mobility + skin integrity

Question 1

by body system

immobility complications

Answer 1

METABOLIC
- metabolic rate is decreased = fluid + electrolyte imbalances
- calorie + protein deficiency as body breaks down proteins = negative nitrogen balance
- weight loss from decreased msucle mass
- weakness from tissue breakdown
- calcium resorption from bones = increased risk for renal failure (kidney has to excrete excess calcium) + pathological fractures
- risk of constipation, fecal impaction, pseudodiarrhea, bowel obstruction

RESPIRATORY
- collapse of aleveoli (atelectasis)
- inflammation of lung from secretions pooling (hypostatic pneumonia)
- ineffective cough = muscus remaining in airways + pneumonia

CARDIO
- orthostatic hypotension, increased cardiac workload, thrombus formation
- dizziness, light-headedness, nausea, pallor, tachycarida, fainting with position changes
- oxygen consumption increases with increased cardiac demand
- accumulation of platelets, fibrin, clotting factors, other blood elements attaches to vessel walls + occludes blood throw (thrombus)

MSK
- protein loss = loss of lean body mass + weakbess
- disuse osteoporosis from bone resorption
- joint contractures (footdrop)

URINARY
- urine does not empty into bladder as readily when lying flat (no gravity to help) = urinary stasis
- urinary stasis, dehydration, + concentrated urine = increased risk for UTI + renal calculi

INTEGUMENTARY
- pressure injury risk
- pressure over bony prominences disrupts cellular metabolism + oxygenation to affected areas

PSYCHOSOCIAL
- changes in coping, cognitive/sensory functions, emotional responses
- depression

Question 2

factors that affect it

skin integrity

Answer 2

nutrition
- proteins, vitamins, minerals for healing
- calories for cellular support for healing
- serum albumin measured as indication for nutrition

tissue perfusion
- oxygen required for healing
- diabetes mellitus + poor tissue perfusion = increased risk for delayred wound healing

infection
- inflammatory phase of healing process is prolonged with infection
- redness, pain, fever, changes in wound drainage volume/character, purulent drainage, odor

age
- inflammatory response + wound healing delayed with age

medical devices (NG tubes, nasal cannula, foley, etc.)

immobility

incontinence

Question 3

wound healing phases

Answer 3

1. inflammatory: begins at time of injury + lasts 3-5 days (local edema, pain, redness, warmth)
2. fibroblastic: 4th day of injury - 2-4 weeks (scar tissue + granulation tissue - new reddish connective tissue with macrophages, new capillaries - in tissue bed)
3. maturation: 3 weeks after injury up to 1 year (scar tissue gets thinner, firm, inelastic on palpation)

Question 4

healing process classification

Answer 4

1. 1st intention: wound edges approximated + held in place until healing occurs, easily closed + dead space eliminated
2. 2nd intention: wounds with tissue loss, gradual filling in of dead space with connective tissue
3. 3rd intention: delayed primary closure, wound intentionally left open for several days for irrigation + removal of debris/exudates, then closed by 1st intention

Question 5

wound drainage types

Answer 5

1. serous = clear/straw coloured + watery
2. serosanguineous = pale/pink + watery
3. sanguineous = red drainage (indicates active bleeding)
4. purulent = yellow/gray/tan/brown/green due to infetion

Question 6

pressure injury types

Answer 6

stage 1
- skin intact
- area is red
- does not blanch with extrnal pressure

stage 2
- skin is not intact
- partial thickness skin loss with exposed dermis
- wound bed is viable, pink/red, moist
- presents as intact or open/ruptured blister

stage 3
- full-thickness skin loss with adipose tissue visibile
- granulation tissue + rolled wound edges are present
- slough (yellow/white) or eschar (black/necrotic) may be present
- undermining/tunneling may be present
- subcuateneous tissue may be damaged/necrotic

stage 4
- full-thickness skin + tissue loss
- exposed/palpable fascia, muscle, tendon, ligament, cartilage, bone
- slough/eschar may be present
- rolled wound edges, undermining, tunneling may be present

unstageable
- full-thickness skin/tissue loss
- damage can’t be assessed, obscured by eschar + slough

suspected deep-tissue injury
- persistent nonblanchable deep red/maroon/purple discoloration
- epidermal serparation shows dark wound bed or blood filled blister

Question 7

dressing types for pressure injuries

Answer 7

stage 1 - none, transparent, hydrocolloid = slow resolution without epidermal losss within 7-14 days

stage 2 - composite film, hydrocolloid, hydrogel with foam/gauze dressing = heals through reepithelialization

stage 3 - hydrovolloid, hydrogel with foam, calcium alginate, gauze = heals through granulation + reepithelialization

stage 4 - hydrogel with foam, calcium alginate, gauze = heals through granulation, reepithelializaton, scar tissue development

unstageable - adherent film, gauze with prescribed solution, enzymes, none = eschar loosens + lifts as healing occurs, surgical debridement may be needed