WEEK 3: NURSING INTERVENTIONS TO

PROMOTE HEALTHY PHYSIOLOGIC

RESPONSES
 Skin, the largest organ in the body, constitutes
15% of the total adult body weight. It is a
protective barrier against disease-causing
organisms and a sensory organ for pain,
temperature, and touch; and it synthesizes
vitamin D.
INTRODUCTION
As nurses, our most important responsibilities
include assessing and monitoring skin
integrity, identifying patient risks for skin
problems, identifying actual problems, and
planning, implementing, and evaluating
interventions to maintain skin integrity.
ANATOMY AND PHYSIOLOGY
 Pressure ulcer, pressure sore,
decubitus ulcer, and bedsore are
terms used to describe impaired
skin integrity related to unrelieved,
prolonged pressure.
PRESSURE ULCERS
It is localized injury to the skin and
other underlying tissue, usually over
a bony prominence, as a result of
pressure or pressure in combination
with shear and/or friction.
 Pressure intensity
PATHOGENESIS OF
PRESSURE ULCERS
Pressure duration

Tissue tolerance
 RISK FACTORS FOR PRESSURE ULCER
DEVELOPMENT

• Impaired sensory perception

• Impaired mobility
• Alteration in level of consciousness
• Shear
• Friction
• Moisture
 Category 1: Nonblanchable redness

Category 2: Partial-Thickness

Category 3: Full-Thickness Skin Loss

CLASSIFICATION OF
PRESSURE ULCERS Category 4: Full-Thickness Tissue Loss

Unstageable/Unclassified: Full Thickness Skin or Tissue

Loss/ Depth Unknown

Suspected Deep Tissue Injury- Depth Unknown

 NUTRITION

TISSUE PERFUSION

FACTORS INFLUENCING INFECTION

PRESSURE ULCER
FORMATION

AGE

PSYCHOSOCIAL IMPACT OF WOUNDS

 • INTRODUCTION – Movement is an
activity most people take for granted.
The ability to move and be active
result to positive benefits to one’s
ACTIVITY,
health status. Mobility is often
MOBILITY
considered an indicator of overall
AND
health because it influences the
EXERCISE
correct functioning of many body
systems.
 BODY ALIGNMENT – the relationship of one
body part to another along a horizontal or
vertical line. Correct alignment involves
positioning so no excessive strain is placed on a
person’s joints, tendons, ligaments, or muscles,
thereby maintaining adequate muscle tone and
contributing to balance.
OVERVIEW
BODY BALANCE- occurs when a relatively low
center of gravity is balanced over a wide, stable
baseof support and a vertical line falls from the
center of gravity through the base of support.
• COORDINATED BODY MOVEMENT – a result of weight,
center of gravity, and balance. Weight is the force exerted on a
body by gravity.

• FRICTION- a force that occurs in a direction to oppose

movement. It increases a patient’s risk for skin and tissue
damage and potential pressure ulcer.
 EXERCISE AND ACTIVITY

•Isotonic exercises
•Isometric exercises
•Resistive isometric exercises
 REGULATION OF MOVEMENT

•SKELETAL SYSTEM. Bones perform five functions in the

body: support, protection, movement, mineral storage, and
hematopoiesis (blood cell formation). Bones serve as
support by providing the framework and contributing to
the shape, alignment and positioning of the body parts.
 JOINTS-
THE CONNECTION
BETWEEN BONES
LIGAMENTS –white, shiny, flexible bands of fibrous tissue that bind joints and
connect bones and cartilage. They are elastic and aid joint flexibility and support.

TENDONS- are white, glistening, fibrous bands of tissue that occur in various
lengths and thickness.

CARTILAGE – is non vascular, supporting connective tissue with the flexibility of

a firm, plastic material.
• SKELETAL MUSCLE – muscles made of fibers that contract when stimulated by an
electrochemical impulse that travels from the nerve to the muscle across the
neuromuscular junction.
• MUSCLE TONE – or tonus, the normal state of balanced muscle tension. Muscle
tone helps maintain functional positions such as sitting or standing without excess
muscle fatigue and is maintained through continual use of muscles.
• NERVOUS SYSTEM – regulates movement and posture. The major voluntary
motor area, are located in the cerebral cortex, is the precentral gyrus, or motor
strip.
• PROPRIOCEPTION- the awareness of the position of the body and its parts.
• BALANCE – A person needs adequate balance to stand, run, lift, or perform ADLs.
 PRINCIPLES OF SAFE PATIENT TRANSFER AND
POSITIONING

• Mechanical lifts and lift teams are essential when a patient is unable to assist.
• When a patient is able to assist, remember the ff principles:
• The wider the base support, the greater the stability of the nurse
• The lower the center of gravity, the greater the stability of the nurse
• The equilibrium of an object is mainitained as long as the line of gravity passes through its
base of support.
• Facing the direction of movement prevents abnormal twisting the spine.
• Dividing balance activity between arms and legs reduces the risk of back injury
 FACTORS INFLUENCING ACTIVITY AND
EXERCISE

• DEVELOPMENTAL CHANGES
• BEHAVIORAL ASPECTS
• ENVIRONMENTAL ISSUES
• FAMILY AND SOCIAL SUPPORT
• CULTURAL AND ETHNIC ORIGIN
Short term effects of
exercise
Increase in stroke volume (SV); increase
in heart rate (HR); increase in cardiac
Cardiovascular system
output (Q); increase in blood pressure
(BP)

Increase in breathing rate; increase in tidal

Respiratory system
volume

Increase in oxygen uptake; increase in

Cardio-respiratory system
carbon dioxide removal

Energy system Increase in lactate production

Increase in temperature of muscles;

Muscular system
increased pliability; muscle fatigue
 IMMOBILITY

PATHOLOGICAL INFLUENCES ON
MOBILITY
ABNORMALITY DESCRIPTION
TORTICOLLIS Inclining head to affected side, in wc
sternocleidomastoid muscle is contracted
LORDOSIS Exaggeration of anterior convex curve of lumbar
spine
KYPHOSIS Increased convexity I curvature of thoracic spine
SCOLIOSIS Lateral S or C shaped spinal column with vertebral
rotation
CONGENITAL HIP DYSPLASIA Hip instability with limited abduction of hips and
occasionally adduction contractures
KNOCK KNEE GENU VALGUM Legs curved inward so knees come together as
person walks
BOWLEGS One or both legs bent outward at knee
FOOTDROP Inability to dorsiflex and invert foot because of
peroneal nerve damage
CLUBFOOT Medial deviation and plantar flexion of foot
PIGEON TOES Internal rotation of forefoot or entire foot; common
in infants
 FACTORS INFLUENCING MOBILITY-IMMOBILITY

BED REST Intervention that restricts patients to bed for therapeutic reasons. The duration of
bed rest depends on illness and injury
SYSTEMIC EFFECTS All body systems work more efficiently with some form of movement. Exercise
has positive outcomes for all major systems of the body.
METABOLIC CHANGES Changes in mobility alter endocrine metabolism, calcium respiration, and
functioning of the GI system.
RESPIRATORY Regular aerobic exercise enhances respiratory functioning. In contrast, lack of
CHANGES movement and exercise places patients at risk for respiratory complications.
CARDIOVASCULAR Immobilization frequently results in orthostatic hypotension, increased cardiac
CHANGES workload, and thrombus formation.
MUSCULOSKELTAL Immobility causes permanent or temporary impairment or permanent disability.
MUSCLE EFFECTS Prolonged immobility often leads to disuse atrophy.
SKELETAL EFFECTS Impaired calcium metabolism; joint abnormalities
URINARY Urinary stasis
ELIMINATION
PSYCHOSOCIAL RESPONSES
Decreased motivation
Decreased perception
Increased sense of powerlessness
Diminished ability to make
Inability to sleep
 REST AND SLEEP

• Physical and emotional health depend on the ability of each

individual to fulfill the basic human needs. One of these
basic human needs to sustain life and health is proper rest
and sleep. Individuals need different amounts of sleep and
rest.
 PHYSIOLOGY OF SLEEP

• SLEEP - a state of consciousness in which the individual’s perception and

reaction to the environment are decreased.
• CIRCADIAN RHYTHYM – 24 hour, day night cycle. Also known as diurnal
rhythm.
• All people have biological clocks that synchronize their sleep cycles. This explains why some
people fall asleep at 8pm, whereas others gp to bed at midnight or early in the morning.
• Failure to maintain an individual’s usual sleep wake cycle due to some factors such as working
rotating shifts, hospital routines for patients, negatively influences the patients overall health
as manifested by anxiety, restlessness, irritability, impaired judgemnet.
•The major sleep center is the hypothalamus.
•Prostaglandin D2, L-tryptophan, and growth
factors control sleep.
•Serotonin is a major neurotransmitter associated
with sleep. A naturally occurring amino acid.
Decreases activity of RAS.
•Reticular activating system maintains a state of
wakefulness and alertness and mediate some
stages of sleep.
REST AND
SLEEP
 SLEEP DISORDERS

•Insomnia
•Sleep apnea
•Excessive daytime sleepiness
•Narcolepsy
•Sleep deprivation
•Parasomnias
COMFORT AND
PAIN
MANAGEMENT
 • The most common reason that people seek
health care; yet it is often underrecognized,
misunderstood, and inadequate treated.
• PAIN IS PURELY SUBJECTIVE.
• Effective pain management improves quality of
PAIN
life, reduces physical discomfort, promotes earlier
mobilization and return to previous baseline
functional activity levels; results in fewer hospital
and clinic visits; decreases hospital lengths of stay,
resulting in lower health care costs.
 NATURE OF PAIN

“ It is whatever the patient says it is.”

“It exists whenever the patient says it does”.
Subjective in nature, only the person experiencing it may describe it.
It is protective because it provides warning signal for tissue injury.
 PAIN

• PAIN THRESHOLD the amount of pain stimulation a person requires

before feeling pain.
• PAIN TOLERANCE – the maximum amount and duration of pain that an
individual is willing to endure.
• PAIN PERCEPTION – actual feeling of pain
• BRADYKININ- universal stimulus for pain
• HYPERALGESIA – excessive sensitivity to pain.
 PHYSIOLOGY OF PAIN

• 1. TRANSDUCTION –thermal, chemical, mechanical stimuli

• 2. TRANSMISSION – neurotransmitters affect the sending of
nerve stimuli
• 3. PERCEPTION – the point at which a person is aware of
pain
• 4. MODULATION – once the brain perceives pain, there is a
release of inhibitory neurotransmitters such as endorphins