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    Impaired Skin Integrity For NCP Oct. 212020

    Uploaded by

    Benjie Dimayacyac
    Notify physician of •To monitor any changes in progression of condition disease and determine treatment effectiveness

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Impaired Skin Integrity For NCP Oct. 212020

    Uploaded by

    Benjie Dimayacyac
    176 views2 pages
    Notify physician of •To monitor any changes in progression of condition disease and determine treatment effectiveness

    Original Title

    Impaired-skin-integrity-for-ncp-oct.-212020

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    © © All Rights Reserved

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    Notify physician of •To monitor any changes in progression of condition disease and determine treatment effectiveness

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    176 views2 pages

    Impaired Skin Integrity For NCP Oct. 212020

    Uploaded by

    Benjie Dimayacyac
    Notify physician of •To monitor any changes in progression of condition disease and determine treatment effectiveness

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Assessment Diagnosis Planning Intervention Rationale Evaluation

    Objective: Impaired skin Short term Independent Short term


     Disruption of integrity related to (Goal met)
    skin surface of accumulation of pro After 4hrs of Assess the wound To monitor progress
    the upper and inflammatory nursing intervention and observe for of wound healing After 4hrs of nursing
    lower cytokines in the the patient will complication intervention the
    extremities system as evidence decrease fever and patient willable to
     Generalized by erythematous, manifest healing of Assess skin for Classical skin manifest healing of
    erythema of edema, peeling of peripheral texture, turgor, features of peripheral
    palms and soles skin around erythema. color, moisture, and Kawasaki disease erythema.
     peeling of fingernails and integrity. involve erythema,
    fingers and toenails secondary swelling, and
    toes. to inflammatory desquamation Long Term
     +Pain process and altered Long term: affecting the skin of (Partially met)
     Cracked lips circulation of the the extremities and
    with fissures skin.  After 8 hours of a polymorphous After 8 hours of the
    nursing rash. nursing intervention
    intervention the the patient will able
    patient will be to decreased the
    able to prevent Dress the child in a Heavy clothing may sign of edema in
    skin breakdown. light clothing. constrict and irritate hands and feet
     Will be able to the rashes.
    display timely
    healing without Discourage the use The use of soaps
    complications. of soaps. makes the skin dry
     Will be able to and predispose to
    maintain skin breakdown.
    physical
    wellbeing. Apply cool, moist Moisture promotes
    compress to the skin breakdown.
    itching skin areas.
    .
    Encourage Extra fluid intake
    adequate fluid helps maintain
    intake. hydration and
    decrease mouth
    tenderness.

    Dependent:

    •Administer •To decrease


    hydroxyzine as inflammation.
    ordered

    Collaborative:

    Refer to dietitian for


    intake of protein- •Protein is
    rich foods such as essential for the
    eggs, beans, formation, repair,
    chicken and maintenance
    of the skin

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