Jarel Duran Carl

Elexer C.Ano
7 y/o July 8 2008
SCIENTIFIC EXPECTED
ASSESSMENT NURSING DIAGNOSIS PLANNING INTERVENTIONS RATIONALE
EXPLANATION OUTCOME
S>Ø Risk for Impaired skin Skin is the primary Short term: >Establish rapport >To gain the client and The client and the
O> the pt. manifested integrity r/t dry skin defense of the body; it SO’s trust. SO shall have
the ff. and behaviors that may protects the body against After 2-4° of NI, the >Monitor VS. >To obtain data for verbalized
lead to skin integrity infections and dses client and the SO will >Note age and sex comparison. understanding of
 Dry skin impairment AEB brought about by the be able to verbalize >to evaluate individual factors
 Observed scratching of scabs invasion of microbes in understanding of degree/source of risk that contribute to
scratching the body. A normal skin is individual factors that >Assess mood, abilities, inherent in the possibility of skin
his scabs moist and intact; dryness contribute to possibility and personal styles. individual situation. integrity impairment
of the skin is more prone of skin integrity >to evaluate pt.’s and takes steps to
to friction that may result impairment and takes >Provide health attitude which may correct the
to impairment of the skin steps to correct the teachings regarding the contribute to skin situation.
integrity as compared situation. importance of breakdown.
with a moist skin. maintaining an intact and >To increase the SO’s The client shall have
Long term: moist skin. knowledge thus, demonstrated
prevention of skin behaviors to
After 1- 3 days of NI the >Teach the SO to give breakdown is realized prevent skin
client will be able to the client a balance, and and taken into breakdown.
demonstrate behaviors nutritious food especially consideration by the
to prevent skin foods rich in Iron and SO.
breakdown. vitamin C > To improve clients
>Instruct the SO to give immune system.
multivitamins to the
client e.g. Growvit.
>To pharmacologically
improve client’s
immune system.

Intractable Vomiting with some signs of DHN

 Risk for Impaired skin integrity r/t abnormal blood profile 2° DHF
 Risk for Imbalanced Fluid Volume r/t susceptibility to bleeding 2° DHF