NURSING CARE

A. Assessment
1. Client identity
Includes: Name, age, gender, religion, education, occupation, medical diagnosis, register number
and date of MRS. This infection is mainly attacked by children and is contagious
2. Main Complaints
Clients come to the health center with complaints of a fever like a cold and a rash filled with
water around their bodies.
3. Past Disease History.
The client said he had never had a skin disease before.
4. Current Disease History.
At this time the client feels his body feels hot like a cold and there is a red rash on his body and
pain when held. Previously the client had never checked health into a health center. The client
consumes medicine from a stall in the form of cold medicine because the client thinks he will get
the flu.
5. Family history.
Previously, the client had experienced chickenpox and the client often visited his neighbors when
his chickenpox had dried up. No family member has the same complaints as him.

B. Assessment of focus
1. Activity / Rest
Sign: decreased detainee strength
2. Ego integrity
Symptoms: problems about family, work, strength, disability.
Signs: anxiety, crying, denying, withdrawing, anger.
3. Eat / liquid
Signs: anorexia, nausea / vomiting
4. Neuro sensory
Symptoms: free area tingling
Signs: changes in orientation, affect, seizure behavior (electric shock), corneal lacerations,
retinal damage, decreased visual acuity
5. Pain / Comfort
Symptoms: Sensitive to touch, pressure, movement of air, temperature of the air.
6. Security
Signs: general deep tissue destruction may be proven for 3-5 days in connection with the
microvascular trambus on the skin.
1. Subjective data
The patient feels weak, does not feel well, has no appetite and has a headache.
2. Objective Data:
a. Integumen: warm, pale skin and the presence of reddish spots on the skin that contains clear
liquid.
b. Metabolic: increase in body temperature.
c. Psychological: withdraw.
d. GI: anorexia.
e. Counseling / learning: about varicella wound care.

C. Nursing Diagnosis
1. Hypertermia is associated with an inflammatory reaction
2. Damage to the integrity of the skin associated with lesions on the skin

D. Interventions and Rational

1. Hypertermia is associated with an inflammatory reaction
Objective: after nursing intervention for 1 x 24 hours the body temperature decreases
Criteria for results: normal body temperature 36.5-37.5 0C
Rational Intervention
a. Monitor patient's body temperature a. Continued increase in body temperature in varicella
patients will provide complications in more severe disease conditions (such as pascavaricella
encephalitis and paskavaricella pneumonia) secondary effects of an increase in general metabolic
rate and dehydration due to hyperthermia.
b. Give cold compresses on the head and axilla b. Give a cold response to large blood vessels
c. Maintain total bed rest during the acute phase c. Reduces the increase in general metabolic
processes
d. Maintain a minimum fluid intake of 2500 ml a day. d. In addition to fulfilling the body's
hydration, it will also increase body heat through the urinary system, so body heat can also come
out through urine.
e. Collaboration of giving analgesics - antipyretics. e. Analgesics are needed to reduce the pain
process. Antipyretics are needed to reduce body heat and provide comfort to patients.

2. Damage to the integrity of the skin associated with lesions on the skin
Objective: after 3x24 hours of nursing intervention the skin integrity improved
Criteria results: no damage to skin integrity occurs
Rational Intervention
a. Assess for damage to the client's skin a. Become basic data to provide information on wound
care interventions
b. Maintain necrotic tissue and conditions around the wound. b. Know the state of skin integrity.
c. Give skin care c. Avoid interference with skin integrity
d. Collaboration with doctors for antibiotics d. Prevent activation of germs that can enter