SKIN INTEGRITY,

SLEEP AND REST,

PAIN AND
COMFORT
FUNDAMENTALS OF NURSING
PRACTICE

SKIN INTEGRITY, SLEEP AND REST, PAIN AND COMFORT

SKIN INTEGRITY
 The skin is the body’s largest organ and the primary defense against pathogenic invasion.
 The skin also contributes to temperature regulation, prevents loss of internal fluids, and
provides sensory awareness.
 The appearance of skin and skin integrity are influenced by:
-Internal factors (genetics, age and status of person’s health, malnutrition)
-External (activity, sun and medications as AB and chemotherapy, corticosteroids)

Impaired skin integrity

-a disruption in the permeability or continuity of one or more components of the integumentary system,
which may result in harmful levels of external factors such as bacteria, heat, chemicals, and moisture
coming into contact with body tissues.

Causes of impaired Skin Integrity

 Infection: Bacteria can enter the body through broken skin: this is more common if there are
open wounds.
 Poor Skin Care: This may happen when the patient does not wash regularly or often, use soap
that is too harsh, or over-use moisturizers that clog up pores.
 Pressure and Friction: This occurs due to touching poisonous plants or exposure to chemicals
such as detergents, cleaning products, over-the-counter medications, and essential oils.
 Injury: This may occur from an accident, such as burn or being bitten by an insect.
  Other Causes: Pressure ulcers, urinary incontinence, or dermatitis.
 Unknown: The cause of the injury is unknown and may be due to surgery, radiation therapy,
excessive exposure to sunlight or certain medications.

Risk Factors for Impaired Skin Integrity

1. Age: Older adults are more prone to skin damage as their skin becomes thinner and more
fragile.

2. Illness: This may be acute illness such as influenza or a chronic disease such as AIDS, multiple
sclerosis or diabetes mellitus; these individuals are more at risk for infection and have difficulty
healing wounds.
3. Immunocompromised Patient: These include patients undergoing organ transplantation,
chemotherapy, or prolonged steroid use; these individuals are more prone to infections, and
their immune system is weakened.
4. Lack of mobility: Patients who use wheelchairs to get around are more prone to pressure sores.
5. Poor Nutrition: Malnourished patients may have a poor immune response and reduced cell
growth, affecting how well they heal or repair wounds.
6. Decreased mental status: Individuals with a reduced level of awareness, for example those who
are unconscious, heavily sedated or have dementia, are at risk for pressure ulcer because they
are less able to recognise and respond to pain associated with prolonged pressure.

Possible Skin Integrity Problems

 Pressure ulcer (bedsore, pressure sore, decubitus ulcer): consist of injury to the skin and
or underlying tissue, usually over a bony prominence, as a result of force alone in
combination with movement.
 Wounds: an injury to the skin can be intentional or unintentional; classified as:
-closed
-open
-acute
-chronic

 Rashes

Signs and Symptoms for Impaired Skin Integrity

Skin discoloration
Purulent discharge from the wound
Edema and swelling
Foul smelling odor
Warm, tender, painful and inflamed skin
Moisture loss, itching

Nursing Assessment
1. Assess the site of impaired tissue integrity and its condition including presence of fracture.
2. Inspect the wound for bleeding and inspect for the presence of foreign bodies.
3. Assess characteristics of the wound, including colour, size (length, width, depth), drainage, and
odor. Include assessing the level of pain and presence of edema.
4. Assess changes in body temperature, specifically increased body temperature.
5. Evaluate the patient’s strength to move (e.g., shift weight while sitting, turn over in bed, move
from bed to chair).
6. Monitor for proper placement of tubes, catheters, and other devices. Assess skin and tissue
affected by the tape that secures these devices.
7. Assess patient’s nutritional status; refer for a nutritional consultation.
8. Assess for fecal/urinary incontinence.
 9. Assess the surface that the patient consumes most of his/her time on (e.g., mattress for
bedridden patient. Cushion for people in wheelchairs).
10. Monitor the status of the skin around the wound. Monitor patient’s skin care practices, noting
the type of soap or other cleansing agents used, the temperature of the water, frequency of skin
cleansing and assess for exposure to chemical irritants.

Nursing Interventions
1. Assess the skin for any changes in color, temperature, moisture loss or evidence of inflammation
which are all early warning signs that there is a problem with impaired skin integrity; this would
require an immediate response by the nurse, who will then consult the physician.
2. Maintain cleanliness of the skin by washing it frequently with warm soapy water; pat or blot the
skin dry with a clean linen towel; do not rub the area.
3. Apply protective skin lotions or creams to protect the individual from external and internal
factors; this may include an antimicrobial lotion if there is drainage from ulceration.
4. Assist the patient to avoid any factors which may cause further breakdown of the skin such as
friction, pressure or shearing; this includes ensuring that shoes fit properly and there is no
excess rubbing against the skin from their clothing.
5. Promote the importance of healthy lifestyle for patients with impaired skin integrity by
encouraging them to maintain adequate nutrition, hydration and engage in regular activities.
This includes observing proper hygiene practices and changing of bedsheets twice a week.
6. Provide education to patients and family members on protecting the individual from further
impairment of their skin integrity

Which nursing intervention should be applied to a client with a nursing diagnosis of risk for skin
integrity impairment related to immobility?
 Provide patients with regular turning such as semi-recumbent position, semi-reclining position
and others that may promote patient mobility or prevent swelling from occurring.
 Ensure that the patient receive adequate nutrition and hydration and have access to regular
exercise like the passive range of motion. This is to increase their mobility and prevent further
breakdown of the skin integrity.

IN ASSESSING THE SKIN INTEGRITY, WE NEED TO CONSIDER THE FF;

•healthy skin should have good turgor (an indication of moisture)
•warm and dry to touch
•free from impairment (cuts, wounds, rashes, abrasions, etc)
•have capillary refill (less than 6 seconds)
Other consideration includes;
*Age
*weight loss
*Poor nutrition and hydration
*Excessive moisture and dryness
*Smoking
*And other conditions affecting blood Flow

SLEEP AND REST

REST
-a condition in which the body is in a decreased state of inactivity, with the consequent of being
refreshed
SLEEP
-state of rest accompanied by altered consciousness and relatively inactivity
-Complex rhythmic state involving a progression of repeated cycles, each representing different
phases of the body and brain activity
-External stimuli is diminished
THINGS NEEDED TO BE ASSESSED DURING SLEEP
 SKELETAL MUSCLE ACTIVITY
 BRAIN WAVES
 BLOOD OXYGEN LEVEL
 HEART RATE
 BREATHING RATE
 EYE MOVEMENT
 HOURS OF SLEEP
 QUALITY OF SLEEP
 TIME OF SLEEP/WAKING

POLYSOMNOGRAPHY
-a type of sleep study which includes at least 3 independent tests that monitor different
body functions during sleep.
 EEG (ELECTROENCEPHALOGRAM(
-Measures and records the brainwave activity
 EOG (ELECTROOCULOGRAM)
-records eye movement.
 EMG (ELECTROMYOGRAM)
-records muscle activity
PHYSIOLOGY OF SLEEP
RETICULAR ACTIVATING SYSTEM (RAS) AND BULBAR SYNCHRONIZING REGION
-Work together to control the cyclic nature of sleep
RAS
-Facilitates reflex and voluntary movements as well as cortical activities related to a state of
alertness
-Wakefulness occurs when this system is activated
HYPOTHALAMUS
-Has control centers for involuntary activities (sleeping and waking)
CIRCADIAN RHYTHMS
 Completes a full cycle every 24 hours
 Physical, mental, and behavioral changes that follow a 24-hour cycle
 Circa in Latin means “approximately” diem means “day”
STAGES OF SLEEP
 NREM (NON-RAPID EYE MOVEMENT ) SLEEP

• Consists of 4 stages
• Stages 1 and 2, consuming 5% and 50% of person’s sleep time, are light
sleep. Person can easily aroused
• Stages 3 and 4, 10% of total sleep time, deep-sleep states, (delta or slow-
wave sleep). Arousal threshold is usually greatest in stage 4
• Parasympathetic nervous system dominates
• Decrease in pulse, RR, BP, MR, body temperature occurs.
 REM (RAPID EYE MOVEMENT) SLEEP

• More difficult to arouse a person. Consumes 20%-25% of sleep.

• Eyes dart back and forth quickly, BP increases, irregular pulse, increase in
gastric secretions
SLEEP CYCLE, REQUIREMENTS, AND PATTERNS
 Most people go through 4-5 cycles of sleep each night. It lasts about 90-100 min each.
 Infants- 14-20 hours
 Toddlers- 12-18 hours
 Preschoolers- 9-26 hours
 School-aged children-10-12 hours
 Adolescents- middle-aged adults- 7-9 hours
 Older adults- 5-7 hours

FACTORS AFFECTING SLEEP

 DEVELOPMENTAL CONSIDERATIONS
 PSYCHOLOGICAL STRESS
 MOTIVATION
 CULTURE
 LIFESTYLE AND HABITS
 PHYSICAL ACTIVITY AND EXERCISE
 DIETARY HABITS
 ENVIRONMENTAL FACTORS
  ILLNESS
 MEDICATIONS

COMMON SLEEP DISORDERS

DYSSOMNIAS
 INSOMNIA- difficulty falling sleep, intermittent sleep, early awakening from sleep
 Causes: old age, women, person with history of depression, stress, jetlag, results
of medication, misuse of alcohol or caffeine
 Interventions: sedative or hypnotics (pharmacologic), stimulus control, sleep
restriction, sleep hygiene, cognitive therapy, multicomponent therapy, relaxation
therapy
 HYPERSOMNIA- excessive sleeping during the day
 Causes: medical condition, coping mechanism in someone who has no desire to
face a new day
NARCOLEPSY
• Condition characterized by an uncontrollable desire to sleep
• Very easy to sleep
• COMMON FEATURES OF NARCOLEPSY
• Sleep attacks
• Cataplexy
• Hypnagogic hallucinations
• Sleep-onset REM periods
• Sleep paralysis
• INTERVENTION- central nervous system stimulant(Ritalin)
SLEEP APNEA
• condition in which the patient experiences the absence of breathing
between snoring intervals
• Breathing may cease for 10-20 seconds , as long as 2 minutes
• Oxygen level in the blood drops, PR becomes irregular, BP increases
• CAUSES: obesity, short thick necks
• EFFECTS: irritable during the day, fell asleep during monotonous
activities, difficulty concentrating, exhibit slower reaction times
 INTERVENTIONS: removing of tonsils, using an oral appliance when sleeping,
CPAP (continuous positive airway pressure)

RESTLESS LEG SYNDROME

• Neurological disorder that causes unpleasant or uncomfortable sensations in the
legs and an irresistible urge to move them
• INTERVENTIONS:
  Massage
 walking
 Doing knee bends
 Moving the legs
 Eliminate use of caffeine, tobacco, and alcohol
 Take a medical analgesic at bedtime
 Use antiembolism stockings at the onset of symptoms
SLEEP DEPRIVIATION
• Refers to the decrease amount, consistency, or quality of sleep
• EFFECTS: loss of concentration, inattention, impaired information processing,
pose serious safety risks, excessive daytime sleepiness,
• CAUSES: Strange environment, physical discomfort, pain, effects of medication,
the need for 24-hour nursing care
PARASOMNIAS
• Patterns of waking behavior that appear during sleep
• EXAMPLES:
• Somnambulism- sleepwalking
• Sleep talking
• Nocturnal erections
• bruxism- grinding of teeth
• Enuresis-urinating during sleep
• Sleep eating disorder
 ASSESSMENT

• Subjective -verbalized by the patient

• Objective -observed by the healthcare provider, laboratory tests
FACTORS TO ASSESS
 Usual sleep-wakefulness pattern
 Recent changes
 Usual sleeping and waking times
 Numbers of hours of undisturbed sleep
 Quality of sleep
 Number of promotion of naps
 Effect of sleep pattern on everyday functioning
 Energy level (ability to perform activities of daily living)
POSSIBLE PROBLEMS
 • INSOMNIA
• NARCOLEPSY
• RESTLESS LEG SYNDROME
• SLEEP APNEA

INTERVENTIONS
 PREVENTION
 Minimize light and noise
 Get regular exercises
 Keep a regular sleep schedule
 Manage temperature
 MANAGEMENT
 Introduce relaxing activities
DOCUMENTATION
 Act or recording the client’s assessment findings
 Acts as a source of information to help diagnose problems
 Offers a basis for determining the educational needs of the client and family
NURSING CONSIDERATION
 Assess the patient sleeping pattern and help him develop a sleeping plan
 Educate the patient on the proper fluid intake
 Assist with hygienic routines
 Providing loose-fitting nightwear
 Encouraging voiding before sleeping
 Making sure bed linen is smooth, clean, and dry

PAIN AND COMFORT

PAIN
• Unpleasant signal that something hurts
• Warning that something is not right on a person’s body
• Can be prickling, tingling, stinging, burning, shooting, aching, or electric
sensation
• Often debilitating symptoms of many diseases
• TYPES OF PAIN: Acute, chronic, cancer, intractable
FACTORS AFFECTING PAIN
 1. BIOLOGICAL FACTORS- age, existing medical conditions, medications, genetics
2. SOCIAL FACTORS- cultural belief, social support
3. PSYCHOLOGICAL FACTORS- stress, coping mechanism, mood and expectations
SIGNS AND SYMPTOMS OF PAIN
 Verbal reports
 Expressions of pain such as crying
 Significant changes in vital signs
 Appetite or eating patterns
 Changes in sleep patterns
 Guarding behavior
PAIN ASSESSMENT
 Broad concept involving clinical judgment basing on observation of the type, significance
and context of the individuals pain experience
POINTS TO CONSIDER IN PAIN ASSESSMENT
 Pain history
 Location of pain
 Intensity of pain
 Cognitive development and understanding pain
 Pain measurement

3 WAYS ON MEASURING PAIN

1. Self-report- what the patient says
2. Behavioral-how the child behaves
3. Physiological-clinical observations

PAIN ASSESSMENT TOOLS

A. FLACC (FACE, LEGS, ACTIVITY, CRY, AND CONSOLABILITY)- Behavioural
B. WRONG-BAKER FACES PAIN SCALE- self-report, 8years and older
C. CRIES SCALE- six months old and younger
D. NUMERICAL RATING PAIN SCALE- over 9 years old
DIAGNOSING PAIN
APPROACHES AND TECHNIQUES TO HELP IDENTIFY THE CAUSE OF PAIN
 Musculoskeletal and neurological examination
 Laboratory tests
 Electro-diagnostic test procedures
  Imaging
 Psychological status
 X-rays
PAIN MANAGEMENT
 Heat or cold treatments
 Physical therapies
 Massage
 Meditation and Yoga
 Cognitive behavior therapy
 Acupuncture
 Paracetamol
 Aspirin
 NSAID’s
PAIN MAANGEMENT STRATEGIES:
 1. Distraction - focuses the client's attention on something other than the pain and
associated negative emotions.
 2. Reframing- teaches client's to monitor their negative thoughts and replace them with
ones that are more positive.
 3. Relaxation technique- used to decrease anxiety and muscle tension
 4. Biofeedback- process through which an individual learn to influence their
psychological response.
 5. Cutaneous stimulation- techniques believed to activate the endogenous opioid and
mona amine analgesia systems. To decrease swelling etc.
NURSING CONSIDERATIONS ADDITION:
 1. Listen to the client's description of pain and to honour patient's rights to receive
appropriate pain management for acute and chronic pain.
 2. Use of the nursing art of therapeutic communication and trust.
 3. Establishment of a therapeutic relationship for effective nursing care of the client
PHARAMACOLOGIC PAIN MANAGEMENT:
 1. Overview of drug management
 2. Addiction, dependence and tolerance
 3. Respiratory depression
 4. Communicating with health care providers about pain
 5. Controlling accompanying symptoms (constipation, nausea etc.)

NONPHARMACOLOGIC PAIN MANAGEMENT

 Importance of strategies
 review of past experience with nonpharmacologic methods
 demonstration of specific techniques
 Deep breathing exercises to help in controlling the pain
 Positioning -put the patient in a comfortable position
 Rub the back If the patient is experiencing labour pain

COMFORT
-According to the MERRIAM-WEBSTER (2010) dictionary comfort means “to give strength and
hope to”, therefore all humans crave for comfort both physically and mentally.
- Comfort is the state of relief from distress or the state of ease and peaceful
contentment or anything that brings pleasure to life that does not cause pain or sorrow
NURSING CONCEPT
The concept of comfort care refers to a patient care plan that emphasizes symptom
control, pain relief, and quality of life. It is usually given to patients who have been in
hospitals several times, and further medical treatment is unlikely to make a difference.

ASSESSMENT
Nursing Assessment
-Individual findings including client's description of current status/situation and factors
impacting sense of comfort.
-Medication use/ nonpharmacological measures
Nursing Assessment
Assess several factors that may cause discomfort and obtain a baseline in each of them.
Subjective Data: patient’s feelings, perceptions, and concerns. (Symptoms)
Objective Data: assessment, diagnostic tests, and lab values. (Signs)
NURSING ASSESSMENT FOR IMPAIRED COMFORT
1. Assess physical causes of discomfort.
2. Assess pain level.
3. Assess for mental or emotional feelings of discomfort.
4. Ask the patient about their comfort goals

NURSING INTERVENTIONS
 Establish a trusting relationship with the patient.
 Building trust can help facilitate treatment plans, and it is more likely for the patient to
express his or her concerns to healthcare staff.
 Make environmental changes to improve the patient’s comfort.
 Using a white noise machine
 Decreasing environmental stimuli such as noisy television
 Adjusting lighting in the room
 Reducing frequent visits from family members
 Offering earplugs and eye mask
 Adjusting the temperature in the room
•Offer hygiene care or items to clean themselves.
•Offer relaxation and calming techniques.
•Administer medications to ease discomfort.
SIGNS AND SYMPTOMS (AS EVIDENCED BY)
1. Subjective: (Patient reports)
 Verbalizes pain, exhaustion, or general unwellness
 Expresses feeling stressed or worried
 Expresses concern about their health or a procedure
 Verbalizes a sense of unease surrounding finances, faith, or support systems

2. Objective: (Nurse assesses)

 Signs of pain: grimacing, guarding, moaning, diaphoresis
 Irritability or restlessness
 State of panic or anxiety
 Rapid breathing
 Increased heart rate