Assessment of wounds and effects of immobility

What should you think of mobility as?

• A continuum with varying degrees

• Mobility → immobility

• The longer the patient is immobile, the greater and more pronounced the consequences

How does immobility affect nutritional and gastrointestinal changes?

• Decreases metabolic rate → decreased appetite → decreased caloric intake (decreased protein intake)

• Constipatioin r/t decreased peistalsis

• Increased calcium resorption from bones

  • increased risk of pathological fractures (fractures from weakened bone)

• Negative nitrogen balance from Amino Acid breakdown exceeding protein intake

  • slowed wound healing (vicious cycle with immobility and pressure injury)

What is crucial for wound healing?

PROTEIN!!

How does immobility affect respiratory changes?

• Decreased lung expansion

• increased risk of atelectasis (not taking deep enough breaths, if you don’t use it you lose it) → diminished/absent lung sounds

• Pneumonia (hypostatic)

• Decrease oxygenation

• Decrease cough

• Pooling of secretions in bases of lungs → crackles

How does immobility affect cardiovascular changes?

• Orthostatic hypotension

  • decreased circulation and pooling

• Increased cardiac workload

  • heart works harder and less efficient

• Thrombus formation (DVT)

  • S: Stasis

  • H: Hypercoagulability

  • E: Epithelial (vessel wall) damage

How does immobility affect musculoskeletal changes?

• Disuse osteoporosis

  • bone Ca++ reabsorbed (demineralization)

• Disuse muscle atrophy

• Joint contracture

  • foot drop

What is foot drop?

• Inability to lift the front part of the foot off the ground

How does immobility affect urinary elimination?

• Urinary stasis: urine in renal pelvis longer r/t lying flat

• Renal calculi (kidney stones) from hypercalcemia

  • Mobilized calcium from bone demineralization

• Infection (UTI) due to urine stasis/incomplete voids

  • Decreased fluid intake can compound

  • Improper perineal care

  • Urinary catheter’s often over-utilized

How does immobility affect psychosocial?

• Isolation

• Emotional and behavioral responses: hostility, giddiness, fear, anxiety

• Sensory alterations: altered sleep patterns, sensory deprivation

• Changes in coping: depression, sadness, dejection

How does immobility affect integumentary?

• Pressure ulcers

• Deep Tissue Injury (DTI)

What are pressure ulcers?

• Ischemia (decreased blood supply)

  • pressure on tissue > vessel pressure which results in tissue death

• Over boney prominences

What is a stage 1 pressure ulcer?

• Skin is unbroken but inflamed

What is a stage 2 pressure ulcer?

• Skin is broken to epidermis or dermis

What is a stage 3 pressure ulcer?

• Ulcer extends to subcutaneous fat layer

What is a stage 4 pressure ulcer?

• Ulcer extends to muscle or bone

• Undermining is likely

What is an unstageable pressure ulcer?

• when it is completely covered with slough or eschar, it can be difficult to determine its depth

What is a deep tissue injury (DTI)?

• Skin is intact with discoloration (purplish/deep red)

• Nonblanchable

• Skin can feel boggy, soft, squishy

How can you assess a person’s risk for a pressure ulcer?

• Braden Scale:

  • Sensory perception: the ability to respond meaningfully to pressure-related discomfort

  • Moisture: How often and to what extent is the patient’s body exposed to moisture?

  • Activity: degree of physical activity

  • Mobility: ability to change body position

  • Nutrition: usual food intake pattern

  • Friction and shear: How often does the patient’s skin rub?

• The LOWER the score, the HIGHER the risk for pressure ulcer/injury development

How should you postion your patient?

• Mk sure your patients body is properly aligned while standing or lying down (spine is straight, not twisted)

  • functional alignment is extremely important to maintain mobility

What are the different positions you can put your pt in?

• Supine

• Fowler’s

• Lateral

• Sims’

• Prone

• Sitting

What is the supine position (dorsal recumbent)?

• lying on their back on a flat bed with a pillow under their head

• pressure ulcer points: head, elbows, shoulders, sacrum, heels

What is the fowler’s position?

• same as the supine position, except the head of the bed is elevated

• Fowler's is 45-60 degrees, low Fowler’s, or semi Fowler’s, is 30-45 degrees, high Fowler’s is 60-90 degrees

• Also think about friction/shear since pt’s tend to slide down in this position

What is the lateral position?

• lying on their side

• great for people with back pains

• pressure ulcer points: side of head, hips, knees, ankles

What is the sim’s position?

• on their side, but rotated, so they’re almost on their stomach or in the prone position

• used for rectal exams and for administering enemas

• also good for preventing pressure injuries on the sides of the hips and tailbone region

What is the prone position?

• lying on their stomach w/ head facing left or right

• helps the lungs expand and improve oxygenation, so it’s used for certain types of ventilation

• pressure ulcer points: shoulders, front of knees, TOES

What is the sitting position?

• lower back and buttocks are touching the back of the seat, the knees are bent 90 degrees and away from the edge of the seat, and the feet are flat on the floor or footrest

• pressure ulcer points: ischial tuberosity

What is a shear injury?

• will not be seen at the skin level because it happens beneath the skin

• IN THE TISSUES

What is a friction injury?

• visible phenomenon; it looks like an abrasion or superficial laceration

What is common between both friction and shear injuries?

• both result from OPPOSING FORCE; the tissues being pushed/pulled along a stationary object

  • i.e repostioning your patient in bed

• BOTH can contribute to pressure injuries

When assessing wounds what does it mean if it is black (eschar)?

• dead tissue

When assessing wounds what does it mean if it is yellow?

• slough: stringy substance attached to wound bed (needs to be removed)

When assessing wounds what does it mean if it is red?

• granulation tissue (new blood vessels = healing!)

When assessing wounds what should you look at?

• Size (LxW): check for tunneling and measure longest length of the wound and widest then perpendicular line to that for width

• Drainage: amount (scant, small, moderate, large, copious)

• Peri-wound appearance: tissue surrouding actual wound

  • red, warm, tender, inflamed?

What are the different colors of wound drainage?

• Sanguinous: bright red, thin blood indicating active bleeding or a new injury

• Serosanguinous: a pale pink or light red, watery mix of blood and plasma

• Serous: pretty clear, thin, watery plasma

• Purulent: puss indicating infection, typically fowl smelling, yellow or green

How can you help with the management and healing of wounds?

• Debridement: removal of slough or possibly eschar

• Closures: sutures, staples, steri-strips, dermabond adhesive

• Protection: dressings/wraps

What is healing by primary intention?

• the wound is closed and the edges come together

• ex: sutures

• fine scar

What is healing by secondary intention?

• the wound edges are too far from one another

• the wound is replaced primarily by connective tissue that grows from the base of the wound upwards

• scar

What is healing by tertiary intention?

• purposeful delayed wound closure

  • usually due to risk of infection

What are the stages of wound healing?

• Hemostasis: stopping the bleeding

• Inflammation: defense and cleanup

• Proliferation: repairing the damage

• Maturation: strengthening the repair

What are some wound care basics?

• dirty = clean it

• deep = fill it

• open = cover it

• dry = moisten it

• wet = absorb it

What are complications of wound healing?

• Dehiscence

• Evisceration

What is dehiscence?

• partial or total separation of wound layers

• coughing, vomiting, sitting up (usually related to pressure)

• splint/bandage wounds to prevent

What is evisceration?

• protrusion of visceral organs

• emergency!!

• use sterile towels soaked in saline

What are some barriers to wound healing?

• Advanced age

• Diabetes

• Nurtironal deficits (protein!)

• Obesity

• Infection

• Poor circulation

• also: chronic inflammation, immune-dysfunction, and radiation