Jarel Duran Elexer C.

Ano 7 y/o

Carl July 8 2008

ASSESSMENT S>Ø O> the pt. manifested the ff.   Dry skin Observed scratching his scabs

NURSING DIAGNOSIS Risk for Impaired skin integrity r/t dry skin and behaviors that may lead to skin integrity impairment AEB scratching of scabs

SCIENTIFIC EXPLANATION Skin is the primary defense of the body; it protects the body against infections and dses brought about by the invasion of microbes in the body. A normal skin is moist and intact; dryness of the skin is more prone to friction that may result to impairment of the skin integrity as compared with a moist skin.

PLANNING Short term: After 2-4° of NI, the client and the SO will be able to verbalize understanding of individual factors that contribute to possibility of skin integrity impairment and takes steps to correct the situation. Long term: After 1- 3 days of NI the client will be able to demonstrate behaviors to prevent skin breakdown.

INTERVENTIONS >Establish rapport >Monitor VS. >Note age and sex >Assess mood, abilities, and personal styles. >Provide health teachings regarding the importance of maintaining an intact and moist skin. >Teach the SO to give the client a balance, and nutritious food especially foods rich in Iron and vitamin C >Instruct the SO to give multivitamins to the client e.g. Growvit.

RATIONALE >To gain the client and SO’s trust. >To obtain data for comparison. >to evaluate degree/source of risk inherent in the individual situation. >to evaluate pt.’s attitude which may contribute to skin breakdown. >To increase the SO’s knowledge thus, prevention of skin breakdown is realized and taken into consideration by the SO. > To improve clients immune system. >To pharmacologically improve client’s immune system.

EXPECTED OUTCOME The client and the SO shall have verbalized understanding of individual factors that contribute to possibility of skin integrity impairment and takes steps to correct the situation. The client shall have demonstrated behaviors to prevent skin breakdown.

Intractable Vomiting with some signs of DHN

 

Risk for Impaired skin integrity r/t abnormal blood profile 2° DHF Risk for Imbalanced Fluid Volume r/t susceptibility to bleeding 2° DHF