University of the East

RAMON MAGSAYSAY MEMORIAL MEDICAL CENTER, INC.

64 Aurora Boulevard, Doña Imelda, Quezon City

COLLEGE OF NURSING

NCM 103: FUNDAMENTALS OF NURSING PRACTICE RLE

CASE STUDY: SKIN INTEGRITY

An elderly female was admitted to the hospital in the fall of 2010 with ischemic
bowel. Her Braden score was 18.

Comorbidities: Atrial fibrillation, coronary artery disease, anxiety and depression

Support surface on admission to hospital: Pressure redistribution mattress

Skin status on admission to hospital: Stage I coccyx PU

Continence status: Continent on admission; liquid diarrhea started on day 4 of the

hospital stay Surgery: Left hemicolectomy and right lower quadrant colostomy
performed on day 6

1. What other important information would you collect given this initial information?

- The subjective data of the patient such as patient health history and family
history.
- Inspection of the client’s stage I coccyx PU.
- History of coronary artery disease.
- Client’s depression

2. Give 3 priority nursing diagnosis for this patient. Rank and explain reasons for
prioritization.
 1. Risk for Impaired Skin Integrity.
- Post-op surgery and client’s bed sores.
2. Unpleasant sensory and emotional experience arising from actual or potential
tissue damage.
- Due to hemicolectomy and colostomy.
3. Deficient knowledge of the condition of the client.

- Absence or deficiency of cognitive information related to coronary artery

disease and ischemic bowel.

3. Create a nursing care plan for your top 1 nursing diagnosis.

Nursing Planning Intervention Rationale Evaluation

Diagnosis

After 6 hours Establish To build After the 3

Risk for after surgery, rapport. therapeutic hours of
Impaired Skin the nurse will relationships nursing
Integrity r/t to come back to Do proper with the client.interventions,
immobility inspect the handwashing the client will
abdominal skin and use clean To avoid maintain skin
AEB Post-op
of the patient, gloves. spreading integrity and
surgery in the record the microorganism demonstrate
client’s Left data and turn Inspect the s. behaviours/tec
hemicolectomy the patient to abdominal hniques to
and right lower avoid bed area of the To see if there promote
quadrant sores. patient for any are any healing/preven
colostomy possible infections seen t skin
infection. around the breakdown.
wound.
Record the
amount and Document the
type of wound data will help
drainage. the next nurse
to plan another
Regularly nursing
inspect diagnosis.
dressings and
reinforce them To avoid
if necessary. infection.

Proper wound Turning the

care as patient to
needed. different sides
to avoid bed
Perform hand sores and to
washing have a proper
before and body
after contact alignment.
with the
patient.
Assessment of
Assess the the condition
overall of the skin
condition of provides
the skin baseline data
for possible
Turn the interventions
patient to for the nursing
sides every 1 diagnosis. A
to 2 hours. healthy skin
Maintain the should have
patient’s good good turgor,
body feel warm and
alignment. dry to the
touch, be free
Teach the from
client and impairment
demonstrate (cuts, wounds,
how to do abrasions,
proper self- excoriation,
care and outbreaks, and
explain the rashes), and
wound healing have quick
process. capillary refill
(less than 6
seconds)
Use an
objective tool
for pressure
ulcer risk
assessment.