Assessment

ASSESSMENT S>”makati sya meron ako sa buong katawan.” O> observed patient constantly scratches whole body. Presence of red papules over upper and lower extremities, nape area, observed poor hygiene and grooming (+) capillary refill Temp: 36.8 C

ASSESSMENT

NSG.DX Impaired Skin Integrity r/t presence of invasive parasites

NSG.DX

RATIONALE A skin infection caused by the itch mite. Scabies is typified by severe itching, red papules. Itching is a allergic reaction to the mite, its egg and feces. In this which may cause disruption of skin surface.

RATIONALE

PLAN After 2 days of NI, patient will be able to prevent further skin breakdown and remained to be free from signs and symptoms of infection.

PLAN

INTERVENTIONS RATIONALE 1.identify 1. to assess causative underlying cause of factor skin disruption (communicable dse.) 2. note characteristic of lesions, inspect extent of skin affection.

2. to assess extent of involvement of skin disruption.

3. provide skin care, keeping areas clean/ dry.

3. to prevent transfer of microorganism and further extension of skin disruption.

4. Monitor vital signs especially temperature

4. may indicate an infection

5. Assist the client in understanding proper daily skin maintenance

5. enhances commitment to plan, optimizing outcomes

INTERVENTIONS

RATIONALE

EVALUATION After 2 days of NI, there will be no further skin breakdown will be noted and patient will remain free from s/sx of infection

EVALUATION

S> Araw-araw ako naliligo, hindi ako nagsha-shampoo at nagsisipilyo.” O> noticed client constantly scratches her body, poor grooming and hygiene, unable to combed hair, and yellowish teeth, presence of scabies all over the extremities, nape area

Self-care deficit: grooming/h ygiene r/t lack of concern and inattention to ADLs

After 2 days of NI, client will be assisted in proper grooming and hygiene

1. Assess current level of functioning; reevaluate daily. 2. Provide physical assistance, supervision and simple Providing only directions/reminder s, encouragement and support, required assistance fosters autonomous as needed. 3. Assist in grooming and Hygiene 4. Instruct client of proper grooming and hygiene

ASSESSMENT

NSG.DX

RATIONALE

PLAN

INTERVENTIONS

1. Provides information about changes in individual abilities necessary for planning/altering care.

After 2 Days of NI, Px will be able to be assisted in proper grooming and hygiene

2. Helps focus attention on task.

3. in able patient to attend to own activities of daily living 4. redirects client to daily routines

RATIONALE

EVALUATION

S>”meron nagsasabi sa akin na boses na papatayin daw nya ako.”, “dati sinubukan ko ng magpakamatay.” “yung ka live-in ko One year na kaming nagsasama nun, 6years ko na syang boyfriend, me chismis na me babae sya, tapos sinasaktan nya ako.” O> patient with flat affect, loss of an important relationship,

Risk for Suicide r/t loss of important relationship

After 2 days of NI, client will be involved in planning course of action to correct existing problems

1. ask directly if thinking of suicide

1. determines intent

2. develop therapeutic nurseclient relationship

2. promote sense of trust, allowing individual to discuss feeling openly

3. encourage expression of feelings and make time to listen to concerns

3. acknowledge reality of feelings and that they are okay.

4. help client identify more appropriate solutions, behavior

4. to lessen sense of anxiety

5. Engage client in psychotherapy program

5. promotes feelings of self-worth and improves sense of well-being

After 2 days of NI, client will be able to be involve in the plan ofaction to correct existing problems