STUDENT- CNUR 103 Lecture - Feb 27- Skin Integrity Pressure Injury and Braden Scale and Pain Management

Skin Integrity, Pressure Injuries, & Pain

• Course recognized as delivered on Treaty 4 Territory and the homeland of the Métis.

• Presented by Sarah Todd, RPN, BSCPN, MN (CNS) on February 27, 2025.

Lecture Objectives

• Maintain skin integrity.

• Identify factors influencing skin integrity.

• Understand the etiology of pressure injuries and associated risk factors.

• Learn best practices for pressure management.

• Discuss the wound healing process and factors affecting it.

• Classify different types of pressure injuries.

• Use risk-assessment tools, particularly the Braden Scale.

• Differentiate between acute and chronic pain and implement pain management strategies.

Skin Integrity

• Functions of Skin:

  • Protection against external harm.

  • Retains fluid and electrolytes.

  • Provides sensory input.

  • Production of Vitamin D.

  • Excretion of sweat, urea, and lactic acid.

  • Aids in expression of emotions.

  • Regulates body temperature.

  • Contributes to immune function.

  • Repairs surface wounds.

  • Identifies internal disorders and diseases.

Influences on Skin Integrity

• Chronic diseases and illnesses.

• Medications affecting skin integrity.

• Health practices including hygiene and nutrition.

• Family and medical history impacting skin.

Risk Factors for Decreased Skin Integrity

• Changes in sensory perception.

• Level of skin moisture.

• Nutrition and hydration status.

• Mobility restrictions and circulatory issues.

• Incontinence conditions.

• Shear and friction from surfaces.

Skin Assessment Techniques

• Health history review.

• Visual inspection of skin condition.

• Palpation for texture and temperature.

Types of Wounds

• Acute Wounds:

  • Heal quickly (5-15 days).

  • Healing duration depends on location and depth.

• Chronic Wounds:

  • Longer healing durations (4-6 weeks or longer).

  • Defined as chronic if healing is disrupted after 2 weeks.

  • Often associated with comorbidities.

Wound Healing Processes

• Primary Intention:

  • Minimal tissue loss; edges neatly approximated (e.g., surgical wounds).

• Secondary Intention:

  • Larger wounds, irregular margins, significant tissue loss (e.g., pressure injuries).

• Third Intention:

  • Delayed healing due to complications like infection (e.g., wound initially left open).

Factors Affecting Wound Healing

• Moist environment necessary for healing.

• Presence of infection or bacteria can prolong healing.

• Localized pressure can hinder healing.

• Patient’s age and body type can influence recovery.

• Chronic diseases and immune suppression affect healing.

• Nutritional status as a critical factor in wound recovery.

Wound Management Types

• Transparent Films (e.g., 3M Tegaderm):

  • Maintain oxygen exchange, waterproof, aid in autolytic debridement.

• Hydrocolloid Dressings (e.g., Comfeel):

  • Occlusive, retain moisture, absorb light to moderate drainage.

• Hydrogels (e.g., Aquasorb):

  • Keep moist environment, used for dry wounds and minor burns.

• Alginates (e.g., AQUACEL):

  • Highly absorbent for exudate, maintain a moist environment.

• Foams (e.g., Mepilex):

  • Absorb drainage, provide cushioning, used for varying depths.

• Antimicrobials (e.g., IODOSORB):

  • Reduce infection risk, maintain wound environment.

• Collagens (e.g., BIOSTEP):

  • Stimulate tissue development in wounds.

Pressure Injuries

• Localized skin and tissue injury due to pressure or shear.

• Commonly occur over bony prominences.

• Risk factors for pressure injuries:

  • Skin moisture levels,

  • Sensory perception issues,

  • Nutrition and hydration.

  • Immobility and advanced age effects.

Categories of Pressure Injuries

• Category I: Intact skin with non-blanchable redness.

• Category II: Partial-thickness skin loss with exposed dermis.

• Category III: Full-thickness tissue loss, subcutaneous fat may be exposed.

• Category IV: Full-thickness tissue loss exposing bone, muscle, or tendon.

Pain and Pain Management

• Pain is unique to each individual, requiring personalized management.

• Pain thresholds and tolerances vary by patient.

• Include both pharmacological (e.g., opioids, NSAIDs) and non-pharmacological interventions in pain management.

Pain Assessment

• Regular assessment of pain must include:

  • Patients' self-reporting of pain.

  • Observations of physical, behavioral, and emotional signs.

• Understanding pain characteristics: onsets, quality, and severity.

Principles of Pain Management

• Acknowledge total pain approach: holistic assessment that includes mental and emotional states.

• Use the World Health Organization (WHO) analgesic ladder to guide pain treatment.

Documentation in Wound Management

• Document wound characteristics accurately:

  • Location, size, wound bed appearance, exudate type, and pain levels.

References

• Donnelly, G., Domm, E. L., & Raisbeck, B. (2020). Fundamentals: Perspectives on the Art and Science of Canadian Nursing.

• Potter, P. A., & Sawhney, M. (2020). Pain Assessment and Management.

Skin Integrity, Pressure Injuries, & Pain

Presented by: Sarah Todd, RPN, BSCPN, MN (CNS) on February 27, 2025.

Lecture Objectives:

• Maintain skin integrity and recognize influencing factors.

• Understand pressure injuries, risk factors, and management best practices.

• Learn the wound healing process and assessment tools, especially the Braden Scale.

• Differentiate between acute and chronic pain and apply pain management strategies.

Skin Integrity Functions:

• Protects against harm, retains fluid, provides sensory input, produces Vitamin D, regulates temperature, and contributes to immune function.

Risk Factors for Decreased Skin Integrity:

• Health conditions, medications, hygiene practices, sensory perception changes, mobility issues, nutrition, and incontinence.

Types of Wounds:

• Acute Wounds: Heal quickly (5-15 days).

• Chronic Wounds: Prolonged healing (4-6 weeks+).

Wound Healing Processes:

• Primary Intention: Minimal loss, clean edges (surgical wounds).

• Secondary Intention: Significant tissue loss (e.g., pressure injuries).

• Third Intention: Delayed healing (e.g., infected wounds).

Wound Management Types:

• Various dressings such as transparent films, hydrocolloid, hydrogels, alginates, foams, antimicrobials, and collagens tailored to specific wound needs.

Pressure Injuries:

• Occur due to pressure or shear, common over bony areas.

• Categories: 1) Intact skin with redness; 2) Partial thickness loss; 3) Full thickness loss; 4) Extensive tissue loss exposing bone/muscle.

Pain Management:

• Pain is individualized; requires assessment and personalized management strategies, including both pharmacological and non-pharmacological options.

Documentation:

• Accurate records of location, size, appearance, exudate type, and pain levels are essential for wound management.

References:

• Donnelly, G., Domm, E. L., & Raisbeck, B. (2020). Fundamentals of Canadian Nursing.

• Potter, P. A., & Sawhney, M. (2020). Pain Assessment and Management.