Obj 8- Explain Activity/Mobility Needs Mental Changes- Social isolation, loneliness, fear,
Factors affecting activity/mobility anxiety, depression and sadness. Effects are gradual or
immediate and vary. Patients may have more time to
Pathological Influences- Congenital defects,
worry about disability, thus adding onto the mental
bone/joint/muscle disorders, central nervous system
effects and causing withdrawal from medical care.
damage and musculoskeletal trauma.
Depression- Characterized by exaggerated feelings of
Obesity- Chronic public health problem, negatively
sadness, melancholy, worthlessness, emptiness and
affects musculoskeletal system and leads to disabilities.
hopelessness out of proportion. Results from worrying
Major international public health problem affecting
about present/future health, finances and family needs.
children and adults. Affects quality of life and ADL
Nervous System Changes- Increased pressure on skin
performance.
activates various pain receptors and damage of skin can
Developmental Changes- Infants/toddlers, gradual
progress to irreversible nerve damage.
moving. Adolescents, rapid growth occurs in females
Damage to CNS- Balance and coordination affects and
sooner than males. Adults, influence of multiple chronic
leads to increasing dependence on caregivers.
diseases. Older adults, progressive loss of total bone
Metabolic Changes- Decreases metabolic rate and
mass and prone to fractures and muscle injuries.
alters metabolism of macros.
Behavioral Aspects- Patient’s knowledge of
Endocrine- Insulin resistance, impaired glucose
exercise/health, their beliefs about exercise/health, and
tolerance and type 2 diabetes development.
current exercise/health habits. One chronic condition
GI Function- Decreased appetite and constipation.
could prevent patients from engaging in needed exercise
Respiratory Changes- Decreased oxygenation and
EX- Asthma gets better with exercise
prolonged recovery.
Environmental Issues- Lack of time needed to engage
Atelectasis- Secretions block a bronchiole/bronchus and
in a daily exercise program. Some businesses help
alveoli collapses as the existing air is absorbed.
employees overcome the time obstacle by offering
Hypostatic Pneumonia- Inflammation of the lung from
physical activity opportunities at their buildings.
stasis/pooling of secretions.
Family/Social Support- Social support is the main
Cardiovascular Changes- Structural changes such as
motivational tool to encourage and promote physical
reduction of venous return, increased heart rate and
fitness. Greater social support=greater the time for
deconditioning.
physical activity.
Orthostatic Hypotension- Drop of blood pressure
Schools- Kids today are less active, resulting in an greater than 20 in Systolic pressure or 10 in Diastolic
increase in childhood obesity and schools help to get pressure from standing/sitting up.
kids to exercise. Physical activity strategies incorporated Symptoms- Dizziness, lightheadedness, nausea,
early into a child’s daily routine provide foundation for tachycardia and fainting.
lifetime of commitment to exercise and physical fitness. Increased Cardiac Workload- As workload of heart
Community- Creating environments make it easier for increases, so does its oxygen consumption. As the heart
people to stay active (aka active communities). Success works harder and less efficiently during periods of
for implementing physical fitness programs depends on prolonged rest. As immobilization increases, cardiac
collaboration among public health agencies, parks and output falls, further decreasing cardiac efficiency and
recreational associations, state and local governmental increasing workload.
agencies, healthcare agencies and members of the Thrombus- Accumulation of platelets, fibrin, clotting
community. factors and the cellular elements of the blood attached to
Ethnic/Culture Origin- Low level of education=high the interior wall of a vein/artery, which occludes the
physical activity at work. lumen of the vessel.
Effects and complications of immobility Urinary Elimination Changes- Increases risk of UTI
Immobility- The inability to move about freely and renal calculi. Urinary output declines on 5/6th day
Bed Rest- Intervention that restricts patients to bed for and urine becomes concentrated, thus resulting in
therapeutic reasons. Can lose 3% of muscle strength elimination changes.
everyday from being on bedrest. Urinary Stasis- In an up position, urine flows down
because of gravity. When a patient is flat, urine is not
,able to overcome gravity, thus the renal pelvis fills patient. Contractures develop in joints not moved
before urine enters the ureters. periodically through their full ROM.
Renal Calculi- Calcium stones that lodge in the renal Gait- Particular manner/style of walking
pelvis/pass through the reuters. Immobile patients at risk, Activity Tolerance- Type/Amount of exercise that a
because of hypercalcemia. patient’s able to do (physical, mental and developmental)
Musculoskeletal Effects- Loss of endurance, Body Alignment- Used for determining normal physical
decreased stability/balance and posture abnormalities changes, identifying posture, trauma, muscle damage
Loss of Muscle Mass- Muscle mass decreases rapidly and nerve changes.
when someone is immobile. A decrease in protein Sitting- Head is upward and neck/vertebrae are in
synthesis, and a loss of muscle and fiber size. straight alignment. Body weight is distributed evenly on
Muscle Atrophy- Protein synthesis is reduced and butt and thighs, thighs are parallel in a horizontal plane,
protein breakdown increased. Autophagic activities play both feet supported on the floor and ankles are flexed.
an important role in early stages of muscular atrophy. Planes of the Body- Sagittal, Transverse and Frontal.
The oxygen supply to disused muscle may be impaired. Diagnosis- Activity intolerance, ineffective breathing
Skeletal Effects- Decrease in bone mass and decline of problem, risk of disuse syndrome, impaired
osteoblasts that stops building the bone matrix, thus physical/skin mobility and social isolation.
reducing bone synthesis. Planning- Goals and outcomes, setting priorities and
Impaired Calcium Absorption- Release of calcium into continuity of care.
circulation. Kidneys excrete excess calcium, but if they EX- Patients' skin remains dry and intact.
are unable to respond appropriately, hypercalcemia Intervention- Lifting techniques and exercise.
results. Evaluation- Patient care and patient expectations
Joint Abnormalities- Can cause joint contractures, Obj 9- Identify Skin Integrity Needs/
which limit ROM in major joints, and thinning and
softening of joint tissue. Wound Healing
Integumentary Changes- Older adults are at greater Risks/Contributing factors for impaired
risk and highest in long-term care facilities. skin integrity
Pressure Ulcer- Limiting blood supply to the skin. Poor Circulation- Poor circulation decreases normal
Ischemia- When blood supply to an organ, tissue, or strength, elasticity and flexibility of the skin. When that
muscles in body are restricted, thus in a lack of oxygen happens, skin is more prone to break in one way or
and tissue damage because cells need oxygen to survive. another. Poor circulation can lead to skin wounds.
Ergonomics in healthcare environment Sun Exposure- Premature aging, wrinkles, skin cancer
Safe Patient Handling and Mobility (SPHM)- Plan and can damage the eyes and immune system.
ahead based on patient assessment. And using safety Pathogenesis of impaired skin integrity
procedures to lift/move patients to reduce injury. 1 Pressure Intensity- Magnitude of pressure exerted
Protecting Pt and healthcare Worker- Manually on a tissue, measured in Pascals (Pa). Higher intensity
lifting/transferring patients results in high incidence means more force is being applied per unit area,
work related problems and back injury. Should include increasing the risk of tissue damage.
lift teams/lift equipment and ergonomics training.
2 Pressure Duration- Length of time that pressure is
Mechanical Equipment- All devices must be applied to a tissue. Even moderate pressure can cause
appropriate for the patient such as weight limit, reason damage if applied for a long period
for device and measured to patient.
3 Tissue Tolerance- Tissue capacity to have pressure
EX- Canes, walkers, wheelchairs and crutches.
without injury, influenced by factors like nutrition,
Relating nursing process as it applies to hydration, skin integrity, and health. Poor circulation or
activity/mobility needs underlying medical conditions reduce tissue tolerance.
Assessment- Tissue Ischemia- Pressure applied over capillary
Mobility- ROM, the max amount of movement available exceeds normal capillary pressure and the vessel is
at a joint. AROM (active ROM), patient does activity. occluded for a prolonged time.
PROM (passive ROM), somebody else does for the Blanching- The normal red tones of skin are absent.
, Friction- Force of 2 surfaces moving across one Know type of dressing, placement of drains, and the
another. equipment needed. Prepare patients for the dressing
Shear- Force exerted parallel to skin, resulting from change such as reviewing previous wound assessment,
both gravity pushing down on the body and resistance evaluating pain, administering analgesics so peak occurs
(friction) between the patient and a surface. during dressing change, describe procedure steps, gather
Skin Moisture- Presence and duration of skin moisture supplies, recognize normal signs of healing and answer
reduces the skin's resistance to other physical factors. questions about the procedure/wound.
Granulation- Red/Moist tissue made up of new blood Drain Placement- Check for signs of fluid/air leakage,
vessels, whose presence of granulation means redness or irrigation and that the drain is below insertion
progression towards healing. site and free of knots. Drain may need to be emptied
Slough- Soft yellow/white tissue and stringy substance. multiple times a day. Record amount of drainage.
Eschar- Black, brown, tan or necrotic tissue Cleaning Skin With Drainage Evacuation-
Irrigations- Requires sterile technique. Flush area with
Types of Dressings an irrigating syringe with constant low pressure flow.
WetToDry- Placing a moist dressing into a wound when Gently washing the action of the irrigations will cleanse
dry, it sticks to underlying tissue and removes damaged the wound of discharge and debris. Useful for open and
tissue. Needs frequent changing to prevent skin deep wounds and wounds involving an inaccessible body
breakdown and microorganism growth. part such as the ear canal, or when cleaning sensitive
Materials- Gauze moistened with saline or water and body parts such as the conjunctival lining of the eye.
then covered with dry dressings Negative Pressure Wound Therapy/Vacuum Assisted
Gauze Sponge- Absorbent and useful in wounds to Closure- The application of negative pressure to a
take away damaged tissue. Used to clean, pack, cover wound through suction to promote healing and collect
wounds, and a temporary absorbent dressing. wound fluid. Edema reduction and fluid removal. Effects
Self Adhesive- A sterile, absorbent pad with an can include angiogenesis, granulation tissue formation,
adhesive backing that molds to the body to stay in place and reduction in bacterial bioburden. Treats acute and
over cuts and grazes. AKA adhesive bandages, sticking chronic wounds. Airtight seal MUST be maintained.
plasters, or medical plasters. Can be used on awkward Securing Wounds- A bandage to hold a sterile dressing
areas of the body, such as neck, elbow and hip. Used for in place over an injured wound.
injuries that aren’t serious to require a full-size bandage Suture/Staples- Sutures are threads or metal used to sew
Hydrocolloid- Complex formulations of colloids and body tissues together. The patient’s history of wound
adhesive components. Support healing in cleaning and healing, the site of surgery, the tissues involved, and the
automatically take away necrotic wounds. Can be purpose of the sutures determine the suture material
wafers, powders, or pastes. Provide a moist environment used. Steel staples are a common type of outer skin
favorable for wound healing and a barrier against closure that causes less trauma to tissue than sutures
bacteria. while providing extra strength. If it is appropriate that
Hydrogel- Gauze/Sheet dressings with water/glycerin the nurse remove them, a healthcare provider’s order is
gel. Hydrates wounds and absorbs small amounts of required. Special scissors with curved cutting tips or
discharge. Used for serious wounds. special staple removers slide under the skin closures for
Foam Alginate- Wounds with large amounts of suture removal.
discharge and those that need packing. Tape/Ties/Bandages/Binders- Uses include creating
Calcium Alginate- From seaweed and come in sheet pressure/immobilizing a body part, supporting a wound,
and rope forms. Creates a soft gel when in contact with reducing or preventing edema, securing a splint and
wound fluid. Highly absorbent for wounds with lots of dressings. Bandages are available in rolls of gauze,
drainage. elasticized knit, elastic webbing, flannel, and muslin.
Composite- Combines two different dressing types into Gauze bandages are lightweight and inexpensive, mold
one. Research is still ongoing regarding which type of easily around contours of the body, and allow air
dressing is best for which type of wound. circulation to prevent skin thinning. Elastic bandages
Changing Dressings conform well to body parts but are also for exerting
pressure.
Factors affecting activity/mobility anxiety, depression and sadness. Effects are gradual or
immediate and vary. Patients may have more time to
Pathological Influences- Congenital defects,
worry about disability, thus adding onto the mental
bone/joint/muscle disorders, central nervous system
effects and causing withdrawal from medical care.
damage and musculoskeletal trauma.
Depression- Characterized by exaggerated feelings of
Obesity- Chronic public health problem, negatively
sadness, melancholy, worthlessness, emptiness and
affects musculoskeletal system and leads to disabilities.
hopelessness out of proportion. Results from worrying
Major international public health problem affecting
about present/future health, finances and family needs.
children and adults. Affects quality of life and ADL
Nervous System Changes- Increased pressure on skin
performance.
activates various pain receptors and damage of skin can
Developmental Changes- Infants/toddlers, gradual
progress to irreversible nerve damage.
moving. Adolescents, rapid growth occurs in females
Damage to CNS- Balance and coordination affects and
sooner than males. Adults, influence of multiple chronic
leads to increasing dependence on caregivers.
diseases. Older adults, progressive loss of total bone
Metabolic Changes- Decreases metabolic rate and
mass and prone to fractures and muscle injuries.
alters metabolism of macros.
Behavioral Aspects- Patient’s knowledge of
Endocrine- Insulin resistance, impaired glucose
exercise/health, their beliefs about exercise/health, and
tolerance and type 2 diabetes development.
current exercise/health habits. One chronic condition
GI Function- Decreased appetite and constipation.
could prevent patients from engaging in needed exercise
Respiratory Changes- Decreased oxygenation and
EX- Asthma gets better with exercise
prolonged recovery.
Environmental Issues- Lack of time needed to engage
Atelectasis- Secretions block a bronchiole/bronchus and
in a daily exercise program. Some businesses help
alveoli collapses as the existing air is absorbed.
employees overcome the time obstacle by offering
Hypostatic Pneumonia- Inflammation of the lung from
physical activity opportunities at their buildings.
stasis/pooling of secretions.
Family/Social Support- Social support is the main
Cardiovascular Changes- Structural changes such as
motivational tool to encourage and promote physical
reduction of venous return, increased heart rate and
fitness. Greater social support=greater the time for
deconditioning.
physical activity.
Orthostatic Hypotension- Drop of blood pressure
Schools- Kids today are less active, resulting in an greater than 20 in Systolic pressure or 10 in Diastolic
increase in childhood obesity and schools help to get pressure from standing/sitting up.
kids to exercise. Physical activity strategies incorporated Symptoms- Dizziness, lightheadedness, nausea,
early into a child’s daily routine provide foundation for tachycardia and fainting.
lifetime of commitment to exercise and physical fitness. Increased Cardiac Workload- As workload of heart
Community- Creating environments make it easier for increases, so does its oxygen consumption. As the heart
people to stay active (aka active communities). Success works harder and less efficiently during periods of
for implementing physical fitness programs depends on prolonged rest. As immobilization increases, cardiac
collaboration among public health agencies, parks and output falls, further decreasing cardiac efficiency and
recreational associations, state and local governmental increasing workload.
agencies, healthcare agencies and members of the Thrombus- Accumulation of platelets, fibrin, clotting
community. factors and the cellular elements of the blood attached to
Ethnic/Culture Origin- Low level of education=high the interior wall of a vein/artery, which occludes the
physical activity at work. lumen of the vessel.
Effects and complications of immobility Urinary Elimination Changes- Increases risk of UTI
Immobility- The inability to move about freely and renal calculi. Urinary output declines on 5/6th day
Bed Rest- Intervention that restricts patients to bed for and urine becomes concentrated, thus resulting in
therapeutic reasons. Can lose 3% of muscle strength elimination changes.
everyday from being on bedrest. Urinary Stasis- In an up position, urine flows down
because of gravity. When a patient is flat, urine is not
,able to overcome gravity, thus the renal pelvis fills patient. Contractures develop in joints not moved
before urine enters the ureters. periodically through their full ROM.
Renal Calculi- Calcium stones that lodge in the renal Gait- Particular manner/style of walking
pelvis/pass through the reuters. Immobile patients at risk, Activity Tolerance- Type/Amount of exercise that a
because of hypercalcemia. patient’s able to do (physical, mental and developmental)
Musculoskeletal Effects- Loss of endurance, Body Alignment- Used for determining normal physical
decreased stability/balance and posture abnormalities changes, identifying posture, trauma, muscle damage
Loss of Muscle Mass- Muscle mass decreases rapidly and nerve changes.
when someone is immobile. A decrease in protein Sitting- Head is upward and neck/vertebrae are in
synthesis, and a loss of muscle and fiber size. straight alignment. Body weight is distributed evenly on
Muscle Atrophy- Protein synthesis is reduced and butt and thighs, thighs are parallel in a horizontal plane,
protein breakdown increased. Autophagic activities play both feet supported on the floor and ankles are flexed.
an important role in early stages of muscular atrophy. Planes of the Body- Sagittal, Transverse and Frontal.
The oxygen supply to disused muscle may be impaired. Diagnosis- Activity intolerance, ineffective breathing
Skeletal Effects- Decrease in bone mass and decline of problem, risk of disuse syndrome, impaired
osteoblasts that stops building the bone matrix, thus physical/skin mobility and social isolation.
reducing bone synthesis. Planning- Goals and outcomes, setting priorities and
Impaired Calcium Absorption- Release of calcium into continuity of care.
circulation. Kidneys excrete excess calcium, but if they EX- Patients' skin remains dry and intact.
are unable to respond appropriately, hypercalcemia Intervention- Lifting techniques and exercise.
results. Evaluation- Patient care and patient expectations
Joint Abnormalities- Can cause joint contractures, Obj 9- Identify Skin Integrity Needs/
which limit ROM in major joints, and thinning and
softening of joint tissue. Wound Healing
Integumentary Changes- Older adults are at greater Risks/Contributing factors for impaired
risk and highest in long-term care facilities. skin integrity
Pressure Ulcer- Limiting blood supply to the skin. Poor Circulation- Poor circulation decreases normal
Ischemia- When blood supply to an organ, tissue, or strength, elasticity and flexibility of the skin. When that
muscles in body are restricted, thus in a lack of oxygen happens, skin is more prone to break in one way or
and tissue damage because cells need oxygen to survive. another. Poor circulation can lead to skin wounds.
Ergonomics in healthcare environment Sun Exposure- Premature aging, wrinkles, skin cancer
Safe Patient Handling and Mobility (SPHM)- Plan and can damage the eyes and immune system.
ahead based on patient assessment. And using safety Pathogenesis of impaired skin integrity
procedures to lift/move patients to reduce injury. 1 Pressure Intensity- Magnitude of pressure exerted
Protecting Pt and healthcare Worker- Manually on a tissue, measured in Pascals (Pa). Higher intensity
lifting/transferring patients results in high incidence means more force is being applied per unit area,
work related problems and back injury. Should include increasing the risk of tissue damage.
lift teams/lift equipment and ergonomics training.
2 Pressure Duration- Length of time that pressure is
Mechanical Equipment- All devices must be applied to a tissue. Even moderate pressure can cause
appropriate for the patient such as weight limit, reason damage if applied for a long period
for device and measured to patient.
3 Tissue Tolerance- Tissue capacity to have pressure
EX- Canes, walkers, wheelchairs and crutches.
without injury, influenced by factors like nutrition,
Relating nursing process as it applies to hydration, skin integrity, and health. Poor circulation or
activity/mobility needs underlying medical conditions reduce tissue tolerance.
Assessment- Tissue Ischemia- Pressure applied over capillary
Mobility- ROM, the max amount of movement available exceeds normal capillary pressure and the vessel is
at a joint. AROM (active ROM), patient does activity. occluded for a prolonged time.
PROM (passive ROM), somebody else does for the Blanching- The normal red tones of skin are absent.
, Friction- Force of 2 surfaces moving across one Know type of dressing, placement of drains, and the
another. equipment needed. Prepare patients for the dressing
Shear- Force exerted parallel to skin, resulting from change such as reviewing previous wound assessment,
both gravity pushing down on the body and resistance evaluating pain, administering analgesics so peak occurs
(friction) between the patient and a surface. during dressing change, describe procedure steps, gather
Skin Moisture- Presence and duration of skin moisture supplies, recognize normal signs of healing and answer
reduces the skin's resistance to other physical factors. questions about the procedure/wound.
Granulation- Red/Moist tissue made up of new blood Drain Placement- Check for signs of fluid/air leakage,
vessels, whose presence of granulation means redness or irrigation and that the drain is below insertion
progression towards healing. site and free of knots. Drain may need to be emptied
Slough- Soft yellow/white tissue and stringy substance. multiple times a day. Record amount of drainage.
Eschar- Black, brown, tan or necrotic tissue Cleaning Skin With Drainage Evacuation-
Irrigations- Requires sterile technique. Flush area with
Types of Dressings an irrigating syringe with constant low pressure flow.
WetToDry- Placing a moist dressing into a wound when Gently washing the action of the irrigations will cleanse
dry, it sticks to underlying tissue and removes damaged the wound of discharge and debris. Useful for open and
tissue. Needs frequent changing to prevent skin deep wounds and wounds involving an inaccessible body
breakdown and microorganism growth. part such as the ear canal, or when cleaning sensitive
Materials- Gauze moistened with saline or water and body parts such as the conjunctival lining of the eye.
then covered with dry dressings Negative Pressure Wound Therapy/Vacuum Assisted
Gauze Sponge- Absorbent and useful in wounds to Closure- The application of negative pressure to a
take away damaged tissue. Used to clean, pack, cover wound through suction to promote healing and collect
wounds, and a temporary absorbent dressing. wound fluid. Edema reduction and fluid removal. Effects
Self Adhesive- A sterile, absorbent pad with an can include angiogenesis, granulation tissue formation,
adhesive backing that molds to the body to stay in place and reduction in bacterial bioburden. Treats acute and
over cuts and grazes. AKA adhesive bandages, sticking chronic wounds. Airtight seal MUST be maintained.
plasters, or medical plasters. Can be used on awkward Securing Wounds- A bandage to hold a sterile dressing
areas of the body, such as neck, elbow and hip. Used for in place over an injured wound.
injuries that aren’t serious to require a full-size bandage Suture/Staples- Sutures are threads or metal used to sew
Hydrocolloid- Complex formulations of colloids and body tissues together. The patient’s history of wound
adhesive components. Support healing in cleaning and healing, the site of surgery, the tissues involved, and the
automatically take away necrotic wounds. Can be purpose of the sutures determine the suture material
wafers, powders, or pastes. Provide a moist environment used. Steel staples are a common type of outer skin
favorable for wound healing and a barrier against closure that causes less trauma to tissue than sutures
bacteria. while providing extra strength. If it is appropriate that
Hydrogel- Gauze/Sheet dressings with water/glycerin the nurse remove them, a healthcare provider’s order is
gel. Hydrates wounds and absorbs small amounts of required. Special scissors with curved cutting tips or
discharge. Used for serious wounds. special staple removers slide under the skin closures for
Foam Alginate- Wounds with large amounts of suture removal.
discharge and those that need packing. Tape/Ties/Bandages/Binders- Uses include creating
Calcium Alginate- From seaweed and come in sheet pressure/immobilizing a body part, supporting a wound,
and rope forms. Creates a soft gel when in contact with reducing or preventing edema, securing a splint and
wound fluid. Highly absorbent for wounds with lots of dressings. Bandages are available in rolls of gauze,
drainage. elasticized knit, elastic webbing, flannel, and muslin.
Composite- Combines two different dressing types into Gauze bandages are lightweight and inexpensive, mold
one. Research is still ongoing regarding which type of easily around contours of the body, and allow air
dressing is best for which type of wound. circulation to prevent skin thinning. Elastic bandages
Changing Dressings conform well to body parts but are also for exerting
pressure.
