UNIVERSITY OF LUZON

COLLEGE OF NURSING
Name ________________________________

Activity 1 – Short Answer Questions

1. What is the long term effects of ultraviolet light (sunlight) on the skin?

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

evidence of advancing age includes:

___________________________ _________________________

___________________________ _________________________

___________________________ _________________________

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?

IMPAIRED SKIN INTEGRITY RELATED TO IMMOBILITY

2. What is your nursing goal?

Patient Skin Integrity is restored as evidenced by healed ulcers on coccyx and
scapula
3. Suggested major interventions?
Pressure ulcer care, Pressure ulcer prevention, Wound care

Give nursing interventions.

 Document skin status on admission and daily
 use an established risk assessment tool to monitor individual risk factors
 Monitor for sources of pressure and friction
 Inspect skin over bony prominences and other pressure ponts when
repositioning at least daily
 monitor any reddened areas closely
 turn every 1 to 2 hours, position with pillows to elevate pressure points off bed
 post turning schedule at bedside
 turn with care (avoid shearing) to prevent injury to fragile skin
 avoid hot water and use mild soap when bathing
 remove excessive moisture on the skin resulting from perspiration, fecal or
urinary incontinence
 apply protective barriers such as creams or moisture asorbing pads to
remove excess moisture as appropriate
 moisturize dry unbroken skin
 apply elbow and heel protectors as appropriate
 use specialty bed and mattress, use sheepskin on bed as appropriate
 describe characteristics of ulcer at regular intervals including size, width,
stage, location, exudates, necrotic tissue
 monitor color, temp, edema, moisture, appearance of surrounding skin
 cleanse the ulcer w/ nontoxic soln in circular motion from the center, apply
dressing as prescribed, cleanse the skin around the ulcer w/ mild soap and
water
 monitor signs and symptoms of infection in the wound
 monitor nutritional status in collaboration with dietitian

4. Evaluation parameters?
 Absence of purulent drainage from ulcer
 decreased size of pressure ulcer
 absence of redness over left scapula and other bony prominences