ENGLISH IN NURSING II

NURSING CARE PLAN OF INTEGUMENT SYSTEM

(CONTACT DERMATITIS)

Created by
Group 5 / A1 2015

Malinda Kurnia Putri 131511133017

Nyuasthi Genta S. 131511133018
Tyas Dwi Rahmadhani 131511133019
Unza Noor Ramadhanti 131511133020
Rizky Sekartaji 131511133028
Itsnaini Lina K. 131511133029
Ima Matul K. 131511133030

NURSING FACULTY
AIRLANGGA UNIVERSITY
SURABAYA
2016
 PROLOGUE

Praise be to Allah, The Cherisher and Sustainer of the worlds, God who has been
giving His blessing and mercy to the writers to complete the paper entitled ”Nursing Care
Plan Patient of Integument System (Contact Dermatitis)". This paper is submitted to
fulfill one of the task of English In Nursing II subject in Faculty of Nursing. In finishing this
paper, the writer really gives their regards and thanks for people who has given guidance and
help,they are:

1. Ira Suarilah, S.Kp., M.Sc as the English lecture, who have teached us and given detail
information.

2. Our Parents who has always pray for us.

3. And all of my friends who has given support to us and help us.

Finally, the writers realizes there are unintended errors in writing this paper. We are
really allows all readers to give their suggestion to improve the content of its paper in order to
be made as one of the good examples for the next paper.Thank you very much for the
attention.

Surabaya, 29th of November 2016

Writers

ii
 TABLE OF CONTENTS

COVER ............................................................................................................................ i

PROLOGUE .................................................................................................................... ii

TABLE OF CONTENTS ................................................................................................. iii

BAB I INTRODUCTION ................................................................................................. 1

1.1. Background ......................................................................................................... 1

1.2. Formulation Problem .......................................................................................... 2

1.3. Purpose ............................................................................................................... 2

BAB II DISCUSSION ...................................................................................................... 3

2.1. Integument System ............................................................................................. 3

2.1.1 Definition of Integument System................................................................ 3

2.1.2 Function of Integument System .................................................................. 3

2.1.3 Skin ............................................................................................................. 4

2.2. Contact Dermatitis .................................................................................................... 5

2.2.1 Definition of Contact Dermatitis ................................................................ 6

2.2.2 Etiology of Contact Dermatitis ................................................................... 6

2.2.3 Pathofisiology of Contact Dermatitis ......................................................... 8

2.2.4 WOC of Contact Dermatitis ....................................................................... 9

2.2.6 Sign and Symptoms of Contact Dermatitis ................................................ 10

2.2.7 Treatment of Contact Dermatitis ................................................................ 11

2.2.8 Complication of Contact Dermatitis ........................................................... 11

3.2. Nursing Care Plan of Contact Dermatitis ........................................................... 12

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 2.2.1 Assessment ................................................................................................ 12

2.2.2 Nursing Diagnoses ................................................................................... 14

2.2.3 Intervention ............................................................................................... 15

2.2.4 Evaluation.................................................................................................. 18

BAB III CONCLUSION .................................................................................................. 19

3.1. Conclusion .......................................................................................................... 19

BIBLIOGRAPHY ............................................................................................................ 20

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 CHAPTER I
INTRODUCTION

1.1. Background
The entire human body outer portion encased by a system called integument
system. Integumentary system is the body's first line of defense against bacteria, viruses
and other microbes. It also helps to provide protection from ultraviolet radiation
berbahaya.Sistem This consists of the skin and its accessories, including nails, hair,
glands (sweat and sebaseous), and specialized nerve receptors (for stimuli internal or
external environment changes).
Integumentary system consists of the body's largest organ, the skin. The skin is a
sensory organ that has receptors to detect heat and cold, touch, pressure and pain. The
skin consists of a layer of epithelial tissue (epidermis) which is supported by a layer of
connective tissue (dermis) and the underlying subcutaneous layer (hypodermis or
subcutis).
Dermatitis is an inflammation of the skin on the epidermis and dermis as a
response to the effect of exogenous or endogenous factors that cause clinical symptoms
of efloresensi polymorphic (erythema, edema, papules, vesicles, scaling) and itching
(Rospa, 2009: 91). There are two types of contact dermatitis, Irritant Contact Dermatitis
(DKI) caused by chemical irritants and Allergic Contact Dermatitis (DKA) caused by
antigen (allergen) which gave rise to the type IV hypersensitivity reactions (cell-
mediated).
Results Febria Suryani in 2011, a factor that can influence the occurrence of
contact dermatitis can be divided into two factors, the direct and indirect factors. Direct
factor includes chemicals and old contacts. Indirect factor is temperature and humidity,
Tenure, Age, Gender, Race, History of Allergy, Hygine personnel, and use of Personal
Protective Equipment. 80% of occupational contact dermatitis (Occupational Contact
Dermatitis) is 20% irritant and allergic. However, recent data from the UK and the US
show that the percentage of occupational contact dermatitis due to allergies may be
much higher, ranging between 50 and 60 percent, thereby increasing the economic
impact of the work DKA.
Because of the magnitude of the incidence of contact dermatitis is a factor, then
as a nurse we should be able to understand and appreciate how the management and

1
 maintenance How can the client with contact dermatitis, so it is expected with this
paper, students can learn and understand more nursing care to clients with contact
dermatitis.

1.2. Formulation problem

1. What is the definition of integument system ?
2. What is the function of integument system ?
3. How is the skin of integument system ?
4. What is the definition of contact dermatitis ?
5. What is the etiology of contact dermatitis ?
6. How is the pathofisiology and WOC of contact dermatitis ?
7. What is the symptoms of contact dermatitis ?
8. What is the treatment of contact dermatitis ?
9. What is the complication of contact dermatitis ?
10. How is the nursing care plan of contact dermatitis ?

1.3. Purpose
1. Knowing definition of integument system
2. Knowing function of integument system
3. Knowing skin of integument system
4. Knowing definition of contact dermatitis
5. Knowing etiology of contact dermatitis
6. Knowing the pathofisiology and WOC of contact dermatitis
7. Knowing symptoms of contact dermatitis
8. Knowing the treatment of contact dermatitis
9. Knowing the complication of contact dermatitis
10. Knowing the nursing care plan of contact dermatitis

2
3
 CHAPTER II
DISCUSSION

2.1 Integument System

2.1.1 Definition

The integumentary system consist of the skin, hair, nails, the subcutaneous
tissue below the skin, and assorted glands. The integumentary system is the
organ system that protects the body from various kinds of damage, such as loss
of water or abrasion from outside.

2.1.2 Function Of The Integument System

1. Protection against injury and infection

a. Physical barriers : continuity of the skin and hardness of keratinzed
cells and properties of the glycolipids. Keratin helps waterproof the
skin and protect from abrasions and bacteria. Glycolipids can prevent
diffusion of water and water-soluable substances between cells.
b. Chemical barriers : skin secretion and melanin. Skin secretions such as
sebum, human defesins (antimicrobial peptides), acid mantle of the
skin retards bacteria growth and/or kills them. Melanin can provides
protection from UV damage
c. Biological barriers : Langerhan’s cells and macrophages. Both of them
can present in the skin helps activate the body’s immune system.
2. Regulates body temperature
a. When body temperature is hotter than the external environment, the
blood vessels in the dermal area dilates and sweat glands are stimulated
into activity.
b. When it is cold outside, the dermal blood vessels constrict and pull the
blood away from the skin and keeps it close to the body core to protect
crucial internal organs
3. Sensory perception : Nervous system
Bare nerve endings like painful stimuli are chemicals, heat and cold
4. Regulates water loss

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 Elimination of nitrogen-containing wastes (amonia, urea, uric acid), sodium
chloride, and water. It regulates water loss
5. Chemical synthesis
Synthesis of Vitamin D (increase calcium absorption in the body). It is
converted to its active form by the body in 2 steps, occuring first in the liver
and completed in the kidneys. When the body is deficient in vitamin D, it is
unable to properly regulate calcium and phosphate levels

2.1.3 Skin

Skin is one of the integumentary system. Skin is made up of two layers that
cover a third fatty layer. The outer layer is called the epidermis; it is a tough
protective layer. The second layer (located under the epidermis) is called the
dermis; it contains nerve endings, sweat glands, oil glands, and hair follicles.

The epidermis is a statified, squamous epithelium layer that is composed

primarily of two types of cells : keratinocytes and dendritic cells. The basal cells
of the epidermis undergo poliferation cycles that providefor the renewal of the
outer epidermis. The epidermis is a dynamic tissue in which cells are constantly
in unsynchronized motion, as differing individual cells population pass not only
one another but also melanocytes and langerhans cells as they move toward the
surface of the skin (Chu,2008).

The dermis is an integrated system of fibrous, filamentous and amorphous

connective tissue that accommodates stimulus induced entry by nerve and
vascular networks, epidrmally derived appendages, fibroblast, macrophages,
and mast cells. The dermis comprises the bulk of the skin and provides its
pliability, elasticity, and tensile strength. It protects the body from mechanical
injury, binds water, aids in thermal regulation, and includes receptors of sensory
stimuli.

A. Characteristics skin
1. The intergument covers the entire body and is the largest organ 2
meters and heaviest organ 16% of body mass of the body
2. Composed of the epidermis and dermis
3. Pliable, yet durable

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 4. Thickness 1.5 to 6.0 mm

B. Types of skin
There are 2 types of skin in the epidermis. They are thin skin and thick skin.

Thin Thick
1-2 mm on most of the body and Up to 6 mm thick on palms of
0.5 mm in eyelids hands and soles of feet
Hairy Hairless
Covers all part of the body, Covers palms of hands and soles of
except palms of hands and soles feet
of feet
Thin epidermis and lacks stratum Thick epidermis and a distinct
lucidum stratum lucidum
Lacks dermal papillae Epidermis ridges are present due to
well developed, numoreous dermal
papillae
Has more sebaceous glands Lacks sebaceous gland, has more
sweat glands
Fewer sweat glands, sensory Sense receptors are also more
receptors than thick skin densely packed

2.2 Contact Dermatitis

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2.2.1 Definition of Contact Dermatitis

Contact dermatitis (CD) is defined as any skin disorder caused by contact with
an exogenous substance that elicits an allergic. The vast majority of cases are
attributable to irritant ICD. CD is also a significant cause of workplace
disability. There are two types of contact dermatitis :

1. Irritant Contact Dermatitis (ICD) : Irritant contact dermatitis is the most

common type of contact dermatitis. This happens when the skin comes in
contact with a toxic material.Also known as ‘hand eczema,’ irritant contact
dermatitis can occur when the skin comes in contact with less irritating
materials like soap or even watertoo often.
2. Allergic Contact Dermatitis (ACD) : Allergic contact dermatitis occurs
when the skin develops an allergic reaction after being exposed to a foreign
substance. This causes the body to release inflammatory chemicals that can
make the skin feel itchy and irritated.

2.2.2 Etiology of Contact Dermatitis

A. Etiology of Allergic Contact Dermatitis
a. Metals
Nickel is the most common cause of ACD (allergy contact dermatitis)
in women inalmost all countries. The greater exposure of women
tohigh-nickel content jewelry is a predisposing factor. Earpiercing is
considered to be the principal inducer of nickelcontact dermatitis.
Hand eczema in nickel sensitive patientsis often of the dyshidrotic type
and may be aggravated bynickelingestion. A threshold of 0.5
microgram ofnickel/cm2/week has been established to which only a
smallnumber of nickel-sensitive patients will react. Chromate is the
most common contact allergen in men andsensitization to it is usually
occupational. Occupationalexposure is most frequent in construction
workers whohandlecement. Other common sources are chrome-
tannedleather, bleaching agents, paints, and printing solutions.
b. Cosmetics and skin care products
Compulsory ingredient labeling of cosmetic products (excluding
perfumes) has greatly facilitated the diagnosis andtreatment of

7
 cosmetic contact dermatitis. Positive patchtests are found
mostfrequently to preservatives, perfumes,active or category-specific
ingredients, excipients/emulsifiers and sunscreens. The relevance of
thepositive patch tests is confirmed if the contact dermatitisdisappears
upon discontinuation of the use of the product.Most allergic reactions
are caused by cosmetics that remainon the skin: “stay-on” or “leave-
on” products.
c. Dermatitis from clothes and shoes
Contact dermatitis to clothes is usually located in the axillae, which is
due to the release ofallergens from the textileunder the action of sweat
and friction. Clothing dermatitisfrom formaldehyde is rare nowadays.
Textile dye dermatitisis usually related to disperse dyes. Leather
articlescontain several substances that may cause ACD:
chrome,adhesives (paratertiary butyl phenol formaldehyde resin),and
dyes.A number of accelerators and antioxidants used in the production
of synthetic rubber may also cause contactdermatitis.
d. Drug dermatitis
Drug dermatitis may be elicited by the active ingredient ofa topical
drug, by the vehicle or by a preservative. Contactsensitization to
antibiotics, antiseptics, and anesthetics isrelatively frequent, especially
in leg ulcer patients. ACDfrom topical corticosteroids has been
reported with increasing frequency. Systemic application of a drug
towhich an individual has been sensitized by a previouscutaneous
exposure may cause systemic contact dermatitis
e. Plant dermatitis
Plant dermatitis can manifest itself in a variety of ways,depending
upon the plant and the means of exposure. Airborne contact dermatitis
mimicking photodermatitis maybe caused by sesquiterpene
lactones.Urushiol, present in poison ivy and poisonoak is the most
common cause ofACD in the United States,with 50% of the adult
population clinically sensitive to it.
B. Etiology of Irritant Contact Dermatitis
a. Sodium lauryl sulfate

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 This chemical is found in some topical medications, particularly acne
medications, as well as a range of soaps and shampoos. It is also a
classic experimental cutaneous irritant.
b. Hydrofluoric acid
A hydrofluoric acid burn is a medical emergency. Remember that
onset of clinical manifestations may be delayed after the acute
exposure. Unfortunately, hydrofluoric acid burns are most frequent on
the digits, where the pain is most severe and management is most
difficult.
c. Solvent
Many individuals are exposed to solvents, particularly at work. Solvent
such as alcohol or xylene remove lipids from the skin, producing direct
irritant contact dermatitis and rendering the skin more susceptible to
other cutaneous irritants, such as soap and water. Irritant contact
dermatitis from alcohol most often is cumulative. Manual workes may
wash their hands inappropriately with solvents to remove oil, grease,
paints, or other materials.

2.2.3 Pathofisiology of Contact Dermatitis

Irritant contact dermatitis is the clinical result of sufficient

inflammation arising from the release of proinflammatory cytokines from skin
cells (principally keratinocytes), usually in response to chemical stimuli.
Different clinical forms may arise. The three main pathophysiological changes
are skin barrier disruption, epidermal cellular changes, and cytokine release.
With sufficient concentration or duration of exposures, a wide range of
chemicals can act as cutaneous irritants. Common cutaneous irritants include
solvents, microtrauma, and mechanical irritants.

Cumulative irritant contact dermatitis from repeated mild skin irritation

from soap and water is common. For example, hand-washing frequency of
more than 35 times per shift was associated strongly with occupational hand
dermatitis in intensive care unit workers (odds ratio = 4.13). Similarly, most
cases of "homemaker's" eczema are irritant contact dermatitis resulting from

9
 repeated skin exposure to low-grade cutaneous irritants, particularly soaps,
water, and detergents.

Solvents cause cutaneous irritation because they remove essential fats

and oils from the skin, which increases transepidermal water loss and renders
the skin susceptible to the increased direct toxic effects of other previously
well-tolerated cutaneous exposures. The alcohol propanol is less irritating to
the skin than the detergent sodium lauryl sulfate.

An acid dissociation constant, is a quantitative measure of the strength

of an acid in solution. p Ka has been shown to be highly predictive of acute
skin irritation for acids and bases: acids with a p Ka of less than 4 and bases
with a p Ka of less than 8 are highly irritative. Microtrauma may produce skin
irritation. A common example is fiberglass, which may produce pruritus with
minimal visible inflammation in susceptible individuals. Many plant leaves
and stems bear small spicules and barbs that produce direct skin trauma.

Skin irritation predispose the skin to develop sensitization to topical

agents. Skin irritation by both nonallergenic and allergenic compounds induce
Langerhands cell migration and maturation. An excerbation or irritant contact
dermatitis may reflect development of allergic contact dermatitis to topical
creams, medication, or rubber gloves.

The pathogenesis of irritant contact dermatitis involves resident

epidermal cells, dermal fibroblasts, endothelial cells, and various leukocytes
interacting with each other under the control of a network of cytokines and
lipid mediators. Keratinocytes play an important role in the initiation and
perpetuation of skin inflammatory reactions through the release of and
responses to cytokines. Resting keratinocytes produce some cytokines
constitutively.

2.2.4 WOC of Contact Dermatitis

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 The Substances of chemical and physical
(Metals, cosmetics and skin care product,
sodium lauryl sulfate ,etc)

Allergic
Irritation

Consumption or
direct contact
Skin irritation

Contact irritant with

Allergen
Damage of Stratum
Corneum
Plasma and basophil
to form the Ig E
Denature of keratin
Causing process of
degranulasi
Remove essential fats
and oils from the skin
The release of
mediator chemicals

Changing the skin

turgor. Reaction
inflammantory
Itchy and swollen
Impaired the
Reaction scratching
epidermis
to excessive
Nursing problem:
Nursing Problem :
Disturbed body image Nursing problem :
Impaired skin
Impaired comfort
Integrity

2.2.5 Sign and Symptoms of Contact Dermatitis

Sign and symptoms of contact dermatitis depend upon the cause and how
sensitive client to the substance that causes the rash. Sign and Symptoms
associated with allergic contact dermatitis include:

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 1. Dry, scaly, flaky skin
2. Hives
3. Oozing or dry blisters
4. Skin redness
5. Skin that appears darkened or leathery
6. Skin that burns with or without sores
7. Extreme itching
8. Sun sensitivity
9. Swelling, especially in the eyes, face, or groin areas

Irritant contact dermatitis may cause slightly different sign and symptoms,
such as:

1. Blistering
2. Cracking skin due to extreme dryness
3. Swelling
4. Skin that feels stiff or tightened
5. Ulcerations
6. Open sores that form crusts

2.2.6 Treatment of Contact Dermatitis

The treatment of contact dermatitis are :
1. Avoid scratching the irritated skin . Scratching can make the irritation
worse or even cause a skin infection that requires antibiotics.
2. Instead, clean the skin with lukewarm water to remove the irritants.
3. Use anti-itch treatments include calamine lotion or hydrocortisone cream.
Doctor can prescribe a more potent steroid cream if these creams don’t
soothe the irritans skin.
4. Taking an antihistamine drug such as diphenhydramine can help to cut
down on itching and reduce your allergic response.

Most cases of contact dermatitis will go away on their own and aren’t cause for
concern. However, seek medical attention if the rash is close to eyes or mouth,
covers a large area of the body, or doesn’t improve with at-home treatment.

2.2.7 Common Complications of Contact Dermatitis

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 When the itching and irritation of contact dermatitis are severe and persistent,
the following complications may arise:
1. Infection
Skin that is moist from oozing or open from irritation or scratching is
susceptible to infection from bacteria and fungi. The most common types of
infection are staphylococcus and streptococcus. These can lead to a
condition called impetigo. This is a highly contagious skin infection. Most
infections can be treated with antibiotics or antifungal medication.
2. Neurodermatitis
Scratching can make skin even itchier. This can lead to chronic scratching
and scaling. As a result, the skin may become thick, discolored, and
leathery.
3. Cellulitis
Cellulitis is a bacterial infection of the skin. It is most often caused by
streptococcus or staphylococcus bacteria. The symptoms of cellulitis
include fever, redness, and pain in the affected area. Other symptoms
include red streaks in the skin, chills, and aches. If people have a weakened
immune system, cellulitis can be life threatening.
4. Diminished Quality of Life
If contact dermatitis symptoms are severe or long lasting, they can affect
your quality of life. They may make it difficult to do job. They may
alsofeel embarrassed about the appearance of skin him. If this is the case,
then should talk to doctor about how to manage that symptoms more
effectively.

2.3 Nursing Care Plan of Contact Dermatitis

A. Assessment
Anamnesa
1. Patient Identity
A bio clients include: name, age, gender, religion, ethnicity / race, education,
languages spoken, occupation, income and address.
2. Main problem
Itching, burning, hair loss
3. History of Nursing

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  History of current illness
Ask, since when patients feel the complaint and any action that patients can do
to mitigate them. In reviewing current medical history, PQRST patterns can be
used to ask the client complaints.
 Previous health history
Does the patient suffering from such diseases or other skin diseases
 Family disease history
Is there a family who had suffered from such diseases or other skin diseases
 History of Medicine or Substance Exposed
Does the patient have to use drugs - drugs applied to the skin or have client
exposure to factors that are not uncommon. For example, exposed to chemicals
or other irritants.
 Employment history or activities of daily living
Habits and daily activities of client need to be asked example, how the client
sleep patterns, causes sleep and rest patterns greatly affect the health of the
skin. The work environment client also need to be assessed to determine
whether the client is in contact with irritant materials.
 Psychosocial history
Psychological state client that need to be assessed, for example, prolonged
stress will affect the health of skin, it can even cause skin disorders
4. Functional Patterns Gordon
Patterns of perception and handling of health
1. Perception of disease
Ask your client’s opinion about health and disease. Is direct clients seeking
treatment or wait semapai the disease interfere with the activity of a client.
2. History of use of drugs
Ask client about the use of certain drugs, use of alcohol and tobacco to
know the client's lifestyle
3. Pattern of nutrition / metabolism
Ask how the pattern and size of the meal client
Ask how the client's appetite
Ask whether the client is experiencing swallowing disorders
4. Elimination Patterns

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 Ask how the bladder and bowel patterns, colors and characteristics
5. Pattern of Activities / Sports
Activity changes typically associated with skin irritation
6. Pattern of Rest / sleep
Ask the client’s sleep habits (duration, sleep quality)
Ask the client's problems sleeping patterns
7. The pattern of cognitive / perceptual and self-concept
Assess client's mental status
Assess client's level of anxiety through facial expressions
Assess the client's vision and hearing
Assess pain
8. Patterns of perception and self-concept
Ask how clients describe himself, whether what happened to client change
the perception clients to describe himself
9. Pattern of relationship role
Ask about client job
Ask about support systems in a client's life such as: partner, friend, ect
10. Pattern of sexuality / Reproduction
Ask the client's sexual problems associated with the disease
11. Coping patterns
Assess client's emotional state and how clients cope anxiety
12. Pattern of value
Ask your client’s religion and whether there are restrictions on religion and
how obedient client practice her faith.

Physical Examination
Assessing the overall skin characteristics:
- Erythema scaly, well defined / flashy
- Dry and raised lesions pruritus
- The existence of holes or total damage to the nail and hand
- Bilaterally symmetrical lesions
- Lesions may occur in the wound scratch mark.
- Acute: erythema and pain.

B. Nursing Diagnoses

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 1. Impaired skin integrity related to alteration in skin turgor
2. Disturbed body image related to alteration in body function (disease)
3. Impaired comfort related to illness-related symptoms

C. Intervention
Diagnoses NOC NIC
Impaired skin integrity Tissue Integrity: Skin & 1. Electrolyte Monitor
related to Alteration in skin Mucous Membranes - Monitor for signs and
turgor symptoms of
Purpose : the client's skin is
hypochloremia:
back to normal, with criteria
hyperirritability, tetany,
results:
muscular excitability, slow
1. Skin temperature
respirations, and
(110101/II)
hypotension
2. Skin integrity
- Teach patient ways to
(110113/II)
prevent or minimize
electrolyte imbalance
- Consult physician if signs
and symptoms of fluid
and/or electrolyte imbalance
persist or worsen
2. Medication Administration:
Skin
- Follow the five rights of
medication administration
- Note patient’s medical
history and history of
allergies
- Determine patient’s skin
condition over area that
medication will be applied
- Monitor for local, systemic,
and adverse effects of the
medication

16
 - Teach and monitor self-
administration techniques,
as appropriate
- Document medication
administration and patient
responsiveness, according
to agency protocol
3. Infection Protection
- Monitor for systemic and
localized signs and
symptoms of infection
- Avoid close contact
between pet animals and
immunocompromised hosts
- Inspect skin and mucous
membranes for redness,
extreme warmth, or
drainage
Disturbed body image Body Image 1. Anxiety Reduction
related to Alteration in body - Explain all procedures,
Purpose: Can recover the
function (disease) including sensations likely
client’s physical condition,
to be experienced during the
with criteria results:
procedure
1. Satisfaction with body
- Help patient identify
function (120006/III)
situations that precipitate
2. Adjustment to changes
anxiety
in health status
- Support the use of
(120009/III)
appropriate defense
mechanisms
2. Counseling
- Provide factual information
as necessary and
appropriate

17
 - Assist patient to list and
prioritize all possible
alternatives to a problem
Impaired comfort related to Comfort Status 1. Medication Administration
Illness-related symptoms Comfort Status: Physical - Maintain agency policies
and procedures for accurate
Purpose: The client’s
and safe administration of
comfort is complete, with
medications
criteria results:
- Follow the five rights of
1. Itching (201013/V)
medication administration
2. Symptom control: 4-5
- Monitor for possible
(201001/V)
medication allergies,
interactions, and
contraindications, including
over-the-counter
medications and herbal
remedies
- Note patient’s allergies
before delivery of each
medication and hold
medications, as appropriate
2. Self-Modification
Assistance
- Assist the patient in
identifying target
behaviors that need to
change to achieve the
desired goal
- Identify with the
patient the most
effective strategies for
behavior change
- Foster flexibility during

18
 the shaping plan,
promoting complete
mastery of one step
before advancing to
the next

D. Evaluation
1. The client's skin is back to normal
2. The client do not suffer disturbed body image
3. The client feel comfort

19
 CHAPTER III
CONCLUSION

3.1. Conclusion
The integumentary system consist of the skin, hair, nails, the subcutaneous
tissue below the skin, and assorted glands. And the function of integument system are
protection against injury and infection, regulates body temperature, sensory perception :
nervous system, regulates water loss , and chemical synthesis.
Contact dermatitis (CD) is defined as any skin disorder caused by contact with
an exogenous substance that elicits an allergic. There are two types of contact dermatitis
(1) Irritant Contact Dermatitis (ICD) : This happens when the skin comes in contact with
a toxic material, and (2) Allergic Contact Dermatitis (ACD) : Allergic contact dermatitis
occurs when the skin develops an allergic reaction after being exposed to a foreign
substance.
Contact dermatitis can caused by metals, cosmetics and skin care product,
clothes and shoes, drug, and plant. Sign and symptoms of allergic contact dermatitis
include dry, scaly, and flaky skin, hives, oozing or dry blisters, skin redness, skin that
appears darkened or leathery, skin that burns with or without sores, extreme itching, sun
sensitivity, swelling, especially in the eyes, face, or groin areas.

20
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