Immobility and Wounds

Question 1

What are the nutritional effects of immobility?

Answer 1

Decreased metabolic rate –> decreased appetite –> decreased caloric intake

Question 2

What effect does immobility have on bones?

Answer 2

Increased calcium resorption from bones leading to an increased risk of fractures

Question 3

Amino acid breakdown exceeding protein intake is know as…

Answer 3

Negative nitrogen balance

Question 4

What are the respiratory outcomes of immobility?

Answer 4

Decreased lung expansion, oxygenation, increased risk of atelectasis, pneumonia, and pooling of secretions in bases

Question 5

Partial or full collapse of alveoli

Answer 5

Atelectasis

Question 6

What are the 3 major cardiovascular outcomes of immobility?

Answer 6

Orthostatic hypotension, increased cardiac workload, and thrombus formation

Question 7

What are the major musculoskeletal outcomes of immobility?

Answer 7

Disuse osteoporosis, muscle atrophy, and joint contracture

Question 8

Joint stiffness in passive ROM due to lack changes in muscles, tendons, ligaments, and joint capsules

Answer 8

Joint contracture

Question 9

What is the pathophysiology of disuse osteoporosis?

Answer 9

Bone calcium is reabsorbed into blood stream causing weakened bones

Question 10

What are the 3 major urinary elimination outcomes of immobility?

Answer 10

Urinary stasis, renal calculi, Infection (UTI)

Question 11

Why are renal calculi more common in immobile patients?

Answer 11

Body becomes hypercalcemic due to bone demineralization.

Question 12

What are the psychosocial outcomes of immobility?

Answer 12

Isolation, emotional outbursts, sensory alteration, and feelings of depression

Question 13

Pressure ulcer: Skin is unbroken but inflamed

Answer 13

Stage 1 PU

Question 14

Pressure ulcer: Skin is broken to epidermis or dermis

Answer 14

Stage 2 PU

Question 15

Pressure Ulcer: Ulcer extends to subcutaneous fat layer

Answer 15

Stage 3 PU

Question 16

Pressure Ulcer: Ulcer extends to muscle or bone, likely with undermining?

Answer 16

Stage 4 PU

Question 17

Decreased blood supply (common in ulcers)

Answer 17

Ischemia

Question 18

What are the indications of deep tissue injury?

Answer 18

Skin that’s discolored, non-blanchable, and feels boggy

Question 19

What is the assessment for pressure ulcer risk?

Answer 19

The Braden Scale

Question 20

These 2 injuries may occur when a patient slides down in a bed or chair or when a bed is elevated and the body shifts creating opposing forces

Answer 20

Shear or friction

Question 21

What is the difference between a shear and friction injury

Answer 21

A friction injury is visible, a shear is not visible

Question 22

Black, dead tissue

Answer 22

Eschar

Question 23

Yellow stringy substance attached to wound bed

Answer 23

Slough

Question 24

exposed red tissue

Answer 24

Granulation

Question 25

What are the 3 aspects of describing wound drainage?

Answer 25

Amount, color, odor

Question 26

Bright red, fresh blood like wound exudate

Answer 26

Sanguineous exudate

Question 27

Wound drainage that's a mixture of blood and serous fluid

Answer 27

Serosanguineous exudate

Question 28

Clear, watery, often slightly yellowish wound drainage

Answer 28

Serous exudate

Question 29

Indication of a wound infection. Wound drainage that is thick, opaque, and foul-smelling.

Answer 29

Purulent drainage

Question 30

Removal of slough or possibly eschar

Answer 30

Debridement

Question 31

Describe the distinguish between primary and tertiary intention

Answer 31

Primary has tight closure and produces a fine scar whereas tertiary intention has a purposeful delayed wound closure

Question 32

Wound healing stage where the body is working on stopping the bleeding

Answer 32

Hemostasis

Question 33

Wound healing stage with the intention of defense and cleanup

Answer 33

Inflammation

Question 34

Wound healing stage where the body is repairing damaged tissues

Answer 34

Proliferation

Question 35

Wound healing stage where the body is working on strengthening its existing repairs

Answer 35

Maturation

Question 36

Partial or total separation of wound layers. Typically occurs when patient is coughing, vomiting, and sitting up.

Answer 36

Dehiscence

Question 37

Protrusion of a visceral organ from a wound site (Medical emergency)

Answer 37

Evisceration

Question 38

What are the 6 major barriers to wound healing

Answer 38

Advanced age, Diabetes, Obesisty, Infection, poor circulation and poor diet