Mobility and Skin Integrity Lecture Review

Practice flashcards covering Mobility, Activity, Exercise, and Skin Integrity based on lecture transcripts from Giddens and Perry/Potter.

How is 'Mobility' defined according to Giddens?

A state or quality of being mobile or movable.

What term describes the state of a patient who has been in the hospital for a while and has lost physical conditioning?

Deconditioned

What are the three types of conditions that can affect mobility according to the text?

Musculoskeletal, neurological, and neuromuscular.

Which anatomic structures are included in the musculoskeletal category of mobility?

Bones, joints, and muscles.

The neurological conditions that affect mobility involve which structures?

The brain, the spinal cord, and the nerves.

Why are the muscular, neurological, and neuromuscular systems considered interdependent?

Optimal mobility requires functional innervation of a voluntary muscle; without innervation, muscles do not contract, and without muscle contraction, no joint can move.

What is the term for the hump on the back caused by losing bone mass in older adults?

Kyphosis

What is considered the biggest answer/risk for many HESI/NCLEX mobility questions?

Risk for falls

When lifting or pivoting a patient to a chair, what should the nurse use to maintain safety?

Proper body mechanics and alignment.

What is the proper technique for supporting a patient who is falling?

Stand with feet apart to provide a broad base, extend one leg and let the patient slide against it to the floor, and bend knees to lower the body.

When using a gait belt to walk a patient, on which side should the nurse stand?

The affected side.

How many bed rails can be up before it is considered a restraint?

More than $3$ rails (only $3$ rails are allowed).

What criteria should be included when setting SMART goals for patient walking distance?

The goal must be measured and timed (e.g., patient will walk $5\,feet$ by the end of the shift).

How is 'Tissue Integrity' defined?

The state of structurally intact and physiologically functioning tissues such as the integument, including the skin, subcutaneous tissue, and mucous membranes.

What type of wound healing occurs with a surgical incision that is stapled or glued and has rapid healing?

Primary intention

Which wound healing process involves leaving the wound open to heal gradually from the base upward with new tissue filling the gap?

Secondary intention

What is 'Tertiary intention'?

A delayed closure that occurs when a wound previously left open is later closed, usually associated with large infected or contaminated wounds.

What is the difference between dehiscence and evisceration?

Dehiscence is the separation of wound edges, while evisceration involves organs protruding through the wound.

What does 'nonblanchable' skin indicate in a Stage 1 pressure injury?

The skin stays red and does not turn white when pushed on, indicating the start of a problem.

What are the characteristics of a Stage 2 pressure ulcer?

Partial-thickness skin loss with exposed dermis; it may be blistered or have a small opening, but is not yet infected.

What defines a Stage 4 pressure injury?

Full-thickness skin and tissue loss where damage extends down to the bone.

Why is a pressure ulcer labeled 'unstageable'?

The full-thickness skin and tissue loss is obscured by slough or eschar, making it impossible to see the depth or if there is tunneling.

What is the significance of 'granulation tissue' in a wound bed?

It is healing pink tissue and is considered a 'good thing.'

What does 'purulent' drainage indicate?

The presence of pus ($PU$).

What is 'serosanguineous' drainage?

A water-consistency mixture of blood and clear fluid that indicates the wound is healing.

What lab value is the most important indicator of the protein levels needed for wound healing?

Prealbumin (or albumin).

What nutrients are essential for wound healing?

Protein, Vitamin C, Vitamin A, and Zinc.

What should the nurse do before beginning a painful dressing change?

Offer the patient an analgesic (pain medication).

What tool is used on a nurse's status board to assess a patient's risk for skin breakdown?

The Braden scale.

What is a 'trochanter roll' used for?

To prevent the external rotation of the hips when a patient is in a supine position.