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Kapiolani Community College

Associate Degree Nursing Program


Nurs320 Nursing Care Plan

Student Name Manaia Genovia Date of Care: 11/10/16 Date Submitted: 11/14/16
Nursing Diagnosis: Impaired Skin Integrity
Related to: Impetigo, Eczema
As manifested by: Cellulitis, abscesses, edema, erythema, serosanguinous and purulent drainage, tender to touch
Scientific Rationale: Impetigo is a highly contagious, superficial skin infection cause by staphylococci or streptococci or both. Bacteria invade
superficial skin in which a break has occurred. Infection can be spread after scratching an affected site. Lesions rapidly spread to adjacent skin
showing a linear pattern of clients scratching. Nonbullous impetigo begins as a single erythematous macule (non-raised discolored spot) that rapidly
progresses to a vesicle (small, blister-like elevation that contain serous fluid) or pustule (small, blister-like elevation that contains pus); vesicle
ruptures leaving a honey-colored crust over superficial erosion.
Hogan, M., Wagner, N. H., Johnson, T. L., & White, J. E. (2013). Pearson nursing reviews & rationales (3rd ed.) (pgs. 217-218) Boston: Pearson.

Outcomes (measurable) Interventions Rationale Evaluation

Short Term -Assess characteristics of abscess, -Data provides information on the - L arm abscess: ~1cm, erythema,
including color, size, drainage and status/condition of the abscess. edema, small sero-sanguineous
Patients skin shows signs of odor Pale tissue color may indicate drainage, tender to touch
healing during antibiotic therapy decreased oxygenation. Odor may L hip abscess: ~0.5cm, edema,
AEB normal body temperature, arise from infection. Serous erythema, tender to touch, small
non-purulent drainage, decreased exudate is a normal part of purulent drainage
edema/erythema size, normal labs inflammation. Pus or purulent
(WBC, ESR, CRP), and blood/wound drainage is an indication of
cultures showing no growth. infection.
-Assess for elevated body -Pt. was afebrile. Temp @ 0800
temperature -Fever is a systemic manifestation 97.6F, @1200 98.0F
of inflammation and may indicate
the presence of infection
-Pt was sent home with a bottle of
-Gently cleanse skin with -Hibiclens acts as a skin cleanser to hibiclens (chlorhexidine) and is
antibacterial soap (hibiclens) help reduce bacteria on the skin instructed to take a shower with it
surface and decrease the risk for once every 2 days
infection
-Instruct patient to avoid To prevent the spread of infection -Pts mother understood the
scratching, picking, or touching from scratching and interfere with importance of decreasing the
abscesses the healing process spread of infection and agreed to
cut her fingernails as soon as they
-Instruct patient to keep fingernails get home.
clean
Long Term
-Apply topical antibiotics such as -To prevent/treat skin infections and -Pts mother was instructed to
Neosporin, polysporin, bacitracin aid in the healing process. apply bacitracin to abscesses after
TID or QID for 5-7 days or as Antibiotics targets and destroys cleansing the area following
ordered during dressing changes microorganisms. dressing changes.
Patients skin returns to normal
-Administer systemic antibiotic -If no response to topical antibiotics -Pt. was sent home with p.o.
structure and shows no signs of
such as diclozacillin, cephalexin, or in 72 hours. Antibiotics targets and antibiotics and was instructed to
infection following completion of
erythromycin destroys microorganisms. continue taking the medication for
antibiotic therapy AEB normal body
the next 8 days
temperature, non-purulent
drainage, decreased
-Reduce pruritus and scratching. -Pts mother will purchase soothing
edema/erythema size, normal labs
Infection can spread after lotions such as cetaphil or eucerin.
(WBC, ESR, CRP), and blood/wound -Administer antihistamines and scratching an affected site. She will administer p.o.
cultures showing no growth. soothing creams/lotions antihistamine for itching as needed.

-Reduce exposure to infection and


-Cover abscess with gauze aid in the healing process. Pt was sent home with dressing
dressings or bandages changes materials and was
instructed to change the dressing
as needed and after
showering/cleansing the area.
-Optimal nutritional status supports
-Encourage intake of protein, immune system responsiveness
vitamin-c, and calorie rich foods. -Pts mother understood the
reasoning for providing her
daughter with extra protein and
vitamin c to aid in the healing
process of her abscesses. She will
try giving her OJ every morning
with breakfast to take with her
medications.

Reference: Gulanick,Meg,andJudithL.Myers.NursingCarePlans:Diagnoses,Interventions,andOutcomes.Philadelphia,PA:Elsevier/Mosby,2014.Print.