Assessment Subjective: -NONE

Diagnosis Risk for impaired skin integrity related to dry skin and behaviors that may lead to skin integrity impairment as evidenced by scratching of scabs.

Planning After 2-4 hours of nursing intervention, the client and significant others will be able to verbalize understanding of individual factors that contribute to possibility of skin integrity impairment and takes steps to correct the situation.

Intervention Establish rapport Monitor V/S Note age and sex Assess mood, abilities, and personal styles. Provide health teachings regarding the importance of maintaining an intact and moist skin. Teach the Significant others to give the client a balance, and nutritious food especially foods rich in iron and vitamin C.

Rationale To gain the client and SOs trust. To obtain data for comparison To evaluate degree/sourc e of risk inherent in the individual situation. To evaluate pts attitude, which may contribute to skin breakdown. To increase SOs knowledge, prevention of skin breakdown. To improve clients immune system.

Evaluation The client and the SO has verbalized understanding of individual factors that contribute to possibility of skin integrity impairment and takes steps to correct the situation.

Objective: - Dry skin - Scratching of scabs

Assessment Subjective: - Hindi na ako madalas makadumi nitong mga nakaraang araw as verbalized by the patient. Objective: - Restless - Abdominal cramping. - Altered bowel sounds. - V/S taken as follows: T: 36.4 PR:60 RR:18 BP:130/90

Diagnosis Cons tipati on relat ed to decr ease d dieta ry intak e.

Planning After 8 hours of nursing interventions, the patient will establish or return to normal patterns of bowel functioning.

Intervention - Determine stool color, consistency, frequency, and amount. Auscultate bowel sounds.

Encourage fluid intake of 2500-3000 ml/day within cardiac tolerance. Recommend avoiding gas-forming foods. Assist in peri-anal skin condition frequently, noting changes or beginning breakdown. Discuss use of stool softeners as indicated. Monitor effectiveness. Encourage to eat high-fiber rich foods.

Rationale - Assists in identifying causative or contributing factors and appropriate interventions. - Bowel sounds are generally decreased in constipation. - Assists in improving stool consistency.

Decrease gastric distress and abdominal distention. Prevents skin excoriation and breakdown.

Evaluation - After 8 hours of nursing interventi ons, the patient was able to establish or return to normal patterns of bowel functionin g.

Facilitates defecation when constipation is present. To enhance easy defecation.

Assessment Diagnosis Subjective: - Acute pain - Masaki related to t at disease process kumikiro (compression/d t yung estruction of pwet-an nerve tissue ko as infiltration of verbaliz nerves or their ed by vascular supply, the obstruction of a patient. nerve pathway, Objective: inflammation), - Facial side effects of grimace. various cancer - Narrowe therapy agents. d focus. - Pain scale of 7/10. - V/S taken as follows: BP:130/ 90 PR:60 RR:18 Temp:36 .4

Planning - After 1 hour of nursing intervention the patient: Verbalizes minimized or controlled feeling of pain. Verbalizes methods that provide relief.

Intervention - Vital signs were monitored until stable and dressing was checked. - Enough rest and sleep was advised. - Intake of pain reliever such as Mefenamic acid and antibacterial medications per doctors order and advice.

Rationale - Alteration from normal maybe signs of infection. Moistened dressings are favorable site for microorganism to culture. - This promotes healing by reducing basal metabolic rate, allowing oxygen, and nutrients to be utilized for tissue growth, healing and regeneration. - NSAID activity includes modulation T-cell function, inhibition of inflammatory cell chemotaxis, decreased release of superoxide radicals of these compounds at inflammatory sites. Antibiotics are used to treat pathogens in skin.

Evaluation Pain is reduced or controlled to a tolerable extent as verbalized of 3/10 scale/score of pain. Relieving methods and relaxation techniques are understood and demonstrated.