Mobility and Skin Integrity Lecture Review
Mobility and Related Concept Definitions
Mobility: This is defined as the state or quality of being mobile or movable.
Immobility: The state of being unable to move.
Disuse Syndrome: A state in which an individual is at risk for deterioration of body systems as a result of prescribed or unavoidable musculoskeletal inactivity.
Deconditioned: A state of being that often occurs in the hospital setting, especially if a patient is hospitalized for an extended period, where they lose their physical conditioning and functional capacity.
Scope of Mobility: The range of mobility falls on a continuum from full mobility to partial mobility to complete immobility.
Anatomy and Physiology of Mobility
Systems Involved: Mobility is primarily driven by the interaction of the muscles, bones, and joints.
Neurological Control: The neurological system is essential for mobility as the brain must signal the body to move. For example, the simple act of raising a pen is directed by the brain.
Conditions Affecting Mobility: There are three primary types of conditions that impact movement, involving different anatomic structures:
Musculoskeletal: Involves bones, joints, and muscles.
Neurological: Involves the brain, spinal cord, and cranial/peripheral nerves.
Neuromuscular: A combination of both musculoskeletal and neurological factors.
Interdependence for Movement: These systems are interdependent. Optimal mobility requires functional innervation of a voluntary muscle. Without innervation, muscles cannot contract, and without muscle contraction, no joint can move.
Risk Factors and Physiological Consequences of Aging
Population at Greatest Risk: Older adults are at the greatest risk for immobility.
Skeletal Changes: Aging leads to a decrease in bone density and an increase in bone brittleness. Spinal column compression and the thinning of vertebrae discs occur.
Kyphosis: A humping of the back caused by loss of bone mass and the changing structure of the spine.
Connective Tissue Changes: There is a loss of resilience and elasticity in the ligaments, alongside increased rigidity and frailty of the cartilage.
Muscle Mass: A reduction in muscle mass and tone is a standard part of aging.
The "Marine's Perspective": A anecdote involves a Marine who required assistance walking to the bathroom all night, remarking that "growing old ain't for sissies."
Assessing and Managing Mobility
Patient History: Nurses must explicitly ask patients about their mobility. A patient's history may reveal they have not walked for three weeks, which significantly impacts the body. Questions should include: "Do you get up?" or "Do you walk to the bathroom?"
Clinical Presentation:
Pain: Joint pain reduces range of motion.
Altered Gait: In conditions like Parkinson's disease, patients exhibit a "shuffling gait." They may experience a sensation of falling over unless they keep moving.
Imbalance: Unsteady patients fall if their center of gravity becomes unbalanced.
Traumatic Injuries: Injuries to the brain, spinal cord, bones, joints, and muscles can compromise mobility. Brain injury units are often strictly quiet areas to manage the severity of the injuries.
Primary Prevention for Mobility: Includes exercise, proper nutrition, and fall prevention.
Falls as a Nursing Priority: On examinations like the HESI or NCLEX, the risk for falls is a very common and critical answer for mobility-related questions.
Screening Tools:
Osteoporosis Screening: Following national guidelines.
Fall Assessment Screenings: Tools used on the nurse's status board to identify high-risk individuals.
Activity and Exercise Frameworks
Benefits of Physical Activity: Elevates mood, enables physical fitness, assists in smoking cessation, boosts energy, manages stress, promotes better sleep, and improves self-image/self-confidence.
Physics of Movement: Friction is a force that occurs in a direction to oppose movement.
Specific Exercise Types:
Isotonic Exercises: Involves muscle contraction and change in muscle length (e.g., walking, swimming, cycling).
Isometric Exercises: Involves tightening or stabilizing specific body parts without moving the joints (e.g., pelvic floor exercises).
Psychosocial Issues: When patients face immobility, nurses should watch for a "loss of hope."
Gait Training with Crutches:
Four-Point Alternating Gait: Requires weight bearing on both legs. Each leg is moved alternately with each opposing crutch.
Three-Point Gait: All weight is borne on one foot; weight is borne on both crutches and then on the uninvolved leg.
Two-Point Gait: Requires at least partial weight bearing on each foot. The crutch is moved at the same time as the opposing leg.
Cane Use: Proper positioning and technique are vital for safety.
SMART Goals in Mobility: Goals must be measured, timed, and attainable. For example, setting a goal for a patient to walk by the end of a shift is more realistic than .
Lifting and Transfer Techniques
Pivot Move: Proper mechanics are required when transferring a patient to a chair; the nurse must pivot the patient using correct body alignment.
Assisting a Falling Patient: If a patient begins to fall while walking:
Stand with feet apart to provide a broad base of support.
Extend one leg and let the patient slide against it toward the floor.
Bend the knees to lower the body as the patient slides to protect both the nurse and the patient.
Safety Equipment: Always use a gait belt when walking a patient, regardless of how well they appear to walk.
Bed Rails: A maximum of side rails can be up on a bed. Having rails up is considered a restraint.
Transfer Tips: Stand on the patient's affected side during the transfer.
Stroke Patients: When dressing a person who has had a stroke, always address the affected side correctly.
Tissue Integrity: Anatomy and Categories of Impairment
Definition: Tissue integrity is the state of structurally intact and physiologically functioning tissues, such as the integument (skin and subcutaneous tissue) and mucous membranes.
Mucous Membranes: Protectants that function in protection, absorption, secretion, and excretion.
Skin Layers: Epidermis (outer), dermis (inner), and accessory structures.
Categories of Impairment:
Trauma/Injury: Ranges from superficial abrasions to deep wounds. A surgical wound is a planned trauma.
Loss of Perfusion: Pressure ulcers are the primary result of inadequate blood flow to tissues.
Immunological Reaction: Examples include hives and rashes.
Infections and Infestations: Bacterial (impetigo), fungal (tinea pedis/athlete's foot), or infestations (scabies, bed bugs).
Thermal or Radiation Injury: Sunburn is a classic thermal injury that may result in blisters.
Lesions: Such as basal cell and squamous cell carcinoma.
Wound Healing Intentions
Primary Intention: Occurs when the edges of a clean wound (like a surgical incision or an appendectomy) are brought together and secured (staples, glue, or sutures). This features the most rapid healing.
Secondary Intention: The wound is left open and allowed to heal gradually from the base upward. The body fills the gap with new tissue; edges are not well approximated.
Tertiary Intention: Delayed closure; occurs when a wound that was previously open is later closed. This is often associated with large, infected, or contaminated wounds.
Pressure Injury Staging
Stage 1: Non-blanchable Erythema: Intact skin. When pressed, the red area does not turn white (blanch).
Stage 2: Partial-Thickness Skin Loss: The skin is open, presenting as a blister or shallow crater. There is no slough present.
Stage 3: Full-Thickness Skin Loss: Damage extends down into the dermis/subcutaneous fat. Slough may be present.
Stage 4: Full-Thickness Tissue Loss: Extensive destruction involving exposed bone, muscle, or tendon.
Unstageable: Full-thickness loss where the base is obscured by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black).
Deep Tissue Pressure Injury: Localized area of non-blanchable dark discoloration (purple or maroon) or blood-filled blister. The area may feel firm or boggy.
Healing Note: A Stage 3 ulcer that has healed is documented as a "healed Stage 3," never downgraded to a lower stage, because the risk for breakdown in that area remains high.
Wound Assessment Terms
Blanching: The normal whitening of the skin when pressure is applied.
Dehiscence: The separation of wound layers.
Evisceration: The protrusion of visceral organs through a wound opening; this is a medical emergency.
Granulation Tissue: Red, moist, pinkish tissue composed of new blood vessels. This is a "good" sign of healing.
Exudate: Fluid, such as pus or serum, that leaks out of blood vessels into nearby tissues.
Purulent: Thick, yellow, green, tan, or brown drainage (pus).
Serosanguineous: Pale, pink, watery; mixture of clear and red fluid. This often indicates the wound is healing.
Slough: Stringy, yellow or white dead tissue that must be removed for healing to occur.
Eschar: Black, brown, or tan necrotic tissue.
Induration: A hardening or thickening of the skin, often around an inflammation site.
Nursing Interventions for Skin and Wounds
Nutrition for Healing: Protein is the most critical nutrient.
Lab Value: Prealbumin (or albumin) is the key indicator of nutritional status for wound healing.
Supplements: Vitamin C, Vitamin A, and Zinc are essential.
Pain Management: Always offer an analgesic (pain medication) before performing a dressing change, as the process can be very painful.
Wound Care Process: Always clean the wound first using normal saline spray. Pat the area dry with sterile gauze before applying a new dressing.
Moist-to-Dry Dressing: If a nurse is in doubt about how to protect a wound, a sterile moist-to-dry dressing (gauze moistened with saline) is a safe interim choice.
Wound Vac (Vacuum-Assisted Closure): A device that uses negative pressure to suck out "bad stuff" and promote healing. This is particularly effective for obese patients whose wounds struggle to close.
Positioning:
Avoid keeping patients in a chair for longer than .
Use the lateral position to avoid pressure points.
Trochanter Roll: Used to prevent external rotation of the hips when a patient is in a supine position.
Heat and Cold Therapy: Do not use directly on open wounds. Always place a barrier, such as a towel or pillowcase, between the pack and the skin.
Braden Scale: A screening tool for pressure ulcer risk. Nurses should know the highest possible score to understand the best-case scenario (higher scores indicate lower risk).
Questions & Discussion
Question: What is the definition of kyphosis?
Response: It is a hump on the back caused by aging, loss of bone mass, spinal column compression, and thinning of the vertebrae discs.
Question: In which clinical area is silence prioritized at Cardinal Hill?
Response: The brain injury unit, because the injuries there are very serious and require a quiet environment.
Question: What was seen by students Eva and Marie during clinicals?
Response: They witnessed a urostomy change, which is a rare and valuable learning experience.
Question: What did they check off on in the previous quarter (02/12)?
Response: The students confirmed they had previously checked off on wound care and wound irrigation.
Question: Are there exam questions on walking with crutches?
Response: No, the crutch gait patterns are complicated and will not be on the exam, but there will be a question regarding the use of a cane.
Question: What are the surgical terms to know for the exam?
Response: Curative and Palliative interventions. Curative is specifically mentioned as an exam topic.