Kapiolani Community College

Associate Degree Nursing Program

Nurs320 Nursing Care Plan

Student Name Manaia Genovia Date of Care: 11/10/16 Date Submitted: 11/14/16
Nursing Diagnosis: Impaired Skin Integrity
Related to: Impetigo, Eczema
As manifested by: Cellulitis, abscesses, edema, erythema, serosanguinous and purulent drainage, tender to touch
Scientific Rationale: Impetigo is a highly contagious, superficial skin infection cause by staphylococci or streptococci or both. Bacteria invade
superficial skin in which a break has occurred. Infection can be spread after scratching an affected site. Lesions rapidly spread to adjacent skin
showing a linear pattern of clients scratching. Nonbullous impetigo begins as a single erythematous macule (non-raised discolored spot) that rapidly
progresses to a vesicle (small, blister-like elevation that contain serous fluid) or pustule (small, blister-like elevation that contains pus); vesicle
ruptures leaving a honey-colored crust over superficial erosion.
Hogan, M., Wagner, N. H., Johnson, T. L., & White, J. E. (2013). Pearson nursing reviews & rationales (3rd ed.) (pgs. 217-218) Boston: Pearson.

Outcomes (measurable) Interventions Rationale Evaluation

Short Term
Patients skin shows signs of
healing during antibiotic therapy
AEB normal body temperature,
non-purulent drainage, decreased
edema/erythema size, normal labs
(WBC, ESR, CRP), and blood/wound
cultures showing no growth.
Long Term
Patients skin returns to normal
structure and shows no signs of
infection following completion of
antibiotic therapy AEB normal body
temperature, non-purulent
-Assess characteristics of abscess,
including color, size, drainage and
odor
-Assess for elevated body
temperature
-Gently cleanse skin with
antibacterial soap (hibiclens)
-Instruct patient to avoid
scratching, picking, or touching
abscesses
-Instruct patient to keep fingernails
clean
-Apply topical antibiotics such as
Neosporin, polysporin, bacitracin
TID or QID for 5-7 days or as
ordered during dressing changes
-Administer systemic antibiotic
such as diclozacillin, cephalexin, or
erythromycin
-Data provides information on the
status/condition of the abscess.
Pale tissue color may indicate
decreased oxygenation. Odor may
arise from infection. Serous
exudate is a normal part of
inflammation. Pus or purulent
drainage is an indication of
infection.
-Fever is a systemic manifestation
of inflammation and may indicate
the presence of infection
-Hibiclens acts as a skin cleanser to
help reduce bacteria on the skin
surface and decrease the risk for
infection
To prevent the spread of infection
from scratching and interfere with
the healing process
-To prevent/treat skin infections and
aid in the healing process.
Antibiotics targets and destroys
microorganisms.
-If no response to topical antibiotics
in 72 hours. Antibiotics targets and
destroys microorganisms.
- L arm abscess: ~1cm, erythema,
edema, small sero-sanguineous
drainage, tender to touch
L hip abscess: ~0.5cm, edema,
erythema, tender to touch, small
purulent drainage
-Pt. was afebrile. Temp @ 0800
97.6F, @1200 98.0F
-Pt was sent home with a bottle of
hibiclens (chlorhexidine) and is
instructed to take a shower with it
once every 2 days
-Pts mother understood the
importance of decreasing the
spread of infection and agreed to
cut her fingernails as soon as they
get home.
-Pts mother was instructed to
apply bacitracin to abscesses after
cleansing the area following
dressing changes.
-Pt. was sent home with p.o.
antibiotics and was instructed to
continue taking the medication for
the next 8 days
drainage, decreased
edema/erythema size, normal labs
(WBC, ESR, CRP), and blood/wound
cultures showing no growth.
Reference: Gulanick,Meg,andJudithL.Myers.NursingCarePlans:Diagnoses,Interventions,andOutcomes.Philadelphia,PA:Elsevier/Mosby,2014.Print.
-Administer antihistamines and
soothing creams/lotions
-Cover abscess with gauze
dressings or bandages
-Encourage intake of protein,
vitamin-c, and calorie rich foods.
-Reduce pruritus and scratching.
Infection can spread after
scratching an affected site.
-Reduce exposure to infection and
aid in the healing process.
-Optimal nutritional status supports
immune system responsiveness
-Pts mother will purchase soothing
lotions such as cetaphil or eucerin.
She will administer p.o.
antihistamine for itching as needed.
Pt was sent home with dressing
changes materials and was
instructed to change the dressing
as needed and after
showering/cleansing the area.
-Pts mother understood the
reasoning for providing her
daughter with extra protein and
vitamin c to aid in the healing
process of her abscesses. She will
try giving her OJ every morning
with breakfast to take with her
medications.