Movement, Wounds, and Infections Control

What are the components of body mechanics?

* Body alignment - being in a neutral position
* Balance
* Coordination - nervous system and skeletal system
* Joint Mobility

Define isometric and give example

muscle contraction without motion - plank

Define isotonic and give example

movement of the joint during muscle contraction - weights

Define isokinetic

use of apparatuses providing resistance

Define aerobic and give example

amount of 02 taken into the body meets/exceeds amount of 02 required to perform activity - jogging/cycling

Define anerobic and give example

amount of 02 taken into body does not meet amount of 02 required to perform activity - sprinting/intense weight training

How often do people who are bedbound need to be moved?

Every 2 hours

What side does a cane go on?

On the good side

What factor would cause the greatest risk for infection?

Decreased sensation because the pt will not be able to tell when something is causing them pain

What is considered a closed wound?

A bruise

When is a wound considered chronic?

When it takes longer to heal than anticipated

When is a wound considered infected?

100,000 organisms/gram of tissue

What is regeneration healing ?

It occurs in epidermal wounds and has no scar

What is a primary intention healing?

Has a clean surgical incision with approximated edges and causes minimal scarring

What is a secondary intention?

* wound edges not approximated
* tissue loss
* Heals from inner layer to surface
* Beefy red tissue
* Pack the wound until it heals

What is tertiary intention healing

* Granulating tissue brought together
* Wound is allowed to heal by secondary intention but then has delayed closure
* creates less scarring than secondary
* Must use sterile technique

What occurs in the inflammatory phase of the healing process?

lasts for 1-5 days and consists of hemostasis and inflammation

What occurs in the proliferation phase of the healing process?

5-21 days cells come to fill the space from the wound - a beefy red layer (granulation tissue) is formed which is easily damaged (epithelialization)

What occurs in the Maturation phase of the healing process?

2-3rd week - 6 months - formation of scar tissue

When are adhesive strips used to close wounds?

* skin tears/lacerations
* support skin after sutures or surgical staples are removed

What are the two types of sutures and when are they used?

* absorptive tissue - deep sutures
* Non absorptive - superficial

Where are surgical staples used?

less likely chance of infection that sutures - given in places where there is not a ton of movement or tension

When is surgical glue used and what is a side effect?

low tension wounds like skin tears, but it does sting

Describe wound drainage: serous exudate

straw colored

Describe wound drainage: Sanguineous

Bloody drainage

Describe wound drainage: serosanguineous

mix of bloody and straw-colored fluid

Describe wound drainage: purulent

yellow, contains pus

Describe wound drainage; purosanguineous exudate

contains blood and pus

Define dehiscence

reopening of a wound

Define evisceration

separation of all layers of the skin where the organs can protrude through it

What are the factors of the braden scale?

Sensory perception, moisture, activity, mobility, nutrition, and friction/shear

* If the score is less than 18 then that means pt is at risk

What do we assess for the wound?

Location, size (in cm) , undermining (based on face of clock) , appearance, drainage, redness, swelling, pain, nutritional status

How can you take a wound culture?

* swabbing - clean tissue first
* needle aspiration
* tissue biopsy

What is a stage 1 pressure ulcer?

* intact, nonblistered skin with persistent redness that has been exposed to pressure

What is a stage 2 pressure ulcer?

partial thickness wound that does not extend below the dermis

* intact or ruptured blisters may also occur

What is a stage 3 pressure ulcer?

Full thickness wound that does not extend through the fascia to the muscle, bone, or connective tissue

* usually forms a "lip” around the wound - tunneling

What is a stage 4 pressure ulcer?

Deeper than stage 3, and involved exposure muscle, bone, or connective tissue - can lead to infection of the bone

What is a Unstageable pressure ulcer?

full thickness wound - amount of necrotic tissue makes it impossible to tell the layer

What is a suspected deep tissue injury?

area of intact skin that is purple or blood filled blister

What are the 6 links of the spread of infection?

* infectious agents
* reservoir
* portal of exit
* mode of transmission
* portal of entry
* Susceptible host