Exam #4 Study Guide
Chapter 48 (Skin Integrity & Wound Care)
Blanching is occur when the normal red tones of the skins are absent. Blanching
doesn’t occur in a dark skin patient
For dark skin patient assess change in sensation, temperature, edema, and tissue
consistency.
Stage 1- intact skin with nonblanchable redness
Stage 2- partial-thickness skin loss involving epidermis, dermis, or both
Stage 3- full thickness tissue loss with visible fat
Stage 4- full thickness tissue loss with exposed bone, muscle, or tendon
Unstageable/unclassified ulcer is a full thickness tissue loss actual depth is
obscured by slough and eschar. After removing the slough and eschar they are
most likely to be stage III or IV
To determine the true depth of the pressure injury slough and eschar need to be
removed.
Warm, moist compress indicated for relieve edema, improve blood flow to
injured part, promote consolidate of purulent drainage
Slough is white, yellow, gray, green, brown, or tan string dead tissue within a
wound. It is important to remove this tissue to prevent infection and promote
healing
Eschar is tan, black, brown, or tan necrotic tissue this also must be removed
before wound can heal
Epibole is when the edges of the wound rolling under the wound
Complication of wound healing
Hematoma/seroma
Infection
A wound that heals by primary intention the skin edges are approximate.
Know what to do with wound dehiscence and evisceration
Dehiscence partial or total separation of wound layers mostly occur 3-11 days
Evisceration wound completely open, and organ present outside of the patient it
is always an emergency, make them NPO, observe for S/S shock, Place damp
sterile gauze over the wound.
Know the type of tissue you see with wound healing
Granulation tissue
Collagen tissue
Epithelialization tissue
Know lab data that may be ordered for someone with a pressure ulcer
Know the Braden scale. What is it used for?
Skin breakdown assessment and prediction of the risk
6 criteria Sensory perception, level of moisture, activity, mobility, nutrition, and friction/shear
Total 6-23
The lower the score indicates a high risk in pressure ulcer.
Dressing reason
Protection
Aid hemostasis, absorbs drainage, support wound site, promotes thermal insulation, provide a
moist environment
Know the different types of wound dressings and for what type of wound they would be used.
For debriding wet to dry /damp to damp dressing
Gauze dressing can be inpergnated with water
Transparent film you can easily assess the wound
Hydrocolloid is a dressing that form a gel that interacts with the wound surface to debride
wounds, support healing in clean granulating wound and debride necrotic wounds, change
every 3 days.
Hydrogel
Foam and alginate dressings for large amount of exudate and those that need packing
Medi honey – very effective of healing for open wound
Composite. Table 48.8
Synthetic dressings digest eschar
Topical enzyme cause breakdown of necrotic tissues
A most environment can facilitate wound closure
A patient can lose as much as 50gram protein per day from an open weeping pressure injury
What is wound debridement? Debridement is removal of nonviable necrotic tissue. Provides a
clean base necessary for healing. Methods of debridement include mechanical, autolytic,
chemical, and sharp/surgical
Know lab values and what values, if low, could affect wound healing
Know strategies to reduce chance of pressure ulcer if someone has the nursing diagnosis:
Impaired Skin integrity.
Skin assessment at least every day
Every shift for patient with high-risk pressure ulcer
Elevate the bed of the head 30 degrees or less
Redistribute pressure and searing force
Reposition at least every 2 hours for risk patient
Protect boney prominences
Use transfer device to lift
Never massage reddened area it will increase capillary breakdown
Chapter 39 (Immobility)
Know which members of the health care team can be involved with patients who have mobility
issues.
What are signs/symptoms related to immobility?
Know how to teach patients to use a cane, walker, and crutches.
Know three-point gait.
Clean from the least contaminated to (most contaminated area) the surrounding gentle friction
With 35ml syringe with a 19-gauge soft Angio catheter to deliver the solution
Soaked dressing considered a biohazard
Prevention is important for healing caloric intake elevated to 30-35ca/kg/day or 1.25 to 1.50 g
protein/kg/day
Vitamin A promote epithelization, closure, inflammatory response, and angiogenesis
Moist application does not promote sweating
Zinc 15-30mg for wound healing
1000mg/day Vitamin C is recommended for wound healing
1ml Volume of drainage equal to 1gram dressing.
Vitamin A 1600 to 2000
Abrasion characterized by Superficial, consider a partial thickness wound
weepy
Cold application reduce muscle tension
Wound must ne cleaned from drainage before taking culture sample
Chapter 38 (Activity and Exercise)
What are the steps to develop a fitness/exercise program?
Nature of movement
• Movement requires a coordinated effort between the musculoskeletal and nervous
systems. Nurses pay attention to body mechanics to avoid injury to self and patients.
• Body mechanics are the coordinated efforts of the musculoskeletal and nervous
systems.
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Today nurses use information about body alignment, balance, gravity, and friction when
implementing nursing interventions such as positioning patients, determining the risk of
patient falls, and selecting the safest way to move or transfer patients.
• Alignment and balance or posture refer to the positioning of joints, tendons, ligaments,
and muscles while standing, sitting, or lying. Body alignment means that the individual’s
center of gravity is stable. Without balance control the center of gravity is displaced.
• Individuals require balance for maintaining a static position (e.g., sitting) and moving
(e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes
(e.g., pregnancy) compromise the ability to remain balanced.
• Medications that cause dizziness and prolonged immobility effect balance.
• Impaired balance is a major threat to mobility and physical safety and contributes to a
fear of falling and self-imposed activity restrictions.
• Weight is the force exerted by gravity. The force of weight is always directed downward.
Therefore, an unbalanced object falls.
• Individuals require balance for maintaining a static position (e.g., sitting) and moving
(e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes
(e.g., pregnancy) compromise the ability to remain balanced. Medications that cause
dizziness and prolonged immobility effect balance. Impaired balance is a major threat to
mobility and physical safety and contributes to a fear of falling and self-imposed activity
restrictions.
• People’s centers of gravity are usually at 55% to 57% of standing height and are in the
midline, which is why only using principles of body mechanics in lifting patients often
leads to injury of the nurse or health care professional
• The greater the surface area of the object that is moved, the greater the friction. Large
objects produce greater resistance to movement. Therefore nurses need to be aware of
the friction that can cause a patient’s skin to shear or tear.
• The force exerted against the skin while the skin remains stationary, and the bony
structures move is called shear.
Pathological influence on mobility
• Congenital or acquired postural abnormalities affect the efficiency of the
musculoskeletal system and body alignment, balance, and appearance. During
assessment observe body alignment and range of motion (ROM).
• Postural abnormalities can cause pain, impair alignment or mobility, or both. Knowledge
about the characteristics, causes, and treatment of common postural abnormalities is
necessary for lifting, transfer, and positioning.
• Injury and disease lead to many alterations in musculoskeletal function.
• Damage to any component of the central nervous system that regulates voluntary
movement results in impaired body alignment, balance, and mobility.
• Trauma from a head injury, ischemia from a stroke or brain attack (cerebrovascular
accident [CVA]), or bacterial infection such as meningitis can damage the cerebellum or
the motor strip in the cerebral cortex. Damage to the cerebellum causes problems with
balance, and motor impairment is directly related to the amount of destruction of the
motor strip.
• Trauma to the spinal cord also impairs mobility.
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Direct trauma to the musculoskeletal area can cause bruises, contusions, sprains, or
fractures. Treatment often includes positioning the fractured bone in proper alignment
and immobilizing it to promote healing and restore function. Even this temporary
immobilization results in some muscle atrophy, loss of muscle tone, and joint stiffness.
•
Movement requires a coordinated effort between the musculoskeletal and nervous
systems. Nurses pay attention to body mechanics to avoid injury to self and patients.
Body mechanics are the coordinated efforts of the musculoskeletal and nervous
systems.
Today nurses use information about body alignment, balance, gravity, and friction when
implementing nursing interventions such as positioning patients, determining the risk of
patient falls, and selecting the safest way to move or transfer patients.
Alignment and balance or posture refer to the positioning of joints, tendons, ligaments,
and muscles while standing, sitting, or lying. Body alignment means that the individual’s
center of gravity is stable. Without balance control the center of gravity is displaced.
Individuals require balance for maintaining a static position (e.g., sitting) and moving
(e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes
(e.g., pregnancy) compromise the ability to remain balanced.
Medications that cause dizziness and prolonged immobility effect balance.
Impaired balance is a major threat to mobility and physical safety and contributes to a
fear of falling and self-imposed activity restrictions.
Weight is the force exerted by gravity. The force of weight is always directed downward.
This is why an unbalanced object falls.
Individuals require balance for maintaining a static position (e.g., sitting) and moving
(e.g., walking). Disease, injury, pain, physical development (e.g., age), and life changes
(e.g., pregnancy) compromise the ability to remain balanced. Medications that cause
dizziness and prolonged immobility effect balance. Impaired balance is a major threat to
mobility and physical safety and contributes to a fear of falling and self-imposed activity
restrictions.
People’s centers of gravity are usually at 55% to 57% of standing height and are in the
midline, which is why only using principles of body mechanics in lifting patients often
leads to injury of the nurse or health care professional
The greater the surface area of the object that is moved, the greater the friction. Large
objects produce greater resistance to movement. Therefore nurses need to be aware of
the friction that can cause a patient’s skin to shear or tear.
The force exerted against the skin while the skin remains stationary, and the bony
structures move is called shear.
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System effect
• You need to know how to apply scientific principles in the clinical setting to determine
the safest way to move patients and to understand the effect of immobility on the
physiological, psychosocial, and developmental aspects of patient care.
• To determine how to move patients safely, assess their ability to move.
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Think of mobility as a continuum, with mobility on one end, immobility on the other,
and varying degrees of partial immobility between the end points. Some patients move
back and forth between mobility and immobility, but for others immobility is absolute
and continues indefinitely.
Manually lifting and transferring patients contributes to the high incidence of workrelated musculoskeletal problems and back injuries in nurses and other health care
staff.
Bed rest is an intervention that restricts patients to bed for therapeutic reasons. Nurses
and health care providers most often prescribe this intervention.
The effects of muscular deconditioning associated with lack of physical activity are often
apparent in a matter of days. This cluster of symptoms is often referred to as the
“hazards of immobility.” The individual of average weight and height without a chronic
illness on bed rest loses muscle strength from baseline levels at a rate of 3% a day.
Immobility also is associated with cardiovascular, skeletal, and other organ changes. The
term 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.
Periods of immobility or prolonged bed rest cause major physiological, psychological,
and social effects. These effects are gradual or immediate and vary from patient to
patient.
The patient with complete mobility restrictions is continually at risk for the hazards of
immobility. When possible, it is imperative that patients, especially the older adults,
have limited bed rest and that their activity is more than bed to chair.
The deconditioning related to reduced walking increases the risk for patient falls.
Know orthostatic hypotension
Dangle your patient feet before getting them up
Mobilization is important to avoid atrophy
Urinary stasis is UTI and Renal calculi /kidney stone/
Hypostatic pneumonia is because of lack of mobility
Turning, coughing, and deep breathing are important
To increase strength and calcium absorption pt. need to do weight bearing activity
What we do to prevent blood clot
Movement. Compression socks, Range of motion exercise
anticoagulant for acutely.
Psychosocial effect
• Illnesses that result in limited or impaired mobility can cause social isolation and
loneliness.
• Patients with restricted mobility may have some depression. Depression is an
affective disorder characterized by exaggerated feelings of sadness, melancholy,
dejection, worthlessness, emptiness, and hopelessness out of proportion to reality. It
results from worrying about present and future levels of health, finances, and family
needs.
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Because immobilization removes the patient from a daily routine, he or she has more
time to worry about disability. Worrying quickly increases the patient’s depression,
causing withdrawal. Withdrawn patients often do not want to participate in their own
care.
Developmental change
Range of motion
contractures are not reversable you must delegate ROM to CNA avoid contractures.
Gait is how your pt walk
• Activity tolerance are
• Physiological
• Emotional
• Developmental
Body alignment is used for:
Determining normal or deviations
Patient awareness of posture & postural learning needs
Identifying trauma, muscle, or nerve dysfunction
Obtaining information on incorrect alignment (i.e., fatigue, malnutrition, psychological
problems)
Proper body alignment full logroll
Turn your pt. every 2 hrs. delegate with CNA
Movement make a hug different for bowl obstruction
How do we assess for immobility effects?
• Metabolic • Respiratory • Cardiovascular • Musculoskeletal • Integumentary • Elimination • Psychosocial –
• Developmental Health promotion
Nutiriton, smoking cessation, excersise
Acute Care
Metabolic
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Respiratory
Provide high-protein, high-calorie diet with vitamin B and C supplements.
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Cough and deep breathe every 1 to 2 hours.
Provide chest physiotherapy.
Cardiovascular
• Reducing orthostatic hypotension – how?? By dangling their feet
• Reducing cardiac workload
• Preventing thrombus formation
• SCDs (sequential compression devise) thromboembolic disease (TED), hose,
and leg exercises
Thromboembolic disease (TED) hose is helpful for venous blood circulation
Psychosocial change with Chaplin, family member, moving pt. to outside
Do not transfer patient by yourself
Do not use an equipment if you are not familiar with it
Be aware of your pt deconditioning