Skin Health related to the Aging Adult
The nurse is assisting an older woman with dementia to dress for an outdoor picnic that will occur at the extended care facility. Which outfit is most appropriate for the event, while ensuring skin protection? 1. A dark long-sleeved shirt with a knee-length skirt and sun visor 2. A loose light-colored and lightweight dress with a wide-brimmed hat 3. A loose white t-shirt and denim pants with a baseball cap 4. A sleeveless tank top and light-colored shorts with a wide-brimmed hat
Answer 2: The nurse would encourage older adults to wear loose, lightweight, light-colored clothing and wide-brimmed hats to prevent exposure to the ultraviolet rays in sunlight that increase the risk for skin cancer.
An older patient has risk factors for developing a pressure injury. Which breakfast tray best represents the nutrients that the patient needs to maintain healthy tissue? 1. Coffee and orange juice with buttered toast and jam 2. Tea with milk and oatmeal with brown sugar and cinnamon 3. Orange juice, low-fat milk, soft-boiled egg, and cantaloupe 4. Biscuits and gravy and strawberries with cream
Answer 3: The nurse would encourage foods that contain high-quality protein, vitamin C, and vitamin A to support healthy tissues.
The nurse is supervising a new UAP who is learning to perform hygienic care for older patients. In which circumstance would the nurse intervene? 1. UAP brushes the patient's dentures over a basin of warm water 2. UAP places a clean turning sheet underneath an immobile patient 3. UAP cuts the toenails straight across for an older diabetic patient 4. UAP cleans and dries the skin of a patient after urinary incontinence
Answer 3: The nurse would remind the UAP that for patients with diabetes or circulatory problems, foot care is performed by a foot care specialist
The nurse is discharging an older adult to home after hospitalization for cellulitis of the right foot, followed by an infection. After reviewing discharge instructions, what statement by the client indicates the need for further teaching by the nurse? a. "I will take the antibiotics until the redness goes away and my foot feels better." b. "I will eat lots of fruit and vegetables and take vitamin C to help this heal." c. "I will be sure to wear shoes to protect my feet when I go out to get the mail." d. "I will manage my pain by putting this foot up on a pillow when it hurts."
Answer: A It is important for the client to understand the need to complete the entire course of oral antibiotics as prescribed in order to prevent recurrence/worsening of cellulitis. Further, if the pain and redness continue despite antibiotics, the client needs to understand the need to follow-up with the health care provider. Extra vitamin C, protective footwear, and elevating the foot are strategies to promote healing.
The nurse is assessing an older adult's skin. The assessment will involve inspecting the skin for color, pigmentation, and vascularity. What should the nurse assess? a. similarities from one side to the other b. changes from the normal expected findings c. appearance of age-related wrinkles d. skin turgor
Answer: B Noting changes from the normal expected findings is the most important component when assessing an older client's integumentary system. Comparing one extremity with the contralateral extremity (i.e., comparing one side with the other) is an important assessment step; however, the most important component is noting changes from an expected normal baseline. Noting wrinkles related to age is not of much consequence unless the client is admitted for cosmetic surgery to reduce the appearance of age-related wrinkling. Noting skin turgor is an assessment of fluid status, not an assessment of the integumentary system.
The nurse is assessing a group of older adults. Which client is at greatest risk for skin breakdown? A person who has: a. altered balance. b. reduced sensation of pressure. c. impaired hearing ability. d. impaired visual acuity.
Answer: B Pressure ulcers usually occur over bony prominences. An alteration in the protective pressure sensation results from a decline in the number of Meissner's and Pacinian corpuscles. Older adults do have altered balance that may result in falls but not skin breakdown. Impaired hearing and vision do not contribute to pressure ulcers.
An older adult has several ecchymotic areas on the left arm. What should the nurse further assess? Select all that apply. a. increased blood supply to the skin b. shingles c. elder abuse d. self-inflicted injury e. increased capillary fragility and permeability
Answer: C, D, E The nurse should always an assess an older adult who has signs of bruising (ecchymosis) for signs of abuse, self-inflicted injuries, or injuries that might have occurred from falls. Also, the aging process involves increased capillary fragility and permeability, and because older adults have a decreased amount of subcutaneous fat, it is also likely that there is an increased incidence of bruise-like lesions caused by collection of extravascular blood in the loosely structured dermis. In addition, older clients do not always realize that injury has occurred because of a diminished awareness of pain, touch, and peripheral vibration. Blood supply to the skin decreases with aging, and thus is not a cause of the ecchymotic areas. Shingles presents as a red rash and fluid-filled blisters.
Nurse's Notes: Client awake and alert, oriented x 4. Client states there is pain in surgical wound and refuses to move in the bed due to pain. Pain described as continuous, stabbing, 10/10 on severity. States no urge to void at present, no bladder distention noted on palpation. Dressing to wound clean, dry and intact. Requests a blanket and states, "I have been cold this morning." --------- The nurse reviews the above nurse's note of an older adult client and implements which intervention to help with the maintenance of skin integrity? a. Apply a warm blanket after checking the client's temperature. b. Change the surgical dressing. c. Administer the ordered pain medication. d. Turn the client to the left side using assistive devices.
Answer: C. The client needs to be encouraged to assist with turning once pain medication is administered. While the client could be turned first, having the pain medication will make it more likely that the client will be successful with movement. Providing a blanket will help with comfort, but is not related to the maintenance of skin integrity. While the surgical dressing would be changed daily and as needed, it would not be more important to the maintenance of skin integrity since there is no indication of a need for this as a priority with the dressing being clean and dry.
The nurse is planning the order of client assessments at the beginning of the shift based on the risk for skin breakdown each client presents. The nurse should assess the clients in which order? All options must be used. a. a client with sickle cell disease who is reporting pain b. an older adult client with a diagnosis of left hip fracture c. a client with diverticulitis who is occasionally incontinent d. a paraplegic client admitted with dehydration and ordered bedrest
Answer: D, B, C, A The client who is paraplegic with dehydration and on bedrest should be seen first. They have the most risk factors for skin breakdown because of limited motion and is ordered bedrest. The next priority is the older adult client with a hip fracture because they will require help with mobility and have risk factors due to mobility and age. The client with occasional incontinence has a risk factor due to wetness and how long the wet garment remains on, and should be seen 3rd. While the client with sickle cell disease is in pain which may affect mobility, there are no other factors that would indicate a risk for skin breakdown, making them the lowest priority based on risk for skin breakdown.
A nurse is caring for an older adult with shingles. The client is experiencing considerable pain related to open blisters on the client's abdomen and back. The client is taking acyclovir and low dose prednisone. The nurse has several prescriptions available. What additional medications or nursing care strategies to promote comfort may be helpful? Select all that apply. a. diphenhydramine 25 mg by mouth every 6 hours PRN b. calamine lotion applied to the affected areas c. warm, dry compresses to the affected areas d. acetaminophen 325 mg by mouth every 6 hours PRN e. ondansetron 4 mg by mouth every 4 hours PRN f. diversionary activities to prevent client scratching
Answer: a, b, d, f Diphenhydramine is an antihistamine that reduces allergic reactions, calamine lotion is a topical antipruritic, and acetaminophen is an analgesic. These medications may help increase client comfort by reducing pain, inflammation, and itching, which, in turn, may reduce client scratching and potentially spreading the virus. Cool wet compresses, not warm, dry compresses, relieve itching and pain. Ondansetron is an antiemetic and would not be helpful for this client's discomfort.
The nurse is planning care for an older adult with a Stage II pressure ulcer. What should the nurse do? Select all that apply. a. Elevate the head of the bed to 50 degrees. b. Obtain daily cultures. c. Cover with protective dressing. d. Reposition the client every 2 hours. e. Request an alternating-pressure mattress.
Answers: C, D, E The client has a stage II pressure ulcer. The nurse should take measures to relieve the pressure and protect the wound. The nurse should keep the ulcer covered with a protective dressing. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria, and obtaining frequent cultures (unless prescribed otherwise) is not necessary.
The nurse is assessing the skin of an older adult client. Which finding requires intervention? a. cherry angioma on arm b. brown patches on face c. large freckles on the hands d. an elevated irregularly shaped mole
Answer: D A mole that is elevated and irregularly shaped should be evaluated because it could be a cancerous growth. A cherry angioma and brown patches on the skin are age-related changes to the skin. Freckles on the hands can be identified as liver spots and are considered an age-related change to the skin.
Which patients have risk factors that place them at greater risk for pressure injuries? (Select all that apply.) 1. Patient who has Alzheimer disease and tends to wander in halls 2. Patient who has type 2 diabetes mellitus and is obese and bedridden 3. Patient who is underweight with left hemiplegia and poor appetite 4. Patient who is thin and frail and recently sustained a hip fracture 5. Patient who is comatose and incontinent of bowels and bladder
Answers 2, 3, 4, 5: Pressure ulcers are a particular risk to older adults who suffer from compromised circulation, restricted mobility, altered level of consciousness, fecal or urinary incontinence, or nutritional problems
What is the most appropriate nursing diagnosis for an older adult who is bedridden because of progressed Parkinson disease? 1. Risk for impaired skin integrity related to immobility 2. Immobility related to Parkinson disease 3. Impaired skin integrity related to incontinence 4. Ischemia related to disuse syndrome
Correct answer: 1 Restricted mobility, such as being bedridden due to progressed Parkinson disease, is a factor that can contribute to the development of pressure ulcers. Therefore, Risk for Impaired Skin Integrity related to Immobility would be the most appropriate nursing diagnosis.
Family members are caring for their aging mother at home. Which statement by the daughter indicates the need for further teaching? 1. "I change Mom's diaper whenever it is really wet." 2. "I make sure Mom eats good meals and extra snacks." 3. "We try to change Mom's position at least every two hours." 4. "I try to use lotion on Mom's skin every morning and evening."
Correct answer: 1 Urine and stool contain waste products that are highly irritating to the skin and must be cleansed promptly with gentle washing and rinsing.
A 71-year-old immobile patient has been in his wheelchair for 2 hours. When repositioning him, the nurse observes a reddened area at the base of the buttocks. How would this observation be best documented? 1. Stage 2 at greater trochanter 2. Stage 1 at ischial tuberosity 3. Stage 1 on iliac crest 4. Stage 0 on posterior superior iliac spine
Correct answer: 2 Pressure ulcers are categorized or staged on the basis of their appearance and the depth of tissue penetration. Early danger signs indicating a risk for breakdown include pale or reddened tissue. In stage I the skin remains intact but is reddened. The base of the buttocks is considered the ischial tuberosity.
The nurse is caring for a comatose older adult with stage 3 pressure injuries over two bony prominences. Which intervention should be added to the plan of care? a. Place lamb's wool under the lift sheet. b. Place the client on a pressure redistribution bed. c. Turn the client every 2 to 4 hours. d. Use an egg crate mattress.
Answer: B. A pressure redistribution bed will allow for constant motion of the client and prevent further breakdown. Lambs' wool may trap heat and exacerbate skin breakdown. Turning should be at a minimum of every 2 hours. Egg crate has not been proven to be effective to prevent the development of pressure injuries and should not be used.
In helping the RN perform an admission and assessment of a new patient, you mutually recognize this patient is at risk for skin tears. Which of the following would be appropriate to include in the care plan? 1. Apply lotion after the daily bath to moisten the skin. 2. Dress patient in short sleeves to allow for better visualization of skin. 3. Apply steri-strips if a skin tear appears. 4. Move and position the patient gently and carefully.
Correct answer: 4 An older adult who is prone to skin tears must be handled carefully and gently. Bathing every day is too often, and can dry out the skin. Application of lotion to keep moisture in the skin is best done twice a day. Long sleeves and trousers, as well as knee-high socks, can protect skin that is prone to tearing. Steri strips should not be used on delicate skin, as further tears can result.
An older female patient complains that her skin feels dry and itchy. What advice should the nurse offer? 1. Advise her not to scratch, and trim her nails so she is less likely to break the skin and get an infection. 2. Suggest that she drink more fluids, use cool water when bathing, and wear cotton clothing only. 3. Direct her to ask her primary care provider for an antihistamine prescription to decrease the itching. 4. Suggest that she bathe less often, use soap sparingly, and apply a skin emollient after each bath.
Correct answer: 4 Dry skin is one of the most common problems of aging. Nursing interventions to decrease the discomfort of dry skin include encouraging reduction of the frequency of baths or showers; use of mild nondetergent soaps; and use of emollients, lotions, creams, and oils to maintain skin moisture.
