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A comprehensive overview of nursing concepts related to mobility, hygiene, and tissue integrity. It covers key factors affecting mobility, including developmental abnormalities, trauma, disease, and age. The document also details the effects of immobility on body systems and outlines nursing measures to prevent complications. Additionally, it explores the importance of hygiene in maintaining patient health and discusses the assessment and care of patients with impaired skin integrity. The document emphasizes the importance of evidence-based practices in nursing care.
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Learning Objectives Assess factors that put patients at risk for problems with mobility Identify factors related to mobility across the lifespan Assess the effects of immobility on body systems Detail the nursing measures to prevent complications of immobility Promote the use of effective techniques of body mechanics among caregivers, patients, and significant others Identify evidence-based practices Mobility Mobility is the ability of a patient to change and control their body position. Mobility exists on a continuum ranging from no impairment (i.e., the patient can make major and frequent changes in position without assistance) to being completely immobile (i.e., the patient is unable to make even slight changes in body or extremity position without assistance). Functional Mobility Functional mobility
Disease Social and cultural factors Physical environment Age Cognitive function Level of depression Comorbidities Teaching r/t Risk Reduction Balanced nutrition Physical activity Routine health checkups Stress management Participation in meaningful activity Avoid tobacco and other substances Need assistance to develop action plans Functional Assessment A comprehensive assessment should be done when the person has demonstrated a loss of function, has experienced a change in mental status, has multiple health conditions, or is considered a frail elderly person living in the community. Screening should be done for children in regards to meeting milestones. Two types: self-reported and performance-based Immobility Immobility can be caused by several physical and psychological factors, including acute and chronic diseases, traumatic injuries, and chronic pain. What Neurological and musculoskeletal disorders affect mobility?
What traumatic injuries or diseases could affect mobility?
Effects of Immobility What complications can patients develop due to being immobile?
Bleeding out Tripod
What assessments are nurses doing when completing hygiene cares?
Learning Objectives Identify patients at risk for impaired skin integrity Identify factors related to alterations in the integumentary system across the lifespan Assess a patient’s skin integrity Note normal from abnormal findings Assess characteristics of a wound Apply correct terminology in the description of wounds Adapt care based on integumentary assessment data gathered Identify evidence-based practices Tissue Integrity Tissue integrity is the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes. Physiologic Processes Skin Function Epithelial cells cover all internal and external body surfaces. Functions include:
Treatment for Deep Tissue Injury and Stage 1 Relieve pressure Encourage frequent turning and repositioning Use pressure relieving devices Implement pressure reduction surfaces Keep client dry, clean and well-nourished and hydrated Treatment for Deep Tissue Injury and Stage 2 Maintain
Clean and/or debride with the following
Nursing Care Identify Risks
First Aid – exposure to extreme temps http://www.bing.com/videos/search? q=Effects+of+Hyperthermia&&view=detail&mid=11483B2B6B5DF3E87D7B11483B2B6B5DF3E87D7B&FORM=V RDGAR ABCDE Melanoma Assessment Asymmetry
Note on board R – redness E – edema E – ecchymosis D – drainage A – approximation
2 upper chambers – Right and left atria 2 lower chambers – Right and left ventricles 2 Atrioventricular valves: Mitral and tricuspid (open with ventricular diastole, close with ventricular systole) 2 Semilunar Valves (Aortic & Pulmonic) – open with ventricular systole, open with ventricular diastole Pulmonary circulation, unoxygenated on LEFT side of heart. Carries deoxygenated blood away from the heart to the lungs, and returns oxygenated (oxygen-rich) blood back to the heart Systemic circulation, Oxygenated, on the RIGHT side of heart. Movement of blood from the heart through the body to provide oxygen and nutrients, and bringing deoxygenated blood back to the heart. Oxygen-rich blood from the lungs leaves the pulmonary circulation when it enters the left atrium through the pulmonary veins.
Normal Cardiac Physiology Unoxygenated blood flows from inferior and superior vena cava Right Atrium tricuspid valve Right ventricle Pulmonic valve lungs through pulmonary system (to get oxygenated) Oxygenated blood flows from the pulmonary VEINS left atrium mitral valve left ventricle aortic valve systemic circulation The atria contract a fraction of a second before the ventricles so their blood empties into the ventricles before the ventricles contract. Systole : simultaneous contraction of the ventricles Diastole : synonymous with ventricular relaxation, when ventricles fill passively from the atria to (70% blood capacity) Which chambers have thicker walls, atria or ventricles? Why? What is the cause of the “lub dub” sounds typically heard when listening to the heart? A: closing of the valves
Repolarization is the return of the ions to their previous resting state, which corresponds with relaxation of the myocardial muscle. This is when the electrical impulse decreases voltage Depolarization is Once an electrical cell generates an electrical impulse, this electrical impulse causes the ions to cross the cell membrane and causes the action potential, also called depolarization. This occurs in the four chambers of the heart : both atria first, and then both ventricles. The sinoatrial (SA) node on the wall of the right atrium initiates depolarization in the right and left atria, causing contraction. Therefore we call the SA node the pacemaker
What is an EKG? The electrocardiogram (EKG) is a representation of the electrical events of the cardiac cycle. Each event has a distinctive waveform, the study of which can lead to greater insight into a patient’s cardiac pathophysiology. Medical terminology? The EKG is a picture of the heart’s electrical activity. The currents that radiate through the surrounding tissue to the skin and is printed out in wave forms on paper through electrodes that we attach to the skin, they sense those electrical currents and transmit them to an ECG monitor. The currents are represented as waveforms that represent the heart’s depolarization-repolarization cycle. The ECG shows the precise sequence of electrical events occurring in the cardiac cells. It allows for monitoring of myocardial contraction and to identify rhythm and conduction disturbances, thus overall cardiac function. 5 electrode placement White = RA (right arm) Black = LA (left arm) Brown = Center, chest, next to sternum Green = RL (right leg) gut Red = LL (left leg) cardiac, heart, right lower Electrodes are placed on different parts of a patient’s limbs and chest to record the electrical activity.