Immobility, Pressure Ulcers Flashcards
What are the risk factors for pressure ulcers?
Impaired sensory perception, impaired mobility, nutrition, alterations in LOC, shear force/friction, moisture, fecal or urinary incontinence.
Nursing knowledge base for pressure ulcers?
Agency for Health Care Policy and Research Guidelines (AHCPR)
Braden Scale
Bates-Jensen Wound Assessment
What is the Braden Scale comprised of?
Sensory perception, moisture, activity, mobility nutrition, friction and shear
What is the Bates-Jensen comprised of?
Size, depth, edges, undermining, necrotic tissue type, necrotic tissue amount, granulation, epithelialization tissue, exudate type, exudate amount, skin color, edema, induration
What is the pathogenesis of pressure ulcers?
Pressure intensity-tissue ischemia and blanching
Pressure duration
Tissue tolerance
What patients are at risk for pressure ulcers?
Trauma victims, older adults, spinal cord injury, patients with fractured hip, diabetes, long term care, critical care
What should be assessed for when it comes to pressure ulcers?
Skin: bony prominences, tube sites, orthopedic devices
Pressure ulcers: Predictive measures, mobility, body fluids, pain
How to position patients and prevent ulcers?
Turn every 1 to 2 hours as indicated. Use draw sheets. Over bed trapeze. Support surfaces, special mattresses, overlay or seat cushion. Elevate heels off bed. Manage moisture. Clean skin. Elevate HOB to 30 degrees or less.
Stage 1 of decubitus ulcers?
Non-blanchable redness of intact skin in localized areas, usually over a bony prominence. Darkly pigmented skin may not ave visible blanching, its color may differ from the surrounding areas.
Stage 2 of decubitus ulcers?
Partial-thickness skin loss or blister presenting as a shallow, open ulcer with a red-pink wound bed without slough. May also present as an intact or open/ruptured, serum-filled blister.
Stage 3 of decubitus ulcers?
Full-thickness skin loss, fat is visible. Bone, tendon, muscles are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage 4 of decubitus ulcers?
Muscle/bone/tendon visible. Full-thickness tissue loss. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.
What to assess for when it comes to pressure ulcers?
Location, extent of tissue involvement, presence of undermining or tunneling, wound size in cm.
Length (head to toe)
Width (side to side)
Depth (deepest part of the visible wound bed)
Unstageable/unclassified pressure ulcers?
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Until enough slough or eschar is removed to expose the base of the wound, the true depth and therefore stage cannot be determined.
What should be done with stable (dry, adherent, intact without erythema or fluctuance) eschar such as on the heels?
It should not be removed because it’s the body’s natural cover
One-way staging as recommended by the WOCN Society?
Down-staging/reverse staging of ulcers is not appropriate.
Use the deepest stage and prefix this with the term “healing” or “healed”
If it reopens in the same anatomical site, it retains its original stage.
What are the 3 components of partial-thickness wound repair?
Inflammatory response
Epithelial proliferation and migration
Proliferation and migration
What are the 4 phases of full-thickness wound repair?
Hemostasis (fibrin)
Inflammatory response
Proliferative phase (epithelialization)
Maturation
What are the types of dressings for pressure ulcers?
Transparent
Hydrocolloid
Negative-pressure wound therapy
What are pathological influences on immobility?
Postural abnormalities, impaired muscle development, damage to the CNS, and musculoskeletal trauma
What are therapeutic reasons for bed rest?
Decrease oxygen consumption, weakness, safety, rest a body part (like a fracture), reduce pain, severity of condition
What are the levels of activity?
Complete bed rest, bed rest with bathroom privileges, bedrest with bedside commode, dangle on the side of bed, up to bedside chair, Out of bed with assistance, OOB ad lib
What systemic effects does immobility have on the metabolic and cardiovascular systems?
Metabolic is endocrine, calcium absorption, and GI function, glucose intolerance, negative nitrogen balance
Cardiovascular is orthostatic hypotension, thrombus, postural hypertension, cardiac muscle atrophy
What systemic effects does immobility have on urinary elimination and respiratory system?
Urinary elimination is urinary stasis and renal calculi
Respiratory is atelectasis, hypostatic pneumonia, nephritis
What systemic effects does immobility have on the skeleton and integumentary system?
Skeleton is impaired calcium absorption, joint abnormalities
Integumentary is pressure ulcers and ischemia.
What are examples of nursing diagnoses for the respiratory system related to immobility?
Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
What are examples of nursing interventions for the respiratory system related to immobility?
Assess lung sounds, for decreased ability to cough, accumulated secretions, colored sputum, fever, shortness of breath changes in skin color, pulse ox.
TCDB every two hours
Suction oropharyngeal airway prn
Chest physiotherapy, provide hydration
What are examples of nursing diagnoses for the cardiovascular system related to impaired mobility?
Risk for orthostatic hypotension
RF impaired tissue perfusion
RF decreased cardiac output
What are nursing interventions for the cardio system related to impaired mobility?
Use anti embolism stockings
Raised and lower HOB several times. Raise HOB to fowler’s before getting out of bed.
Dangling and assisting client to stand
Observe for symptoms
A blood clot that adheres to the wall of a blood vessel or organ
A clot or part of a clot that has broken off from the place where it was formed and has traveled to another organ
Thrombus
Thromboembolism
Blocks blood flow to the area beyond where it lodges, can be lethal if it travels to the heart, lungs, or brain
An abnormal and possibly permanent condition characterized by fixation of the joint.
Joint contracture
What are nursing interventions for the musculoskeletal system related to impaired mobility?
Passive and active range of motion/ROM
Continuous passive motion machine/CPM
Mobility aids such as canes, walkers, crutches
How to do passive range of motion exercises/PROM?
Slow and smooth movements to the point of resistance, not past capacity. Repeat each movement five times. Stand on the side closest to the joint being exercised. Support distal and proximal joint.
What are nursing interventions for the urinary system related to impaired mobility?
Assess intake and output. Turn frequently, OOB ASAP. Hydrate the patient. Proper positioning on the bedpan.
What are nursing interventions for the GI system related to impaired mobility?
Hydration 1100 mL - 1400 mL a day minimum. Getting them out of bed, ROM. High fiber diet laxatives if needed (stool softeners don’t increase peristalsis). Frequent position changes.
What are the psychosocial effects of immobility?
Emotional and behavioral responses. Hostility, giddiness, fear, anxiety, mood changes. Sensory alterations (disorientation). Altered sleep patterns. Changes in coping. Depression, sadness, rejection, isolation.
What are nursing interventions for the psychosocial aspects related to immobility?
Activities, reading, reducing noise when working night shift to help the patients get better sleep.
Cluster activity to get things done at once, to give them periods of uninterrupted sleep.
Keep a routine.
Develops when pressure on the skin is greater than pressure inside the small peripheral blood vessels supplying blood to the skin.
Tissue ischemia
What are nursing interventions for the integumentary system related to immobility?
Repositioning minimum every two hours. Sit in chair only one hour uninterrupted. Moisturize skin but not too moist, use a barrier cream. Adequate hydration and diet. Relieve pressure.
Patients need how much of fluids per day to help prevent renal calculi and urinary tract infection?
2000 and 3000 mL
