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Objective One: Physiology of Wound
Healing
 Taylor: Page 900-Periop
Objective Two: Factors That Affect Wound
Healing
 Taylor: Pages 902-904-Discuss in Periop
Objective Three: Wound Classification
Systems
 Taylor: Page 900-Discuss in Periop
Objective Four: Plan Of Care for Client
With Impaired Skin
 Taylor: Pages 904-921-Discuss In Periop
Objective Five: Effects of Heat/Cold and
Care Plan
 Taylor: Pages 921-927
Applying Heat and Cold As Nursing
Interventions
 Effects Of Applying Heat
 Effects Of Applying Cold
 Factors Affecting Heat and Cold Tolerance
 Precautions For the Safe Use of Heat and Cold
 Uses of Heat and Cold Applications
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Effects Of Applying Heat
Effects Of Applying Cold
Factors That Affect Heat And Cold
Tolerance
Precautions for Heat and Cold
Uses Of Heat and Cold
Care Plan for Heat/Cold Applications
 Assessing
 Diagnosing
 Planning
 Implementing
 Evaluating
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Assessing
 Physical and Mental Status
 Area Of Application
 Condition of Equipment
Diagnosing
 Risk for Altered Peripheral Tissue Perfusion
 Anxiety
 Risk For Infection
 Risk for Injury
 Pain
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Planning
 Verbalize increased comfort, as evidenced by decreased
muscle spasms, increased ability to rest, decreased local
inflammation, and decreased edema
 Have evidence of wound healing
 Verbalize and demonstrate safe hot and cold application
Implementing
 Patient Teaching
 Applying Heat/Cold
Applying Heat and Cold
Applying Heat/Cold
General Guide Lines
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Evaluating
 Verbalized increased comfort
 Verbalized increased ability to sleep and rest
 Demonstrate evidence of wound healing
 Demonstrate a decrease in symptoms of inflammation and
edema
 Verbalize and demonstrate safe hot and cold applications
Objective Six: Definition, Physiology, and
Risk Factors
 Taylor: Pages 929-931
Definition
Physiology
Risk Factors Braden Scale
Risk Factors Braden Scale
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Risk Factors Norton Scale
Objective Seven: Care Plan for Client with
Pressure Ulcer
 Taylor: Pages 931-939
Plan Of Care
 Assessment
 Diagnosing
 Planning
 Implementing
 Evaluating
Assessing
 Nursing History
 Physical Assessment
 Mobility
 Nutritional Status
 Moisture And Incontinence
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Assessing
 Nursing History
Assessing Physical Assessment
Assessing Physical Assessment
Assessing
 Mobility
 Nutritional Status
 Moisture And Incontinence
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Diagnosing
 Impaired Skin Integrity
 Impaired Tissue Integrity
 Risk For Impaired Skin Integrity
 Risk For Impaired Tissue Integrity
 Risk for Infection
 Self-Care Deficit
 Impaired Bed Mobility/Physical Mobility
 Altered Tissue Perfusion
Diagnosing
 Pain
 Altered Nutrition: Less Than Body Requirements
 Altered Sensory Perception
 Urinary Incontinence
 Bowel Incontinence
 Disturbed Body Image
 Anxiety
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Planning
 Participate in the prescribed treatment regimen to promote
wound healing
 Demonstrate progressive healing of the pressure ulcer
 Demonstrate increase in body wt. And muscle size
 Remain free of infection at site of pressure ulcer
Planning (continued)
 Demonstrate self-care measures necessary to prevent
development of a pressure ulcer (if able)
 Develop no new areas of skin breakdown
 Family: Family members will demonstrate care measures
necessary to prevent development of a pressure ulcer
Implementing Preventing Pressure Ulcers
Protecting the Skin From External
Mechanical Forces
Protecting the Skin From External
Mechanical Forces
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Protecting the Skin From External
Mechanical Forces
Implementing
 Teaching Pt’s and Families About Prevention
 Teaching for Home Care
 Providing Care in Other Treatment Options
Evaluating
 Participate effectively in preventive and treatment regimens
 Prevent development of any additional areas of skin breakdown
 Demonstrate progressive healing of pressure ulcer
 Improve overall physical condition (including nutritional state and
mobility status)
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Evaluating
 Remain free of infection at any pressure ulcer site
 Communicate need for additional support (environmental,
physical, and psychosocial)
 Respond effectively to the teaching strategies
Websites
 Wound Care Information Network
 www.medicaledu.com/wndguide.htm
 The Nursing Institute
 www.springnet.com/ce.htm
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Activity
Lecture by:
Maggie Keil,MNe, RN
Objective One: Physiology of Mobility
Taylor: Pages 948-953-Read On Your Own
Objective Two: Factors that Affect Mobility
Taylor: Pages 953-960-Read On Your Own
Objective Three: Responses to
Mobility/Immobility
Taylor: Pages 960-964-Read On Your Own
Objective Four: Plan of Care to Enhance
Mobility Status
Taylor: Pages 964-1003
Twiname and Boyd: Pages 133-136
The Nursing Process
Assessing
Diagnosing
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Planning
Implementing
Evaluating
Assessing
Nursing History
Physical Assessment
Nursing History
Daily Activity Level
Endurance
Exercise and Fitness Goals
Mobility Problems
Physical or Mental Health Alterations
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External Factors
Problems
Physical Assessment
General Ease of Movement and Gait
Physical Assessment
Alignment
Physical Assessment
Joint Structure and Function
Physical Assessment
Muscle Mass, Tone and Strength
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Physical Assessment
Endurance
Assessment-Diagnostic Tests and
Procedures
Xrays
Hgb/Hct (H and H )
Diagnosing
Diagnosing (r/t mobility)
Risk for Disuse Syndrome
Self-care Deficits
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Impaired Walking
Impaired Wheelchair Mobility
Impaired Transfer Ability
Impaired Bed Mobility
Pain
Diagnosing (r/t mobility, activity intolerance)
Impaired Skin Integrity
Risk for Infection
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Urinary Retention
Constipation
Altered Nutrition: Less than body requirements
Impaired Gas Exchange or Ineffective Airway Clearance
Diagnosing (r/t mobility, activity intolerance)
 Risk For Injury
 Disturbed Sensory Perception
 Ineffective Health Maintenance
 Impaired Home Maintenance Management
 Noncompliance
 Sexual Dysfunction
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 Disturbed Body Image
 Anxiety
 Ineffective Coping
Diagnosing (collaborative problems and
wellness dx)
Potential complication
Potential for Enhanced Activity Level
Potential for Enhanced Compliance With Exercise
Regimen
Planning (No Problems)
Follow a program of regular physical exercise that
improves cardiovascular function, endurance, flexibility and
strength
Planning for Long-Term Goal-Short-term
outcomes
 By the next visit, 2/20/02, the pt. will:
 Identify four personal benefits of regular exercise
 Describe and exercise program(activities, frequency, duration) the
pt. is willing to follow
 Identify his/her target heart range
 Obtain medical clearance for the exercise program if at high risk for
complications
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 List support systems that will reinforce exercise efforts
Planning(High risk for specific mobility
problems)
 Demonstrate correct body alignment whenever observed
(alignment)
 Adhere to an every-2-hour positioning schedule alignment
 Demonstrate full ROM(joint mobility)
 Demonstrate adequate muscle mass, tone, and strength to perform
functional activities of daily living(muscle mass, tone, strength)
Implementing
 Apply Principles of Body Mechanics
 Positioning Patient:
 Common Devices
 Protective Positioning
 Assisting With ROM
 Moving
 Ambulating
 Designing Exercise Programs
 Teaching Exercise Benefits to Populations at Risk
Apply Principles of Body Mechanics
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Common Devices
Protective Positioning
Protective Positioning
Protective Positioning
Assisting With ROM
Assisting With ROM
Moving Clients
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Moving/Logrolling
Moving/ Assistive Devices
Ambulating
Ambulating/Client Education
Ambulating-Safe Falling
Ambulating Wt. Bearing
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Ambulation-Assistive Devices
Ambulating With A Cane
Ambulating With A Walker
Designing Exercise Programs
Implementing
Teaching Exercise Benefits To Populations At Risk
Evaluating
General ease of movement and gait
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Body alignment
Joint structure and function
Muscle mass, tone, and strength
Endurance
Activities of daily living capacity
Use of appropriate adaptive devices
Have A Nice Weekend!
Mrs. Keil