Cues Subjective: Last time, katol-katol jud. Daghang nanggawas nga samad-samad sa iya, as verbalized by mother.

Objective: Presence of rashes on skin

Objective of Care At the end of 24 hours of nursing intervention, the client will be able to: 1. Participate in prevention measures and treatment program.

Intervention

Rationale

Implementation

Evaluation

Nursing Diagnosis Impaired skin integrity related to trauma

a. Obtain a history of condition, including age at onset, date of first episode, original site/characteristic of lesions, duration of the problem, and changes that might have occurred overtime. b. Discuss importance of early detection of skin changes and/or complications

a. To assess extent of involvement/injury.

b. To promote wellness

2. Display timely healing of skin lesions, wounds, or pressure sores without complication.

a. Determine nutritional status and potential for delayed healing or tissue injury by exacerbated by malnutrition. b. Keep the area clean and dry, carefully dress wounds.

a. To asses causative or contributing factors

(Source: pp. 757-762 NANDA. Nurses Pocket Guide, 12th edition)

b. To assist bodys natural process of repair.

c. Review importance of health, intact skin, as well as measures to maintain proper skin functioning.

c. The integumentary system is the largest multifunctional organ of the body. To promote wellness.

ASSESSMENT Subjective Data: Ang nabal-an man nako, mawala ran a siya. Kanang part ra siya sa pagdako. (What I know is that it goes away soon. Its just a phase, a part of growing up.) Objective Data: - Client tried to explain the situation but missed some important information

OBJECTIVE OF CARE At the end of 10-20 minutes of nursing intervention, the client will be able to: 1. Verbalize understanding of condition, disease process, and treatment.

INTERVENTION

RATIONALE

IMPLEMENTATION

EVALUATION

a. Determine clients ability to, readiness and barriers to learning.

a. Individual may not be physically, emotionally, or mentally capable at this time. b. To determine factors pertinent to the learning process. May need to help SO and/or caregivers to learn. c. To meet the learners needs. d. Reinforces learning process; allows client to proceed at own pace.

b. Assess the level of the clients capabilities and possibilities of the situation.

Nusring Diagnosis: Knowledge deficit related to inaccurate information.

c. State objectives clearly in the learners terms. d. Provide written information or guidelines and self-learning modules for the client to refer as necessary.

2. Identify relationship of signs/symptoms to the disease process, and treatment.

a. Provide information relevant only to the situation. b. Relate information to clients personal desires, needs, values, and beliefs. c. Begin with information

a. To prevent information overload.

b. So that client feels competent and respected.

c. To facilitate learning.

the client already knows and move to what the client doesnt know, progressing from simple to complex. d. Deal with the clients anxiety or other strong emotions. Present information out of sequence, if necessary, dealing first with the material that is most anxiety producing. e. Provide information about additional learning resources, like websites.

Can arouse interest/limit sense of being overwhelmed.

d. To facilitate learning when the anxiety is interfering with clients ability to learn.

e. May assist with further learning and promote learning at own pace.

(Source: pp. 495-499 NANDA. Nurses Pocket Guide, 12th edition)

(Source: pp. 495-499 NANDA. Nurses Pocket Guide, 12th edition)