Nursing Care Plan Impaired Skin Integrity

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Nursing

Cues Nursing Diagnosis Inference Objective Rationale Evaluation


Intervention

Subjective ◊ Impaired skin Aedes Aegypti Short Term Goal Independent ◊ After 3 days of
integrity r/t nursing intervention,
◊ “Nagkapasa-pasa changes in the ◊ After 3 days of ◊ Vital signs monitored ◊ Changes in vitals the goal is met
ako na maliliit, wala barrier function of nursing intervention, and recorded. signs may indicate through
na ngayon may mga the skin Dengue Virus proper skin hygiene infection. demonstration of
bakas na lan konte,” Type I and maintenance of proper skin hygiene
as verbalized. (Chikungunya Virus) skin integrity is ◊ Instructed proper ◊ Proper hygiene will and compliance with
demonstrated. hygiene and self-care prevent infection and treatment and
Objective as well in her complication. A clean medication.
surroundings. environment
◊ c marks of IgG adheres to occurrence of any
petechial rash on the platelet disease.
the extremity (initiates destruction
of the platelet)
◊ c non
pitting bipedal Dependent
edema
◊ Vitamin C promotes
thrombocytopenia ◊ Administered
3 wound healing and
◊ V/S taken as (50,000/mm or prescribed meds such
diuretics decreases
follows: less) as ascorbic acid and
renal vascular
furosemide.
resistance and may
T= °C
increase renal blood
P= bpm increased
flow.
R= cpm potential for
BP = mmHg hemorrhage

stimulates
intense
inflammatory
response

petechial rash,
high fever,
headache

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