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ASSESSMENT

DIAGNOSIS

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective: Lalong dumadami ang rashes ko as verbalized by the patient. Objective: With generalized skin rash With no evident bleeding T: 36.8 P: 84 R: 22 BP: 120/70

Risk for impaired skin integrity related to generalized body rash

To prevent further skin impairment. To give medication or ointment on rashes to alleviate itchiness per doctors order. To lessen swelling on patients IV site.

Provide skin hygiene and advised to use oatmeal or non irritating soaps. Keep bed and clothes clean, dry and linens wrinkled free. Encourage to reposition every 2 or 3 hours. Provide warm compress on IV site.

To maintain skin integrity at optimal level and to reduce or alleviate itchiness. To avoid further skin impairment. To prevent friction that may further irritate skin. To reduce swelling on IV insertion site.

After 8 hours of duty, the patient still has rashes but has verbalized less itchiness. The swelling on patients IV site has been reduced.

Patients name: Alias, Roland Bed: #21 Diagnosis: DHF II, UTI Student Nurse: Meryll Krizha Maghirang

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