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What body systems are effected by immobility?
No body system is immune from effects of immobility. Metabolic changes, respiratory, cardio, msculoskeletal
What system is checked and when is it checked when a person is immobile?
Respiratory system and checked every 2 hrs
What is the most common respiratory problem with immobility
Atelectasis and hypostatic pnemonia
What are the physiological effects of immobility
emotional and behavioral responses, sensory alterations and changes in coping. Changes include hostility, giddiness, fear and anxiety. Creates sleep-wake alterations, client may become depressed b/c of changes in role and self-concept
What is acute care
taking immediate action to relieve specific issues such as in an emergent situation
What is restorative care?
medicare, medicaid, maximize functions and abilities, optimum level of health, independent manage ADL's, social and emotional participation. Collaborative working relationship.
What assessment do you want to do before the client becomes immobile
Early ROM assessment is best to do before client becomes Immobile
When do you assess restraints
must assess every 2 hours and every 30 minutes for the 1st 2 hours, flowsheet must be completed, document why and have 2 finger allowance. Using restraints is an independent nursing judgement
What is a pressure ulcer
impaired skin integrity related to unrelieved prolonged pressure. Localized areas of necrotic tissue, tissue compressed b/t bony prominence and external surface
What are factors contributing to pressure ulcers?
decreased mobility, decreased sensory, fecal and urine incontinence, poor nutrition, interference with cell metabolism obliterates blood flow, anything that stops blood flow and causes tissue ischemia (lack of blood supply)
When a person is beginning to form pressure ulcers what type of diet is recommended?
High protein, high caloric to rebuild tissue b/c when immobile amnio acids are coming out of muscle, this type of diet helps rebuild
What factors contribute to pressure ulcers
- Pressure intensity
- tissue intolerance
What is pressure intensity
capillary closing pressure as the minimal amount of pressure required to collapse a capillary. If the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for prolonged period of time tissue ischemia can occur
what is tissue ischemia
lack of oxygen leads to tissue death (tissue is white)
What is reactive hyperemia (transient hyperemia)
- (redness) once blood flow continues and oxygen returns to pressure area. Visible local vasodialation occurs.
- if you put your finger over red spot it blanches white then red comes back (if red does not come back and blanching stays then there is deep tissue loss)
How do you assess metabolic functioning
Use anthropometric measurements (height, weight, skinfold thickness) to evaluate msucle atrophy
How do you assess pressure ulcers in dark skinned clients
if it appears darker than surrounding skin, has a purplish/bluish huse, if there is initial warmth when compared with surrounding skin, later coolness as tissue is devitalized
What is nonblanching erythema (abnormal reactive hyperemia)
excessive vasodilation and induration in response to pressure. The area does not blanch when you apply pressure deep tissue damage is probable (redness just stays when pressure applied)
What is shear
- Force exerted parallel to skin resulting from both gravity pushing down on the body and resistance b/c the client and a surface (when person slides down in bed)
- underlying tissue capillaries are stretched and angulated by shear force
- tissue damage occurs deep in tissues, causing undermining of dermis
What is friction
- the force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens
- affect epidermis (top layer)
- occurs when lifting client up in bed
what is tissue tolerance
- the ability of tissue to endure pressure
- depends on the integrity of the tissue and the supporting structures
What is a stage I pressure ulcer
intact skin with nonblanchable redness of a localized area usually over a bony prominance
what is a stage II pressure ulcer
partial-thickness skin loss involving epidermins, dermis or both. The ulcer is superficial and presents clinically as an abrasion, blister or a shallow crater
What is a stage III pressure ulcer
Full-thickness tissue loss. Sub Q fat may be visible, but bone, tendon, or muslce are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling
what is a Stage IV pressure ulcer
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling.
Where are the primary areas of breakdown
greater trochanter, sacrum, ishial tuberosity, heels
What are some treatments for pressure ulcers
wound vacs, wet to dry dressing, nutrition
What are some factors influencing pressure ulcer formation
- tissue perfusion
- psycholocial impact of wounds
how do you assess for risk of pressure ulcer
use braden scale
What is granulation tissue
red moist tissue composed of new blood vessels which indicate progression toward healing
What is slough
soft yellow or white tissue (stringy substance attached to wound bed) need to remove this before would can heal
what is eschar
black or brown necrotic tissue, also need to remove before it can heal
What is dehiscence
partial or total separation of wound layers
what is evisceration
protrusion of visceral organs through a wound opening
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