CUES

NURSING DIAGNOSIS

PLAN OF CARE

Subjective: Sobrang kati ng balat as verbalized the patient. Objective: - skin rashes - edema - swelling - redness - lesion - presence of pus

Impaired skin After 4 hours of integrity r/t illness nursing intervention, the client will able to display timely healing of skin rashes, edema, swelling, redness, lesion, presence of pus without complication

INTERVENTION/ IMPLEMENTATI ON - Monitor vital signs and record it. - Note presence of compromised vision, hearing, or speech - Periodically remeasure/ photograph wound observe for complications - Keep the area clean/dry, carefully dress wounds, prevent infection - Apply appropriate dressing - Provide good nutrition including vitamins

RATIONALE

EAVALUATION

- To have baseline data - When compromised may affect responses - To monitor progress of wound healing

The goal was met. The client was able to displayed timely healing of skin rashes, edema, swelling, redness, lesion, presence of pus without complication

- To assist bodys natural process of repair - For wound healing - To provide a positive nitrogen balance to aid in skin/tissue healing - To prevent infection

- Administer medication, as ordered

CUES

NURSING DIAGNOSIS Impaired oral mucous membrane r/t dehydration

PLAN OF CARE

INTERVENTION/ IMPLEMENTATI ON - Monitor vital signs and record it - Note presence of illness/disease/trau ma - Encourage adequate fluids

RATIONALE

EAVALUATION

Subjective: Masakit ang aking lalamunan kapag lumulunok ako as verbalized by the patient. Objective: - bleeding - oral lesions - fissures - edema - irritated - excessive vomiting

After 4 hours of nursing intervention, the client will able to restore/maintain integrity of oral mucosa

- To have baseline data - That affect oral health

The goal was met. The client was able to restored/maintained integrity of oral mucosa

- To prevent dry mouth and dehydration - To reduce discomfort/impr ove intake - To promote healing - Affecting health or integrity of oral mucous membranes - To provide protection/reduc e oral discomfort/pain - To prevent infection.

- Provide dietary modifications - Provide adequate nutrients and vitamins - Asses medication use possibility of side effects

- Provide anesthetic lozenges or analgesics - Administer antibiotics, as ordered