Nursingcrib.com Nursing Care Plan Impaired Skin Integrity 4j3725

Cues

Nursing Diagnosis

Subjective ◊ “Nagkapasa-pasa ako na maliliit, wala na ngayon may mga bakas na lan konte,” as verbalized.

◊ Impaired skin integrity r/t changes in the barrier function of the skin

Inference

Independent ◊ Vital signs monitored and recorded.

Dengue Virus Type I

◊ After 3 days of nursing intervention, proper skin hygiene and maintenance of skin integrity is demonstrated.

◊ Changes in vitals signs may indicate infection.

◊ Instructed proper hygiene and self-care as well in her surroundings.

◊ Proper hygiene will prevent infection and complication. A clean environment occurrence of any disease.

(Chikungunya Virus)

IgG adheres to the platelet

(initiates destruction of the platelet) Dependent thrombocytopenia

T= P= R= BP =

3

(50,000/mm or less)

°C bpm m mmHg

Rationale

Short Term Goal

◊ c non pitting bipedal edema ◊ V/S taken as follows:

Nursing Intervention

Aedes Aegypti

Objective ◊ c marks of petechial rash on the extremity

Objective

increased potential for hemorrhage

stimulates intense inflammatory response

petechial rash, high fever, headache

◊ istered prescribed meds such as ascorbic acid and furosemide.

◊ Vitamin C promotes wound healing and diuretics decreases renal vascular resistance and may increase renal blood flow.

Evaluation

◊ After 3 days of nursing intervention, the goal is met through demonstration of proper skin hygiene and compliance with treatment and medication.