrition– Tissue perfusionTissue perfusion– InfectionInfection– AgeAge– Psychosocial impact (true impact unknown)Psychosocial impact (true impact unknown)

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AssessmentAssessment Assess skin for signs of ulcer Assess skin for signs of ulcer

developmentdevelopment Pressure ulcer assessmentPressure ulcer assessment

– Risk assessmentRisk assessment– MobilityMobility– Nutritional statusNutritional status– Body fluidsBody fluids– PainPain

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Wound AssessmentWound Assessment

Type: abrasion, laceration, puncture, Type: abrasion, laceration, puncture, etc.etc.

Appearance: red, inflamed, clean, dirtyAppearance: red, inflamed, clean, dirty Drainage: TACODrainage: TACO DrainsDrains ClosuresClosures PalpationPalpation CulturesCultures

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InterventionsInterventions

PreventionPrevention Frequent skin assessmentFrequent skin assessment Keep skin clean and dryKeep skin clean and dry Don’t use soaps and hot waterDon’t use soaps and hot water Apply moisturizersApply moisturizers Control/contain incontinence, perspiration Control/contain incontinence, perspiration

or wound drainageor wound drainage PositioningPositioning Therapeutic bed/mattressTherapeutic bed/mattress

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Wound ManagementWound Management Clean wounds with noncytotoxic wound Clean wounds with noncytotoxic wound

cleanserscleansers– Normal salineNormal saline– Commercial wound cleansersCommercial wound cleansers

Cytotoxic cleansers used for chemical Cytotoxic cleansers used for chemical debridementdebridement– Dakin’s solution (sodium hypochlorite soln)Dakin’s solution (sodium hypochlorite soln)– Acetic acidAcetic acid– Providone-iodineProvidone-iodine– Hydrogen PeroxideHydrogen Peroxide

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DebridementDebridement Removal of nonviable, necrotic tissueRemoval of nonviable, necrotic tissue MechanicalMechanical

– Wet-to-dry saline gauze dressingWet-to-dry saline gauze dressing– Wound irrigationWound irrigation

AutolyticAutolytic– Uses synthetic dressings that allow the eschar Uses synthetic dressings that allow the eschar

to be self-digested by enzymes in wound fluidsto be self-digested by enzymes in wound fluids ChemicalChemical

– Topical enzyme preparations (Dakin’s, sterile Topical enzyme preparations (Dakin’s, sterile maggots)maggots)

SurgicalSurgical– Removal of devitalized tissue b use of scalpel, Removal of devitalized tissue b use of scalpel,

scissors or other sharp instrumentscissors or other sharp instrument

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Wound Management Cont’d.Wound Management Cont’d.

Topical growth factors regulate healing Topical growth factors regulate healing of chronic woundsof chronic wounds

Education of client and caregivers is Education of client and caregivers is importantimportant

Nutritional statusNutritional status Protein status = necessary for healing; Protein status = necessary for healing;

rebuilds epidermal tissuerebuilds epidermal tissue Hemoglobin = decreases delivery of O2 Hemoglobin = decreases delivery of O2

to tissues leading to further ischemiato tissues leading to further ischemia

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74

DressingsDressings Dry or moistDry or moist

– GauzeGauze

HydrocolloidHydrocolloid– Protects the wound from surface Protects the wound from surface

contaminationcontamination

HydrogelHydrogel– Maintains a moist surface to support healingMaintains a moist surface to support healing

Wound V.A.C.Wound V.A.C.– Uses negative pressure to support healingUses negative pressure to support healing

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Types of DressingsTypes of Dressings

Brands vary by institution Brands vary by institution Follow recommendations of wound Follow recommendations of wound

care nursecare nurse See page 1313 of textSee page 1313 of text Wound VAC (vacuum assisted Wound VAC (vacuum assisted

closure)closure)– Negative pressureNegative pressure– See pages 1321-1323See pages 1321-1323

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Other Wound DevicesOther Wound Devices DrainsDrains

– HemovacHemovac– Jackson-PrattJackson-Pratt

ClosuresClosures– StaplesStaples– SuturesSutures

BindersBinders Montgomery strapsMontgomery straps SlingsSlings Sitz bathsSitz baths

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77

Heat and Cold TherapyHeat and Cold Therapy

Assessment for temperature Assessment for temperature tolerancetolerance

Bodily responses to heat and coldBodily responses to heat and cold Factors influencing heat and cold Factors influencing heat and cold

tolerancetolerance EducationEducation httphttp://://www.youtube.com/watch?vwww.youtube.com/watch?v

=Hx26HCML3W8=Hx26HCML3W8

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Nursing DiagnosisNursing Diagnosis

Impaired Skin Integrity r/t Impaired Skin Integrity r/t immobility as evidenced by immobility as evidenced by stage III decubitus ulcer on stage III decubitus ulcer on coccyxcoccyx

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Plan (stage I ulcer)Plan (stage I ulcer)

On-going skin assessment On-going skin assessment Nutritional assessmentNutritional assessment Pressure relief for affected areasPressure relief for affected areas Preventative care for intact skinPreventative care for intact skin

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GoalsGoals Pt. will not have increase in size of Pt. will not have increase in size of

pressure ulcer during hospitalizationpressure ulcer during hospitalization Pt. will not develop infection in Pt. will not develop infection in

pressure ulcer during hospitalizationpressure ulcer during hospitalization Pt. will have nutritional needs Pt. will have nutritional needs

identified by dietitianidentified by dietitian Patient and family will develop a plan Patient and family will develop a plan

(with assistance of nursing) for (with assistance of nursing) for preventing further skin breakdownpreventing further skin breakdown

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InterventionsInterventions RN to assess skin q shiftRN to assess skin q shift Dietician to complete nutritional Dietician to complete nutritional

assessment and recommend a diet assessment and recommend a diet within 24 hourswithin 24 hours

Assistive personnel to reposition patient Assistive personnel to reposition patient q 2 hours using the following scheduleq 2 hours using the following schedule– 8am supine8am supine– 10 am left side10 am left side– 12 noon prone12 noon prone– 2pm right side……….2pm right side……….

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RationaleRationale

Decreasing the duration of pressure on Decreasing the duration of pressure on skin will prevent further skin skin will prevent further skin breakdown. (Perry and Potter, p. 1281)breakdown. (Perry and Potter, p. 1281)

Wound healing requires proper Wound healing requires proper nutrition. (Perry and Potter, p. 1290)nutrition. (Perry and Potter, p. 1290)

Family caregivers require education and Family caregivers require education and counseling for interventions to be counseling for interventions to be effective. (Perry and Potter, p. 1310)effective. (Perry and Potter, p. 1310)

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Outcome EvaluationOutcome Evaluation

By discharge date, patient had By discharge date, patient had developed stage I ulcer developed stage I ulcer – Evaluate and update plan for ulcer Evaluate and update plan for ulcer

preventionprevention Patient has gained 3lbs by discharge Patient has gained 3lbs by discharge

and serum proteins have increasedand serum proteins have increased Family has decided on transfer to Family has decided on transfer to

LTC for further patient careLTC for further patient care


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