The skin is described in terms of its color which can be yellow, ecchymosed, purple, green, blanched and reddened, for example. These stockings are gently and smoothly pulled over the client's legs without any wrinkles or uneven pressure. Ask the patient about the date of their last bowel movement, and monitor stool patterns and stool characteristics. Herdman, T. H., & Kamitsuru, S. The stages of wound healing are the homeostasis phase, the inflammation phase which is also referred to as the exudate and lag phase, the proliferative and granulation phase, and the maturation phase. Shearing is a combination of both pressure and friction that can cause some distortion of the client's skin and its underlying tissues. Friction occurs when a person's body is being rubbed against a surface such as a bed. Some of the orthopedic devices that nurses apply, maintain and remove include traction devices, splints, braces and casts: Traction, simply defined, is a physical pulling force that exerts pulling on the bodily part. Compression stockings require a physicians order and should be applied in the morning and taken off at night. Monitor 24-hour trend of intake and output, as well as for symptoms of dysuria, urgency, or frequency. Topical antibiotics that are often used to treat wounds, as based on the identified offending microorganism, include, among others: Nursing care consists of all of the phases of the nursing process including assessment, nursing diagnosis, planning implementation and evaluation. Skin traction is the most commonly used type of traction. These risk factors are assessed by the nurse to determine the etiology of an identified deficit and to recognize that, because of one or more risk factors, a client is at risk for impairments in terms of their mobility, gait, strength and motor skills. WebActive and passive range of motion (ROM) exercises prevent complications of immobility in the musculoskeletal system. The incentive spirometer encourages a client to complete slow, deep breathing to keep their bronchioles open. The nurse should monitor these clients to insure that they are performing these active range of motion exercises in the correct manner and to the greatest possible extent of movement for all of the joints of the body. Some nursing diagnoses related to immobility can include: Mobility is defined as the "ability to move freely, easily, rhythmically, and purposefully in the environment. Some of the elements of this teaching should include: The client positions that are used for maintaining good bodily alignment and optimal physiological functioning include the Sims or the semi prone position, the Fowler's position, the dorsal recumbent position, the prone position and the lateral position. Mobility can be assessed by using direct observation of the client's movements and mobility and using some standardized tests such as the Timed Get Up and Go Test with which the nurse assesses the client's ability to rise from a chair, walk, and then return to the chair and sit, the Assessment Tool for Safe Patient Handling and Movement, the Egress test which the nurse uses to assess the client's ability to sit and then stand, march in place and advance forward with each foot and return to the same position. The plan is tailored to the needs of the individual and will include the specific joints to move. These stages are: The treatment of pressure ulcers is complex and it often includes a combination of treatments and therapies. When you have the hose positioned correctly, pull the remainder of the stocking up to the knee or hip, depending upon the length of the hose. Some casts are solid and others are what are referred to as a bivalve cast which has two pieces. A deep-vein thrombosis (DVT) is a blood clot that forms within the deep veins, usually of the lower leg, but can occur anywhere within the cardiovascular system. Pressure occludes the vessels that oxygenate the area and it also causes cellular damage because harmful substances, such as toxins, accumulate in the area where the pressure is exerted. However, as the client sits or stands upright during the day, blood tends to pool in the lower legs. Braces are applied to various parts of the body to provide support and alignment of the part. For example, the nurse will determine whether or the client is able to: SEE Basic Care & Comfort Practice Test Questions. Assess for the presence of urinary tract abnormalities related to immobility, such as suprapubic distention or tenderness that can result from urinary retention. She got her bachelors of science in nursing with Excelsior College, a part of the New York State University and immediately upon graduation she began graduate school at Adelphi University on Long Island, New York. If there is writing on the stocking, it should be on the outside and facing away from the skin when worn. [4] See Table 13.3 for the definition and selected defining characteristics of this diagnosis. Risks of immobility are well-known, and complications are viewed as avoidable. Some of the psychological hazards of immobility can include apathy, isolation, frustration, a lowered mood, and depression. Some nursing diagnoses related to immobility can include: At risk for pressure ulcers related to immobility Muscular weakness and muscular atrophy related to immobility ROM exercises facilitate movement of specific joints and The later signs of compartment syndrome include burning pain secondary to ischemia, paresthesia secondary to neurological impairment, hypoesthesia secondary to sensory nerve damage, pulselessness, and cool and pale skin. All of these measures are used not only for immobilized clients but also for many post-operative clients. Accessibility StatementFor more information contact us atinfo@libretexts.org. Refer to the Objective and Subjective Signs of Pain subsection in Chapter 6.3 to review observations to make and report. This technique entails the positioning of the client in different positions so that all areas of the lungs and airways are able to be drained of respiratory secretions using the force of gravity.
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