Transcript Chapter 48: Skin Integrity and Wound Care

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
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– The positioning of the joints, tendons,
ligaments and muscles while standing, sitting,
and lying
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Gravity and Friction
– Gravity is the force of weight downward
– Friction is force that opposes movement
Physiology and Regulation of
Movement
Long bones contribute to height
 Short bones occur in clusters
 Flat bones provide structural contour
 Irregular bones make up the vertebral
column and some bones of the skull
 Functions of MSK

– Protects vital organs
– Aids in calcium regulation
– Production and storage of blood
Joints
Synostotic = bones joined by bones; no
movement; example: skull
 Cartilaginous = cartilage unites bony
components; allows for growth while providing
stability; example: 1st sternocostal joint
 Fibrous = ligament or membrane unites two
bony surfaces; limited movement; Example:
tib/fib
 Synovial = A true joint; freely movable;
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– Pivotal
– Ball and socket
– Hinge
Ligaments/Tendons/Cartilage
Ligaments = white, shin, flexible bands of
fibrous tissue binding joints together and
connecting bones and cartilages
 Tendons = white, glistening, fibrous bands
of tissue that connect muscle to bone;
strong, flexible
 Cartilage = nonvascular, supporting
connective tissue
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Skeletal Muscle
Ability of muscles to contract and relax are the
working elements of movement
 Muscles are made of fibers that contract when
stimulated by an electrochemical impulse that
travels from the nerve to the muscle
 Muscles associated with posture converge at a
common tendon
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– Lower extremities, Trunk, Neck, Back
Coordination and regulation of different muscle
groups depend on muscle tone (normal state of
balanced muscle tension)
 Muscle tone helps maintain functional positions
such as sitting or standing
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The Nervous System
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The motor strip is the major voluntary motor
area and is located in the cerebral cortex
A majority of motor fibers descend from the
motor strip and cross at the level of the medulla
Motor fibers from right motor strip control
voluntary movement on left side of body and
motor fibers on left control movement on right
side of body
Impulses descend from motor strip to spinal
cord
Impulse exits the spinal cord through efferent
motor nerves and travels through the nerves
The Nervous System Cont’d.
Neurotransmitters or chemicals transfer electric
impulses from the nerve to the muscle
 Neurotransmitters stimulate the muscles causing
movement
 Movement is impaired by disorders that alter
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– Neurotransmitter production
– Transfer of impulses from the nerve to the muscle
– Activation of muscle activity
Pathological Influences on Mobility
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Postural abnormalities: congenital or
acquired postural abnormalities affect the
efficiency of the MSK system as well as
body alignment, balance, and appearance
– Can cause pain, impair alignment or mobility
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Impaired muscle development: patients
with muscular dystrophy experience
progressive, symmetrical weakness and
wasting of skeletal muscle groups, with
increasing disability and deformity
Pathological Influences on Mobility
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Damage to the Central Nervous System: damage
to any component of the CNS that regulates
voluntary movement results in impaired body
alignment, balance, and mobility
– Complete transection of the spinal cord results in a
bilateral loss of voluntary motor control below the
level of trauma
– Damage to the cerebellum causes problems with
balance and motor impairment is directly related to
amount and location of destruction
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Trauma to the Musculoskeletal System: direct
trauma results in bruises, contusions, sprains,
and fractures
Mobility and Immobility
Mobility refers to a person’s ability to move
about freely and immobility refers to the
inability to do so
 The effects of muscular deconditioning
associated with lack of physical activity are often
apparent in a matter of days
 Disuse atrophy describes the tendency of cells
and tissue to reduce in size and function in
response to prolonged inactivity resulting from
bed rest, trauma, casting, or local nerve damage
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The Effects of Immobility
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Metabolic changes
– Negative nitrogen balance
– Calcium resorption (loss)
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GI changes
– Constipation → Impaction → Mechanical Obstruction
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Respiratory changes
– Atelectasis → Pneumonia
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Cardiovascular changes
– Orthostatic hypotension
– Increased cardiac workload
– Thrombus formation (Virchow’s triad)
The Effects of Immobility Cont’d.
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Musculoskeletal changes
– ↑ protein breakdown → ↓ lean body mass
– Osteoporosis
– Joint contractures
 Foot drop
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Changes in urinary elimination
– Urinary stasis
– Renal calculi
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Integumentary changes
– Pressure ulcers
Older Adults
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Immobility can lead to….
– Loss of mobility and functional decline
– Weakness, fatigue, and increased risk for falls
– Shallow breathing resulting in pneumonia
– Inadequate turning/repositioning results in
skin breakdown and pressure ulcers
– Anorexia and insufficient assistance with
eating leads to malnutrition
– Multiple interruptions and noise impair sleep,
causing fatigue, depression, and confusion.
Mobility
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ROM = amount of movement at a joint
– Active/Passive
– See pages 1232 – 1236
Gait = style of walking
 Exercise and activity tolerance: age and illness
can affect this
 Body Alignment
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– Standing/Sitting/Lying
 Patients with impaired mobility, decreased sensation,
impaired circulation, and lack of voluntary muscle control are
at risk for damage to the MSK system when lying down
Range of Motion
Safe Patient Handling
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Protecting the Patient and Health Care
worker
– Manually lifting and transferring clients
contributes to the high incidence of workrelated MSK problems and back injury
– Lift teams/lift equipment
– Ergonomics training
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Plan ahead based on patient assessment
Assistive Devices for Patient
Movement
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All devices must be appropriate for patient
– Weight limit
– Reason for Device
– Measured to patient
Canes
 Walkers
 Wheel chairs
 Crutches
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Gait Belt
Wearing a Gait Belt
Using a Gait Belt
Ambulating With a Walker
Assessment
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Metabolic
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I&O
Lab values
Height and weight
Nutritional intake
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– Breakdown
– Color changes
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Respiratory
CV
– Pulses/Cap refill
– Edema/DVT
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MSK
– Muscle tone/strength
– Contractures
Elimination
– I&O
– Bowel sounds
– Frequency and consistency
of stool
– Dietary intake
– Auscultate lungs
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Integument
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Psychosocial
– Anxiety
– Depression
– Sleep deprivation
Plan
Goals and outcomes individualized
 Set priorities
 Collaborative care: team approach
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Interventions
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Health promotion
– Education
– Prevention
– Early detection
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Prevention of work-related MSK injuries
– Use of ergonomics
Exercise
 Bone health
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– Screening
– Maintain independence with ADLs
– Assistive ambulatory devices
Interventions Cont’d.
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Metabolic
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High-protein, high-calorie diet
Vitamin B for skin integrity and wound healing
Vitamin C for replacing protein stores
TPN
Enteral feedings
Respiratory
– Turn, cough, and deep breathe (TCDB)
– Chest physiotherapy (CPT)
– 2000 mL of fluid daily if not contraindicated
Interventions Cont’d.
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CV
– Mobilize ASAP, dangle or sit in chair at
minimum
– Isometric Exercise
– Discourage use of valsalva maneuver
– DVT prophylaxis
 TEDS – apply properly, remove at least bid
 Avoid crossing legs, sitting for prolonged periods of
time, wearing constrictive clothing, putting pillows
under the knees, and massaging legs
 Meds
Interventions Cont’d.
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MSK
– ROM
– CPM in orthopedics
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Integument
– Screen for risk (Braden Scale)
– Prevention
– Position changes
Interventions Cont’d.
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Elimination
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Adequate hydration
If incontinent, provide frequent skin care
Catheterize prn
Foods high in fiber
Stool softners/cathartics prn
Psychosocial
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Schedule care to prevent interruption of sleep
Depression screening (GDS)
Provide stimulation and re-orient prn
Involve clients in own care as much as possible
Positioning
Semi Fowler’s Position
Sim’s or Left Lateral Position
Now let’s write a nursing care
plan regarding immobility
Chapter 48: Skin
Integrity and Wound
Care
Skin
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Two layers
– Epidermis = has several layers
 Stratum corneum = thin, outermost layer
– Allows for evaporation of water from skin
– Permits absorption of topical meds
 Basal layer
– Dermis = provides strength, support and
protection of underlying muscles, bones, and
organs
Pressure Ulcers
 Impaired
skin integrity (damage to
the skin) related to unrelieved,
prolonged pressure and/or
shearing/friction
 AKA: Pressure sore, decubitus ulcer,
bedsore
 Localized injury to the skin or other
underlying tissue, usually over a body
prominence
Pathogenesis
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Pressure Intensity
– Tissue ischemia can occur due to capillary
occlusion for a prolonged period of time
– Patient’s with decreased sensation cannot
respond to discomfort associated with
ischemia hence tissue death results
– Blanching = occurs when normal red tones of
the light skinned client is absent (doesn’t
occur in darkly pigmented skin)
Pathogenesis Cont’d.
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Pressure Duration
– Low pressure over a prolonged time period
– High-intensity pressure over shot period
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Tissue Tolerance
– Depends on integrity of the tissue and the supporting
structures
– Shear, friction and moisture make skin more
susceptible to damage from pressure
– Ability of underlying skin structures to assist with
redistribution of pressure
 Affected by poor nutrition, increased aging, and low BP
Risk Factors
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Impaired sensory
perception
Impaired mobility
Alteration in LOC
Shear
Friction
Moisture
Classification of Pressure Ulcers
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Stage I: Intact skin with non-blanchable
redness of a localized area
Stage II: Partial-thickness skin loss involving
epidermis, dermis or both; superficial abrasion,
blister, or shallow crater
Stage III: Full-thickness tissue loss;
subcutaneous fat may be visible, slough may be
present; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with
exposed bone, tendon, or muscle; slough or
eschar may be present on some parts; often
includes undermining and tunneling
Unstageable if bed is full of slough or eschar
STAGE I ULCER- GREATER TROCHANTER
STAGE II ULCER – ISCHEAL TUBEROSITY
STAGE III
STAGE IV ISCHEAL TUBEROSITY AND
SACRUM
Definitions
Granulation tissue = red moist tissue composed
of new blood vessels; indicates healing
 Slough = stringy substance attached to wound
bed; needs removed before wound can heal
 Eschar = black or brown necrotic tissue; must
be removed before wound can heal
 Exudate = Type (consistency), Amount, Color,
and Odor of wound drainage; part of your
assessment
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Process of Wound Healing
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Primary intention = edges are well
approximated or closed; risk of infection
low; heals quickly; minimal scar formation
– Example: surgical wound
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Secondary intention = wound is left open
until becomes filled with scar tissue;
chance of infection is great; longer healing
time
– Example: burn, pressure ulcer, severe
laceration
Complications of Wound Healing
Hemorrhage/hematoma
 Infection
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– Second most common health care associated infection
Dehiscence = partial or total separation of
wound layers
 Evisceration = protrusion of visceral organs
through wound opening
 Fistulas = abnormal passage between two
organs or between organs and the outside of
the body
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Prediction and Prevention of
Pressure Ulcers
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Risk Assessment
– Braden Scale (see slide in chapter 47)
– Prevention
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Factors influencing pressure ulcer formation and
wound healing
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Nutrition
Tissue perfusion
Infection
Age
Psychosocial impact (true impact unknown)
Assessment
Assess skin for signs of ulcer development
 Pressure ulcer assessment
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– Risk assessment
– Mobility
– Nutritional status
– Body fluids
– Pain
Wound Assessment
Type: abrasion, laceration, puncture, etc.
 Appearance: red, inflamed, clean, dirty
 Drainage: TACO
 Drains
 Closures
 Palpation
 Cultures
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Interventions
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Prevention
Frequent skin assessment
Keep skin clean and dry
Don’t use soaps and hot water
Apply moisturizers
Control/contain incontinence, perspiration or
wound drainage
Positioning
Therapeutic bed/mattress
Wound Management
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Clean wounds with noncytotoxic wound
cleansers
– Normal saline
– Commercial wound cleansers
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Cytotoxic cleansers used for chemical
debridement
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Dakin’s solution (sodium hypochlorite soln)
Acetic acid
Providone-iodine
Hydrogen Peroxide
Debridement
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Removal of nonviable, necrotic tissue
Mechanical
– Wet-to-dry saline gauze dressing
– Wound irrigation
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Autolytic
– Uses synthetic dressings that allow the eschar to be
self-digested by enzymes in wound fluids
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Chemical
– Topical enzyme preparations (Dakin’s, sterile
maggots)
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Surgical
– Removal of devitalized tissue b use of scalpel, scissors
or other sharp instrument
Wound Management Cont’d.
Topical growth factors regulate healing of
chronic wounds
 Education of client and caregivers is
important
 Nutritional status
 Protein status = necessary for healing;
rebuilds epidermal tissue
 Hemoglobin = decreases delivery of O2 to
tissues leading to further ischemia
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Dressings
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Dry or moist
– Gauze
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Hydrocolloid
– Protects the wound from surface contamination
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Hydrogel
– Maintains a moist surface to support healing
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Wound V.A.C.
– Uses negative pressure to support healing
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Types of Dressings
Brands vary by institution
 Follow recommendations of wound care
nurse
 See page 1313 of text
 Wound VAC (vacuum assisted closure)
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– Negative pressure
– See pages 1321-1323
Other Wound Devices
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Drains
– Hemovac
– Jackson-Pratt
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Closures
– Staples
– Sutures
Binders
 Montgomery straps
 Slings
 Sitz baths
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Heat and Cold Therapy
Assessment for temperature tolerance
 Bodily responses to heat and cold
 Factors influencing heat and cold
tolerance
 Education
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http://www.youtube.com/watch?v=Hx26HCML3
W8
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Nursing Diagnosis
 Impaired
Skin Integrity r/t
immobility as evidenced by stage
III decubitus ulcer on coccyx
Plan (stage I ulcer)
 On-going
skin assessment
 Nutritional assessment
 Pressure relief for affected areas
 Preventative care for intact skin
Goals
Pt. will not have increase in size of
pressure ulcer during hospitalization
 Pt. will not develop infection in pressure
ulcer during hospitalization
 Pt. will have nutritional needs identified by
dietitian
 Patient and family will develop a plan
(with assistance of nursing) for preventing
further skin breakdown
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Interventions
RN to assess skin q shift
 Dietician to complete nutritional
assessment and recommend a diet within
24 hours
 Assistive personnel to reposition patient q
2 hours using the following schedule
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– 8am supine
– 10 am left side
– 12 noon prone
– 2pm right side……….
Rationale
Decreasing the duration of pressure on
skin will prevent further skin breakdown.
(Perry and Potter, p. 1281)
 Wound healing requires proper nutrition.
(Perry and Potter, p. 1290)
 Family caregivers require education and
counseling for interventions to be
effective. (Perry and Potter, p. 1310)
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Outcome Evaluation
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By discharge date, patient had developed
stage I ulcer
– Evaluate and update plan for ulcer prevention
Patient has gained 3lbs by discharge and
serum proteins have increased
 Family has decided on transfer to LTC for
further patient care
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