Foundations of Nursing: Mobility, Immobility, Activity, and Wound Healing

Vocabulary flashcards covering core nursing concepts on mobility, immobility complications, wound healing types, and pressure injury staging.

Immobility

Inability to move independently or restriction of movement, which can be temporary, long-term, partial, or complete.

Orthostatic Hypotension

A sudden drop in blood pressure when moving from lying to sitting to standing, caused by the loss of normal gravity-compensating circulatory reflexes in immobile patients.

Virchow's Triad

The three contributing factors to thrombus formation: stasis of blood, vessel wall injury, and hypercoagulability.

Deep Vein Thrombosis (DVT)

Blood clot formation typically in the legs, characterized by unilateral swelling, warmth, redness, and calf pain, which carries a life-threatening risk of pulmonary embolism.

Muscle Atrophy

The wasting away or loss of muscle tissue strength and size due to lack of physical activity, which begins within $24\text{--}48\text{ hours}$ of bed rest.

Urinary Stasis

A condition where urine stays in the bladder longer than normal because the bladder does not empty completely in a supine position.

Renal Calculi

Kidney stones formed when excess calcium released from demineralized bones enters the bloodstream, is filtered by the kidneys, and precipitates in the urine.

Atelectasis

The collapse of small airways (alveoli) caused by shallow breathing, poor lung expansion, and mucus pooling in immobile patients.

Hypostatic Pneumonia

A lung infection caused by fluid pooling and secretion collection in the lungs when patients cannot take deep breaths or cough effectively.

Contracture

Permanent shortening of muscles, tendons, and ligaments that causes a joint to become stiff and fixed in one position.

Pressure Ulcers (Pressure Injuries)

Localized tissue damage caused by prolonged pressure over bony prominences that compresses blood vessels and blocks oxygen delivery.

Ischemia

Lack of blood flow to tissue that deprives cells of oxygen, leading to cellular death, skin breakdown, and tissue necrosis if sustained.

Stage 1 Pressure Injury

Localized area of intact skin with non-blanchable redness over a bony prominence that may be warm, firm, or painful.

Stage 2 Pressure Injury

Partial-thickness skin loss with exposed dermis, presenting as a shallow open wound or an intact or ruptured blister with a pink/red wound bed and no slough.

Stage 3 Pressure Injury

Full-thickness skin loss in which adipose tissue (fat) is visible, with potential slough, undermining, or tunneling, but without exposure of muscle, tendon, or bone.

Stage 4 Pressure Injury

Full-thickness tissue loss with exposed or directly palpable bone, muscle, or tendon, often accompanied by slough, eschar, and tunneling.

Unstageable Pressure Injury

Full-thickness skin or tissue loss where the true extent of tissue damage cannot be confirmed because the wound bed is completely covered by slough or eschar.

Deep Tissue Pressure Injury (DTPI)

Intact or non-intact skin presenting with localized purple or maroon discoloration due to damage of underlying soft tissue from pressure and shear.

Primary Intention

Wound healing in clean surgical incisions with well-approximated edges closed by sutures, staples, or adhesive, resulting in minimal tissue loss and a small scar.

Secondary Intention

Wound healing in large or irregular wounds with non-approximated edges that heal from the bottom up with granulation tissue, forming a large scar.

Tertiary Intention (Delayed Primary Closure)

Wound healing in which a contaminated or high-risk wound is initially left open to be cleaned and monitored before being closed surgically with sutures later.

Hematoma

A collection of blood under the skin caused by inadequate hemostasis, vessel trauma, or anticoagulant therapy.

Seroma

A collection of serous fluid under a surgical incision presenting as a fluctuant swelling with clear or yellow drainage.

Dehiscence

Partial or complete separation of wound layers or edges, occurring most frequently $5\text{--}10\text{ days}$ post-operatively.

Evisceration

Protrusion of internal visceral organs through an open wound, representing a surgical emergency.

Adhesions

Bands of scar tissue forming between organs or tissues, commonly occurring after abdominal surgery and posing a risk for bowel obstruction.

Keloid

An elevated scar that grows beyond the boundaries of the original wound due to excessive collagen formation during healing.

Fistula

An abnormal passage or communication connecting two internal organs or an internal organ to the outer skin.

Serous Drainage

Clear, watery wound drainage that is a normal part of healing.

Sanguineous Drainage

Bright red wound drainage indicating active bleeding.

Serosanguineous Drainage

Pink, thin wound drainage that is normal during early healing.

Purulent Drainage

Thick, yellow or green wound drainage that indicates an infection.

Braden Scale

A risk assessment tool for pressure injuries evaluating six categories: sensory perception, moisture, activity, mobility, nutrition, and friction/shear.