Kingdom of Saudi Arabia
Ministry of Higher Education
Al-Jouf University
Collage of Applied Medical Sciences
Department of Nursing
Subject: concept of nursing (123 nur)
Outline:
1- Define Immobility:
2- effect of Immobility:
3- Pressure ulcer
4- Stage of Pressure ulcer
5- Causes Pressure ulcer
6- Pathophysiology Pressure ulcer
7- Signs and symptoms Pressure ulcer
8- Complications of Pressure ulcer
9- Diagnosis
10- Treatment of Pressure ulcer
Define Immobility:
Refers to a reduction in the amount and control of movement a person has.
Normally people move when they experience discomfort due to pressure on an area of
the body. Healthy people rarely exceed their tolerance to pressure. However. Paralysis,
extreme weakness, pain, or any cause of decreased activity can hinder person's ability to
change positions independently and relative the pressure, even if the person can
perceive the pressure.
Effect of Immobility:
a. Cardiovascular System.
(1) Venous stasis caused by prolonged inactivity that restricts or slows venous circulation.
Muscular activity, especially in the legs, helps move blood toward the central circulatory
system.
(2) Increased cardiac workload due to increased viscosity from dehydration and decreased
venous return. The heart works more when the body is resting, probably because there is less
resistance offered by the blood vessels and because there is a change in the distribution of
blood in the immobile person. The result is that the heart rate, cardiac output, and stroke
volume increase.
(3)Thrombus and embolus formation caused by slow flowing blood, which may begin clotting
within hours, and an increased rate in the coagulation of blood. During periods of immobility,
calcium leaves bones and enters the blood, where it has an influence on blood coagulation.
(4)Orthostatic hypotension probably due to a decrease in the neurovascular reflexes, which
normally causes vasoconstriction, and to a loss of muscle tone. The result is that blood pools
and does not squeeze from veins in the lower part of the body to the central circulatory
system. The immobile person is more susceptible to developing orthostatic hypotension. The
person tends to feel weak and faint when the condition occurs.
b. Respiratory System.
(1) Hypostatic pneumonia. The depth and rate of respirations and the movement of secretions
in the respiratory tract is decreased when a person is immobile. The pooling secretions and
congestion predispose to respiratory tract infections. Signs and symptoms include:
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Increased temperature.
Thick copious secretions.
Cough.
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Increased pulse.
Sharp chest pain.
Dyspnea.
(2) Atelectasis: When areas of lung tissue are not used over a period of time, incomplete
expansion or collapse of lung tissue may occur.
(3) Impaired coughing: Impairment of coughing mechanism may be due to the patient's
position in bed decreasing chest cage expansion.
c. Musculoskeletal System.
(1) Muscle atrophy. Disuse leads to decreased muscle size, tone, and strength.
(2) Contracture. Decreased joint movement leads to permanent shortening of muscle tissue,
resistant to stretching. The strong flexor muscles pull tight, causing a contraction of the
extremity or a permanent position of flexion.
(3) Ankylosis. Consolidation and immobility of a joint in a particular position due to
contracture.
(4) Osteoporosis. Lack of stress on the bone causes an increase in calcium absorption,
weakening the bone.
d. Nervous System.
(1)Altered sensation caused by prolonged pressure and continual stimulation of nerves.
Usually pain is felt at first and then sensation is altered, and the patient no longer senses the
pain.
(2)Peripheral nerve palsy.
e. Gastrointestinal System.
(1) Disturbance in appetite caused by the slowing of gastrointestinal tract, secondary
immobility, and decreased activity resulting in anorexia.
(2) Altered digestion and utilization of nutrients resulting in constipation.
(3) Altered protein metabolism.
f. Integumentary System.
Risk of skin breakdown, which leads to necrosis and ulceration of tissues, especially on bony
areas.
g. Urinary System.
(1) Renal calculi (kidney stones) caused by stagnation of urine in the renal pelvis and the high
levels of urinary calcium.
(2) Urinary tract infections caused by urinary stasis that favors the growth of bacteria.
(3) Decreased bladder muscle tone resulting in urinary retention.
h. Metabolism.
(1) Increased risk of electrolyte imbalance. An absence of weight on the skeleton and
immobility causes protein to be broken down faster than it is made, resulting in a negative
nitrogen balance.
(2) Decreased metabolic rate.
(3) Altered exchange of nutrients and gases.
i. Psychosocial Functioning.
(1) Decrease in self-concept and increase in sense of powerlessness due to inability to move
purposefully and dependence on someone for assistance with simple self-care activities.
(2) Body image distortions (depends on diagnosis).
(3) Decrease in sensory stimulation due to lack of activity, and altered sleep-wake pattern.
(4) Increased risk of depression, which may cause the patient to become apathetic, possibly
because of decreased sensory stimulation; or the patient may exhibit altered thought processes.
(5) Decreased social interaction.
Pressure ulcer
Pressure ulcers, commonly called pressure sores or bedsores, are localized areas of
cellular necrosis that occur most often in the skin and subcutaneous tissue over bony
prominences. These ulcers may be superficial, caused by local skin irritation with
subsequent surface maceration, or deep, originating in underlying tissue. Deep lesions
often go undetected until they penetrate the skin, but by then, they've usually caused
subcutaneous damage.
Most pressure ulcers develop over five body locations: sacral area, greater trochanter,
ischial tuberosity, heel, and lateral malleolus.
AGE ALERT Age also has a role in the incidence of pressure ulcers. Muscle is lost
with aging, and skin elasticity decreases. Both these factors increase the risk for
developing pressure ulcers.
STAGES OF PRESSURE ULCER:
A stage 1:
pressure ulcer is an observable pressure-related alteration of intact skin. The indicators,
compared with the adjacent or opposite area on the body, may include changes in one or
more of the following factors: skin temperature (warmth or coolness), tissue consistency
(firm or boggy feel), or sensation (pain or itching). The ulcer appears as a defined area of
persistent redness in lightly pigmented skin; in darker skin, the ulcer may appear with
persistent red, blue, or purple hues
A stage 2 pressure ulcer is characterized by partial-thickness skin loss involving the
epidermis or dermis. The ulcer is superficial and appears as an abrasion, blister, or shallow
crater.
A stage 3:
pressure ulcer is characterized by full-thickness skin loss involving damage or necrosis of
subcutaneous tissue, which may extend down to, but not through, the underlying fascia. The
ulcer appears as a deep crater with or without undermining of adjacent tissue
A stage 4:
Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to
muscle, bone, or support structures (for example, tendon or joint capsule) characterize a
stage 4 pressure ulcer.
Causes:
Possible causes of pressure ulcers include:

immobility and decreased level of activity
 friction causing damage to the epidermal and upper dermal skin layers
 constant moisture on the skin causing tissue maceration
 impaired hygiene status, such as with fecal incontinence, leading to skin breakdown
 malnutrition (associated with pressure ulcer development)
 medical conditions such as diabetes and orthopedic injuries (predispose to pressure ulcer
development)
 psychological factors, such as depression and chronic emotional stresses (may have a role in
pressure ulcer development).
Pathophysiology:
A pressure ulcer is caused by an injury to the skin and its underlying tissues. The pressure
exerted on the area causes ischemia and hypoxemia to the affected tissues because of
decreased blood flow to the site. As the capillaries collapse, thrombosis occurs, which
subsequently leads to tissue edema and progression to tissue necrosis. Ischemia also adds to an
accumulation of waste products at the site, which in turn leads to the production of toxins. The
toxins further break down the tissue and eventually lead to the death of the cells.
Signs and symptoms:
Signs and symptoms of pressure ulcers may include:
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blanching erythema, varying from pink to bright red depending on the patient's skin color; in
dark-skinned people, purple discoloration or a darkening of normal skin color (first clinical
sign); when the examiner presses a finger on the reddened area, the “pressed on” area whitens
and color returns within 1 to 3 seconds if capillary refill is good
 pain at the site and surrounding area
 localized edema due to the inflammatory response
 increased body temperature due to initial inflammatory response (in more severe cases, cool
skin due to more severe damage or necrosis)
 nonblanching erythema (more severe cases) ranging from dark red to purple or cyanotic;
indicates deeper dermal involvement
 blisters, crusts, or scaling as the skin deteriorates and the ulcer progresses
 usually dusky-red appearance, doesn't bleed easily, warm to the touch, and possibly mottled
(deep ulcer originating at the bony prominence below the skin surface).
Complications:
Possible complications of pressure ulcers include:
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progression of the pressure ulcer to a more severe state (greatest risk)
secondary infections such as sepsis
loss of limb from bone involvement.
Diagnosis
Diagnosis is based on:
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physical examination showing presence of the ulcer
wound culture with exudate or evidence of infection
elevated white blood cell count with infection
possibly elevated erythrocyte sedimentation rate
total serum protein and serum albumin levels showing severe hypoproteinemia.
Treatment
Treatment for pressure ulcers includes:
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Repositioning by the caregiver every 2 hours or more often if indicated, with support of
pillows for immobile patients; a pillow and encouragement to change position for those able
to move
 Foam, gel, or air mattress to aid in healing by reducing pressure on the ulcer site and
reducing the risk for more ulcers
 Foam, gel, or air mattress on chairs and wheelchairs as indicated
 Nutritional assessment and dietary consult as indicated; nutritional supplements, such as
vitamin C and zinc, for the malnourished patient; monitoring serum albumin and protein
markers and body weight
 Adequate fluid intake (I.V. if indicated) and increased fluids for a dehydrated patient
 Good skin care and hygiene practices (for example, meticulous hygiene and skin care for the
incontinent patient to prevent breakdown of the affected tissue and skin)
 Stage II, cover ulcer with transparent film, polyurethane foam, or hydrocolloid dressing
 Stage II or IV, loosely fill wound with saline- or gel-moistened gauze, manage exudates with
absorbent dressing (moist gauze or foam) and cover with secondary dressing
 Clean, bulky dressing for certain types of ulcers, such as decubiti
 Surgical debridement for deeper wounds stage III or IV as indicated.