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Mobility, Hygiene, and Tissue Integrity: Nursing Concepts and Practices, Lecture notes of Nursing

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.

Typology: Lecture notes

2023/2024

Uploaded on 10/30/2024

laura-alsleben
laura-alsleben 🇺🇸

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Mobility and Hygiene
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
Is the ability of a person to move around in their environment, including walking, standing up from a chair,
sitting down from standing, and moving around in bed. The three main areas of functional mobility are the
following:
Bed Mobility
The ability of a patient to move around in bed, including moving from lying down to sitting and sitting to
lying down.
Transferring
The action of a patient moving from one surface to another. This includes moving from a bed into a chair or
moving from one chair to another.
Ambulation
The ability to walk. This includes walking with assistance from another person or an assistive device such as
a cane, walker, or crutches.
Functional Ability Defined
The physical, psychological, cognitive, and social ability to carry on the normal activities of daily life.
Activities of daily living (ADLs)
Personal care, mobility, eating, hygiene, grooming such as dressing, bathing, mouth care, dressing, and
toileting.
Instrumental activities of daily living (IADLs)
Managing money, grocery shopping, cooking, house cleaning, laundry, taking medications, using the phone,
accessing transportation
Ability fluctuates on a continuum.
Risk to Functional Ability
Developmental abnormalities
Physical or psychological trauma
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Mobility and Hygiene

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

  • Is the ability of a person to move around in their environment, including walking, standing up from a chair, sitting down from standing, and moving around in bed. The three main areas of functional mobility are the following:  Bed Mobility
  • The ability of a patient to move around in bed, including moving from lying down to sitting and sitting to lying down.  Transferring
  • The action of a patient moving from one surface to another. This includes moving from a bed into a chair or moving from one chair to another.  Ambulation
  • The ability to walk. This includes walking with assistance from another person or an assistive device such as a cane, walker, or crutches. Functional Ability Defined  The physical, psychological, cognitive, and social ability to carry on the normal activities of daily life.  Activities of daily living (ADLs)
  • Personal care, mobility, eating, hygiene, grooming such as dressing, bathing, mouth care, dressing, and toileting.  Instrumental activities of daily living (IADLs)
  • Managing money, grocery shopping, cooking, house cleaning, laundry, taking medications, using the phone, accessing transportation  Ability fluctuates on a continuum.  Risk to Functional Ability  Developmental abnormalities  Physical or psychological trauma

 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?

  • MS

 What traumatic injuries or diseases could affect mobility?

  • Breaking the spine

 Effects of Immobility  What complications can patients develop due to being immobile?

  • Bed sores (main one)
  • Clots  What systems can it degrade?
  • Skin
  • Musculoskeletal
  • Lungs (pulmonary)  What are benefits of mobilization?
  • Mental health
  • Joints  Assistive Devices  Gait belts

 Bleeding out  Tripod

  • Sitting, elbows on the knees, leaning forward  Fall Prevention  What cues can flag nurses to implement fall risk precautions?
  • Blood pressure drops, pulse goes up
  • Dizziness
  • Stoke history
  • Unsteady gate  Hygiene  Personal hygiene needs vary with clients' health status, social and cultural practices, and the daily routines they follow at home.  It has a profound effect on overall health, comfort, and well-being.  Hygiene includes
  • Bathing
  • Eye and ear care
  • Oral hygiene
  • Foot care
  • Perineal care (private area)  Cultural and Social Practices  What can nurses do to help carry out the importance of hygiene practices but making sure to be respectful and observant of each client’s specific cultural needs?
  • Ask what their general routine is at home.
  • Let them do what they can  What are some safety cues we need to consider?

 What assessments are nurses doing when completing hygiene cares?

  • Skin  Brusing  Sores
  • Oral  Bad breath  Sores from dentures
  • Foot care  Fungus  Ingrown toenail  Swelling
  • Perineal care  Hemorrhoids  Rash  Sores  Smells

 Tissue Integrity

 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:

  • Protection
  • Absorption
  • Secretion

 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

  • Maintain a moist healing environment  Promote
  • Promote natural healing  Provide
  • Provide Nutritional supplements  Administer
  • Administer analgesics  Treatment for Deep Tissue Injury and Stage 3  Clean and/or debride with the following
  • Prescribed dressing
  • Surgical intervention  Provide nutritional supplement  Administer analgesics  Administer antimicrobials  Treatment for Deep Tissue Injury and Stage 4

 Clean and/or debride with the following

  • Prescribed dressing
  • Surgical intervention  Perform nonadherent dressing changes every 12 hr.  Treatment can include skin grafts  Nutritional supplements  Administer analgesics  Administer antimicrobials  Treatment for Deep Tissue Injury and Unstageable  Debride until staging is possible  Primary Intention  Healing by primary intention means suturing, stapling, gluing, or otherwise closing the wound so that it heals beneath the closure.  This type of healing occurs with clean-edged lacerations or surgical incisions, and the closed edges are referred to as being approximated.  Secondary Intention  Secondary intention occurs when the edges of a wound cannot be approximated (brought together), requiring that the wound heal be filled in from the bottom up through the production of granulation tissue.  Examples of common wounds that heal by secondary intention are pressure injuries and skin tears. Wounds that heal by secondary intention are at higher risk for infection and must be protected from contamination.  Tertiary Intervention  “Tertiary intention” refers to the healing of a wound that has remained open or has been reopened, often due to severe infection.  The wound is typically closed at a later date when infection has resolved.  Wounds that heal by secondary and tertiary intention have delayed healing times and increased scar tissue.  Complications of Wound Healing  Dehiscence
  • Partial or total rupture (separation) of a sutured wound, usually with separation of underlying skin layers  Evisceration
  • A dehiscence that involves the protrusion of visceral organs through a wound opening  Cause
  • Fluid in the wound
  • Sudden straining (coughing, sneezing, vomiting)  Who is at risk
  • Chronic disease, advanced age, obesity, invasive abdominal cancer, vomiting, excessing straining, dehydration, malnutrition, ineffective suturing, abdominal surgery, infection  Nursing Intervention
  • Holding pillow when coughing. Evisceration and dehiscence require emergency treatment: Call for help, notify the provider, stay with the client, cover the wound with sterile towels, maintain calm keep NPO  Assessment/Data Collection  Appearance
  • Note the color of open wounds

 Nursing Care  Identify Risks

  • Braden scale – see scale
  • Sensory perception. Moisture, activity, mobility, nutrition, and friction and shear  Health History  Examination / Assessment of skin
  • Inspection
  • Palpation  Clinical Management:
  • Primary Prevention
  • Screening  Collaborative Interventions  Interrelated Concepts  Wound Assessment http://www.youtube.com/watch?v=s76P1DdtBAA&list=PL4D2A0C39C020A2C ◦  Learning Activity  You are a nurse working in a long-term care facility. You have been assigned to care for Mr. Johns, a 74-year-old client recently diagnosed with a urinary tract infection, resulting in frequent incontinence. Mr. Johns suffered a CVA (stroke) six months ago and has difficulties ambulating and attending to his own needs because of weakness on his right side. Mr. Johns is alert and oriented to person, place, and time, but has decreased sensation on his entire right side. He spends most of his time in bed or sitting at his bedside in a wheelchair due to his difficulty with ambulation. He eats about 50% of his meals. While assessing Mr. Johns, you note that he is thin for his height, incontinent of foul-smelling urine, and has a deepened reddened area on his sacrum.  What additional information, including lab work, would you like to gather to further assess Mr. Johns’ potential for pressure injury development?
  • Blood test for vitamin deficiency / white blood cell count, monitor water intake, repositioning program, toileting program, nutrition intake

 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

  • Two sides or halves are not the same  Border
  • Borders are not well defined  Color
  • Different color in the same mole  Diameter
  • Diameter larger than 6mm  Evolving
  • Dramatic change in shape, color, or appearance  Asymmetry Border Color Diameter Evolving 

 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

  • Ride Side Left Side

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

  • To help remember the difference between depolarization and repolarization, think of R in repolarization, think of the R as REST. Remember that repolarization is the resting phase of the cardiac cycle.
  • The electrical signal travels through the network of conducting cell "pathways," which stimulates your upper chambers (atria) and lower chambers (ventricles) to contract. The signal is able to travel along these pathways by means of a complex reaction that allows each cell to activate one next to it, stimulating it to "pass along" the electrical signal in an orderly manner. As cell after cell rapidly transmits the electrical charge, the entire heart contracts in one coordinated motion, creating a heartbeat.
  • The electrical signal starts in a group of cells at the top of your heart called the sinoatrial (SA) node. The signal then travels down through your heart, triggering first your two atria and then your two ventricles. In a healthy heart, the signal travels very quickly through the heart, allowing the chambers to contract in a smooth, orderly fashion.
  • The heartbeat happens as follows:  The SA node (called the pacemaker of the heart) sends out an electrical impulse.  The upper heart chambers (atria) contract.  The AV node sends an impulse into the ventricles.  The lower heart chambers (ventricles) contract or pump.
  • The SA node sends another signal to the atria to contract, which starts the cycle over again.
  • This cycle of an electrical signal followed by a contraction is one heartbeat.  SA node and atria
  • So what is happening is the SA node sends an electrical impulse. The electrical signal travels from your SA node through muscle cells in your right and left atria triggering the muscle cells to contract your atria. The atria then contracts pumping blood into your left and right ventricles.  AV node and ventricles
  • After the electrical signal has caused your atria to contract and pump blood into your ventricles, the electrical signal arrives at a group of cells at the bottom of the right atrium called the atrioventricular node, or AV node. The AV node briefly slows down the electrical signal, giving the ventricles time to receive the blood from the atria. The electrical signal then moves on to trigger your ventricles. The signal travels down a bundle of conduction cells called the bundle of His , which divides the signal into two branches: one branch goes to the left ventricle, another to the right ventricle.  These two main branches divide further into a system of conducting fibers, the Purkinje fibers , that spreads the signal through your left and right ventricles, causing the ventricles to contract.
  • When the ventricles contract, your right ventricle pumps blood to your lungs and the left ventricle pumps blood to the rest of your body.
  • After your atria and ventricles contract, each part of the system electrically resets itself, Or enters the repolarization phase

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.

  • Electrodes are attached to a patient that are then attached to wires to record an ECG.
  • The data gathered from these electrodes allows the 12 leads of the ECG to be calculated.  Ways to also remember location:
  • White – right
  • snow over trees, so white over green
  • smoke over fire, so black over red
  • brown, close to the heart  An ECG is a graphical display of electrical energy generated by the heart. The paper is a grid where time is measured along the horizontal axis, and voltage is measured along the vertical axis. One complete cardiac cycle has
  • P, Q, R, S, (QRS complex), and a T wave.  P Wave The P wave represents the depolarization of the left and right atrium and also corresponds to atrial contraction. Strictly speaking, the atria contract a split second after the P wave begins. Because it is so small, atrial repolarization is usually not visible on ECG. In most cases, the P wave will be smooth and rounded