Download 10. Mobility and Immobility Skin Integrity and Wound Care

Mobility and Immobility,
Skin Integrity and Wound Care
Mobility refers to a person's ability to move about freely.
Immobility refers to: the inability to move about freely.
NANDA definition of immobility: is a state in which the individual
experiences or is at risk of experiencing limitation of physical
movement.
Effect of immobility on physiological condition of clients
including changes in the following systems
1.
2.
3.
4.
5.
6.
Metabolic.
Respiratory.
Cardiovascular.
Musculoskeletal.
Integumentary.
Urinary elimination.
Metabolic changes/ Deficiency of calories and protein
causing
Metabolic changes:
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Immobility disrupts normal
metabolic functioning including:
Metabolic rate.
Metabolism of carbohydrates,
fats, and protein.
Fluid and electrolyte imbalances.
Calcium imbalance.
GIT disturbances (anorexia,
diarrhea, fecal impaction, and
constipation).
A deficiency of calories and
protein causing:
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Anorexia.
Negative nitrogen balance.
Weight loss.
Decreased muscle mass.
Weakness result from tissue
catabolism.
Protein loss leads to decreased
muscle mass, especially in the
liver, heart, lungs, GIT, and
immune system.
CHANGES
Respiratory changes
Cardiovascular changes
 Hypostatic pulmonary
The three major changes are:
complications:
 Orthostatic hypotension.
 pneumonia
 Increased cardiac workload.
 Leads to
O2 , prolong recovery,
and add to the client’s discomfort.  Thrombus formation.
 Decline in the client’s ability to
cough productively. Increase of
mucus distribution in the bronchi
especially in supine, prone, or
lateral position. Mucus
accumulation in the airways.
Because the mucus is an excellent
media for bacterial growth
hypostatic pneumonia result.
ORTHOSTATIC HYPOTENSION
Orthostatic hypotension: is a drop of
25 mm Hg systolic and of 10 mm
Hg diastolic in blood pressure
when the client rises from a lying
or sitting position to a standing
position.
Causes of Orthostatic hypotension in
immobilization
o Decreased
circulating
fluid
volume.
o Pooling of blood in the lower
extremities.
 These factors result in decreased
venous return followed by a
decrease in cardiac output which is
reflected by a decreased in blood
pressure
increasing
heart
workload.
THROMBUS FORMATION:
A thrombus:
 is an accumulation of platelets, fibrin, clotting factors, and the
cellular elements of the blood attached to the anterior wall of a
vein or artery, sometimes occluding the lumen of the vessels.
Factors that can cause thrombus formation:
1. Loss of integrity of the vessel wall (e.g., atherosclerosis).
2. Abnormalities of blood flow (e.g., slow blood flow in veins
associated with bed rest and immobility).
3. Alterations in blood constituents (e.g., a change in clotting
factors or increased platelet activity).
Musculoskeletal changes:
Immobility lead to permanent impairment of mobility which causing:
 Loss of endurance (staying power) of the muscles.
 Decreased muscle mass.
 Atrophy.
 Decreased stability.
 Impaired calcium metabolism.
 Impaired joint mobility.
Integrumentary changes:
A pressure ulcer, or decubitus ulcer, is the consequence of ischemia and anoxia
to tissue. Tissues are compressed, blood diverted, and blood vessels
powerfully constricted by continual pressure on the skin and underlying
structures; thus cellular respiration is impaired, and cells die.
Pressure Areas
Urinary elimination changes

In the upright position, urine flows out of the renal pelvis and into the
ureter and bladder because of gravitational forces.
 In recumbent or flat position, the kidneys and the ureters move toward a
more flat surface. Urine format by the kidney must enter the bladder
against gravity. Because the peristaltic contractions of the ureters are
insufficient to overcome gravity, the renal pelvis may fill before urine
enters the ureters (Urinary stasis).
Urinary stasis increases the risk of:
 Urinary tract infection.
 Renal calculi.
Renal calculus:
 Are calcium stones that lodge in the renal pelvis and pass through the
ureters.
Causes of renal calculi in immobilized client:
 Altered calcium metabolism.
 The resulting hypercalcemia
Predisposing factors with
renal calculi formarion
Causes of urinary tract
infection:


Fluid intake diminish.
 Other causes, such as fever.
 Increase the risk for
dehydration.
 As a result of previous
factors, urinary output
declines on or about the fifth
or sixth day.
 Urine become highly
concentrated
Concentrated urine.
 Poor perineal care after bowel
elimination, particularly in
women.
 Use of an indwelling urinary
catheter.
Psychosocial effects of immobility:
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Depression.
Behavioral changes.
Changes in the sleepwake cycle.
Impaired coping.
Assessment clients for mobility:
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Range of motion.
Gait.
Exercise and activity tolerance.
Body alignment:
Standing.
Sitting.
Lying.
The skin is the largest organ in the body and serves a variety of important
functions in maintaing health and protecting the individual from injury.
Impaired skin integrity is not a frequent problem for most healthy people but
is a threat to older people, to clients with restricted mobility, chronic
illnesses, or trauma, and those undergoing invasive health care procedures.
Intact skin refers to the presence of normal skin and skin layers uninterrupted
by wounds. The appearance of the skin and skin integrity are influenced by
internal factors such as genetics, age, and the underlying health of the
individuals as well as external factors such as activity.
A wound is a type of injury in which skin is torn, cut, or
punctured (an open wound), or where blunt force trauma causes a
contusion
Body wounds are either intentional or unintentional.
Intentional trauma occurs during therapy e.g., operations or venipuncture,
removing tumor.
Unintentional wounds are accidental; e.g. a person may fracture an arm in an
automobile collision.
If the tissues are traumatized without a break in the skin, the wound is closed.
The wound is open when the skin or mucous membrane surface is broken.
Wounds may be described according to how they
are acquired
Incision wounds:
Sharp instrument ''open, deep or shallow''.
Contusion wounds: blow from a blunt instrument '' closed,
skin appears ecchymosed (bruised)''.
Puncture wounds: penetration of the skin and often the
underlying tissues by a sharp instrument, either intentional or
unintentional ''open wounds''.
Lacerated wounds: tissue torn apart, often from accident
''open, edges are often jagged''.
Abrasion wounds: Surface scrape ''open, involving the skin''.
Penetrating wounds: penetrating the skin and underlying
tissues.
'' Open wound ''.
Types of wounds according to degree of wound
contamination
1.
2.
3.
4.
Clean wounds: uninfected wounds in which minimal inflammation is
encountered.
Clean – contaminated wounds: surgical wounds in which the
respiratory, alimentary, genital or urinary tract has been entered. No
evidence of infection.
Contaminated wounds: open, fresh, accidental wounds and surgical
wounds involving a major break in sterile technique or a large amount
of
spillage from the gastrointestinal tract. Show evidence of
inflammation.
Dirty or infected wounds: containing dead tissue and wounds with
evidence of a clinical infection, such as purulent drainage.
Pressure Ulcers. Etiology of pressure ulcers.
Pressure Ulcers were previously called decubitus ulcers, pressure sores, or
bedsores. It is any lesions caused by unrelieved pressure that result in
damage to underlying tissues.
Pressure ulcers are due to localized ischemia, a deficiency in the blood supply
to the tissue. The tissue is compressed between two hard surfaces, usually
the surface between the bed and the skeleton, when the blood cannot reach
the tissue, the cells are deprived of oxygen and nutrients, waste products of
metabolism accumulate in the cells, and the tissue consequently dies.
Prolonged, unrelieved pressure also damages the small blood vessels.
After the skin has been compressed, it appears pale, as if the blood had been
squeezed out of it. When pressure is relieved, the skin takes on a bright red
flush called reactive hyperthermia. The flush is due to vasodilatation, a
process in which extra blood supply to compensate for the preceding period
of impeded blood flow.
Risk factors
Friction and Shearing
Two other factors frequently act in conjunction with pressure to produce
pressure ulcers:
Friction: is a force acting parallel to the skin surface, such as sheets rubbing
against skin create friction. Friction can abrade the skin, that is, remove the
superficial layers, making it more prone to breakdown.
Shearing force: combination of friction and pressure. It occurs commonly
when the a client assumes a Fowler’s position. In this position, the body
tends to slide downward toward the foot of the bed. This downward
movement is transmitted to the sacral bone and the deep tissues . At the
same time, the skin over the sacrum tends not to move because of the
adherence between the skin and the bed linens. The skin and superficial
tissues are thus relatively unmoving in relation to the bed surface, whereas
the deeper tissues are firmly attached to the skeleton and move downward.
This causes a shearing force in the area where the deeper tissues and the
superficial tissues meet. and the superficial tissues meet. The force damages
the blood vessels and tissues in this area.
Stages of pressure ulcers
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Stage 1:- red color and the skin don’t return to normal color even the
pressure is released.
Stage 2 :- redness accompanied by blisters or shallow break in the skin
Stage 3 :- break in the skin extending to the subcutaneous tissue
Stage 4:- ulcer involves loss of all skin layers exposing muscle and bone.
Wound Healing
Healing is a quality of living tissue , it is also referred to as regeneration
(renewal) of tissues.
Healing can be considered in terms of types of healing and phases of healing.
Types of Wound Healing
There are two types of healing, influenced by the amount of tissue loss.
1- Primary intention healing
Occurs where the tissue surfaces have been approximated (closed) and there is
minimal or no tissue loss; it is characterized by the formation of minimal
granulation tissue and scarring. It is also called primary union or first
intention healing.
e.g. closed surgical incision
Primary intention healing is healing of a wound where the wound edges heal
directly touching each other.
2- Secondary intention healing
It is extensive and involves considerable tissue loss, and in which
the edges cannot or should not be approximated. e.g., pressure
ulcer.
Secondary intention healing differs from primary intention healing
in three ways:
1- The repair time is longer
2- Scarring is greater
3- Susceptibility to infection is greater
Phases of wound healing
Inflammatory phase: is initiated immediately after injury and last 3 to 6 days.
Two major processes occur during this phase:
• Hemostasis
• Phagocytosis
Hemostasis (the cessation of bleeding) results from vasoconstriction of the
larger blood vessels in the affected area, deposition of fibrin (connective
tissue) and the formation of blood clots in the area. The blood clots, formed
from blood platelets, provide a matrix of fibrin that becomes the framework
for cell repair.
The inflammatory phase also involves vascular and cellular responses to
remove any foreign substances and dead and dying tissues. The area appears
reddened and edematous. After 24 hours post injury, large macrophages
enter the area these macrophages engulf microorganisms and cellular debris
by a process known as phagocytosis.The macrophages also secrete
angiogenesis factors which stimulate the formation of epithelial buds at the
end of injured vessels, leads to reanastomosis.
This phase include mildly elevated temperature, leukocytosis, and generalized
malaise.

Proliferative phase: extends from day 3 or 4 to about day 21
postinjury. Fibroblasts (connective tissue cells), which migrate
into the wound begin to synthesize collagen (whitish protein),
these substance adds tensile strength, this decreases the chance
that wound open again. Capillaries grow across the wound, ↑ the
blood supply. Fibroblasts move from the bloodstream into
wound, depositing fibrin , the tissue becomes a translucent red
color. This tissue , called granulation tissues , is fragile and
bleeds easily.

Maturation (Remodeling phase): begins about day 21 and can
extend 1 or 2 years after the injury. During maturation, the
wound is remodeled and contracted. The scar becomes stronger
but the repaired area is never as strong as the original tissue.
Hand abrasion
Approximate days since injury
0
2
17
30
Types of wound exudate
Exudate: - is material such as fluid and cells that has escaped
from blood vessels during the inflammatory process and is
deposited in tissue or on tissue surfaces.
There are three major types of exudates:1- Serous exudate
Consist chiefly of serum (the clear portion of the blood) derived
from blood and the serous membranes of the body, such as the
peritoneum. It looks watery and has few cells.
e.g fluid in a blister from a burn.
2- Purulent exudate
Is thicker than serous because of the presence of pus (leukocyte, dead
tissue debris, dead and living bacteria). The process of pus formation is
referred to as suppuration; bacteria that produce pus are called pyogenic
bacteria. Purulent exudates vary in color, some acquiring tinges of blue,
green, or yellow. The color may depend on the causative organism.
3- Sanguineous (hemorrhagic) exudates consist of large amounts of red
blood cells, indicating damage to capillaries that is severe enough to
allow the escape of red blood cells from plasma .
Mixed types of exudates like:
Serosanguineous ( consisting of clear and blood tinged drainage)
purosanguineous (consisting of pus and blood )
Complications of wound healing
1- Hemorrhage
Hemorrhage is abnormal massive bleeding; internal hemorrhage may be
detected by swelling or distention in the wound. Hematoma, a localized
collection of blood underneath the skin that may appear as a reddish blue
swelling (bruise).
The nurse should know the location of the pt’s incision to inspect the site of
operation for bleeding at intervals for the first 48 hours, not less than Q
8hours. Any undue amount of bleeding should be reported, additional sterile
dressing, fluid replacement, may need surgical interventions.
Occurs in slipped sutures, dislodged clot, infection, erosion of blood vessels by
a foreign
2- Infection
Staphylococcus aurous, E. coli, Aerobacter aerogenes and pseudomonas
aeroginosa. The main important area of prevention lies on aseptic techniques
in wound care, cleanliness and environmental disinfection are important. The
symptoms appear within 36-48 hours.
The temperature and pulse increase, wound become tender, swollen, and warm.
Nursing intervention will be through the use of warm antiseptic solutions to
flush the wound. Take culture at site of operation. Specific antibiotics. A
wound can be infected with microorganisms at the time of injury, during
surgery, or postoperatively
3- Dehiscence with possible Evisceration
Dehiscence: partial or total rupturing of sutured wound.
Evisceration: the protrusion of the internal viscera through an incision area. A
number of risk factors including obesity , malnutrition, multiple trauma,
failure of suturing, coughing, vomiting, and straining, dehydration . Wound
dehiscence is more likely to occur 4 to 5 days postoperatively.
Sudden straining , such as coughing or sneezing, may precede dehiscence. The
client may feel " something has given away “. When dehiscence or
evisceration of a wound occurs, the wound should be supported by large
sterile dressing moistures with sterile saline. Place the client in bed with
knees bent to decrease pull on the incision. The surgeon is notified at once.