UNIVERSITY OF LUZON

COLLEGE OF NURSING
Name _Jake Yvan Dizon______________________

Activity 1 – Short Answer Questions

1. What is the long term effects of ultraviolet light (sunlight) on the skin?
- It causes skin cells to age causing them to loose elasticity and
wrinkly

2. Observations/ normal changes in the skin with aging considered to be

evidence of advancing age includes:
Wrinkled skin Patches in the skin
___________________________ _________________________
Sogging skin Dry skin
___________________________ _________________________
Easily Damaged Increased fragility
___________________________ _________________________

Activity 2 CASE SCENARIO

An 87 year old woman with history of stroke 1 month ago admitted to

nursing facility from acute care hospital. On assessment client responds to touch and
voice by opening eyes, no verbal response. Right hemiplegia. Incontinent.
Percutaneous Endoscopic Gastrostomy (PEG) tube in place. Height estimated at 5 ft 3
inches. Weight before stroke was 123 lbs. In bed most of the day. Transferred to chair
for 2 hours three times a day. Skin is dry and thin. Purpura on forearms, skin tear in left
wrist with edges approximated with Steri-Strips. Stage 2 pressure ulcer on coccyx, 4
cm in diameter deep, base dark pink. No tunnelling. Serosangenous drainage, no odor.
Stage 1 pressure ulcer on left scapula.

Questions: Make a nursing care plan

1. What is your nursing diagnosis?

2. What is your nursing goal?
3. Suggested major interventions? Give at least 3 interventions.
4. Evaluation parameters?
 Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis
Objective Impaired Short term -Assess the -responses to
Data: skin goal skin, note interventions
-Dry and Thin integrity the and teaching
-Purpura on related to After 6-8 hrs color,turgor -to establish plan and
forearms pressure of nursing and comparative baseline actions
-Skin tear on ulcer intervention sensation. providing opportunity performed
left wrist secondary client will: Describe for timely intervention
- Presence of to and -patient have
level 2 ulcer prolonged -Have measure reduced the
pressure on immobility reduced risk wounds and risk for skin
coccyx and for impaired observed integrity and is
approximately unrelieved skin integrity changes -improve nutrition able to
4cm and level pressure - Patient’s and hydration will demonstrate
1 pressure caregiver will -Emphasize improve skin understanding
ulcer on the demonstrate importance conditions and skill in
left scapula understanding of adequate wound healing
and skill in nutrition and
care of wound fluid intake -Goals
partially met
Long term -wound dressing
goal protect the wound -Modifications
-Reduce risk -Provided and the surrounding of plan of care
of infection and applied tissues
-Ulcer will wound
regain skin dressing
integrity carefully

-to disperse pressure

over time or
-Increase decreasing the tissue
the load
frequency of
turning the
position of
the patient to
stay off the -to prevent
ulcer. contamination/sprea
d of infection
-Prevent the
ulcer from
being
exposed to
feces and
use topical
creams
ointments or
dressings