Manguiat, Ciara Loreal M.
NCMA 111
BSN 1-Y2-5
Subjective Data:
- Skin has been dry and scaly for the past several months
- “Fly-away hair that I can do anything with”
- Brittle fingernails
- Supposed to take Synthroid daily for “my low thyroid”
- Been nibbling on crackers, lunch meat, and sodas daily
- Lack of energy, cannot last a day without one or two 30 minutes nap
- Skin has been dry and scaly for the past several months
- “Fly-away hair that I can do anything with”
- Brittle fingernails
- Supposed to take Synthroid daily for “my low thyroid”
- Facial and preorbital edema are present.
- Dry flaking skin that is cool to the touch and yellow tinged
- Multiple bruises on both forearms and anterior lower legs.
- Scalp hair is dry and dull and breaks easily, scalp scaling.
- Sparse hair is noted in the axillae and the pubic area.
- Fingernails are short and dry; cuticles are dry and torn.
- Toenails are thick and yellow
The patient is experiencing low levels of thyroid that causes
dryness of skin. Hence, the client was bothered for the past several
months.
Hypothyroidism and/or Impaired Skin Integrity
Major: Dry-skin, Water-electrolyte imbalance, and Edema
Confirm the diagnosis because it meets the defining characteristics
and is confirmed by the patient.
NURSING CARE PLAN
Evelyn Vaughn
Objective Data:
- Lethargic
- Dry flaking skin that is cool to the touch and yellow tinged.
- Facial and preorbital edema are present.
- The client’s facial expression is blank
- Multiple bruises on both forearms and anterior lower legs.
- Scalp hair is dry and dull and breaks easily, scalp scaling.
- Sparse hair is noted in the axillae and the pubic area.
- Fingernails are short and dry; cuticles are dry and torn.
- Toenails are thick and yellow
- Lethargic - Been nibbling on crackers, lunch meat,
- Lack of energy, cannot last a day and sodas daily
without one or two 30 minutes nap
- The client’s facial expression is
blank
The patient is experiencing inactiveness, lack The client was not eating a proper meal, thus,
of energy, thus, cannot last a day without having a poor appetite.
naps.
Fatigue Malnutrition and/or Imbalanced nutrition:
Less than body requirements
Major: Expresses lethargy, lack of energy, Major: Food less than recommended dietary
weakness, and increased rest requirement allowance
Confirm the diagnosis because it meets the Confirm the diagnosis because it meets the
defining characteristics and is confirmed by defining characteristics and is confirmed by
the patient. the patient.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
Subjective Data: Risk for impaired skin Short term: Independent: Independent: Short term:
The patient stated that her integrity, skin After 8 hours of Monitor site of impaired Systematic inspection After 8 hours of nursing
skin has been dry and scaly infection, and easy nursing intervention, tissue integrity at least can identify impending intervention, the patient's dry
for the past several months fatiguability secondary the patient's dry and once daily for color problems early. and scaly skin minimized.
to Hypothyroidism scaly skin minimizes. changes, redness,
“Fly-away hair that I can’t related to lethargy, dry swelling, warmth, pain, or Long term:
do anything with” flaking skin and scalp, Long term: other signs of infection. Accordance with the method,
brittle fingernails, and Accordance with the the patient has an excellent
Brittle, easily broken multiple bruises on method, the patient Assess patient’s Inadequate nutritional wound healing and avoided
fingernails. both forearms and will be able to have nutritional status; refer for intake places the patient the infection from spreading
anterior lower legs. excellent wound a nutritional consultation at risk for skin to the rest of the skin,
Supposed to take Synthroid healing and avoid or institute dietary breakdown and preserving the client’s
daily for “my low thyroid” infection spreading to supplements. compromises healing, integrity.
the rest of the skin, causing impaired tissue
Been nibbling on crackers, preserving the client’s integrity. Goal was met.
lunch meat, and sodas integrity.
daily Analyze skin in a
systematic manner. Look To check the infection
Lack of energy, cannot last for irritating and allergicand consequences. To aid
a day without one or two contact points. Inspect allhealing in the wounds,
30 minutes nap skin areas. Pay particular and to keep track of how
attention to where skin well the wound is
continuously touches. healing. Skin is
Objective Data: especially prone to
- Lethargic breakdown because of
- Dry flaking skin changes in peripheral
that is cool to the Educate patients and circulation.
touch and yellow caregivers about proper
tinged. skin care. Educating patients and
- Facial and caregivers methods to
preorbital edema maintain skin integrity
are present. enhances their sense of
- Multiple bruises on self-efficacy and prevents
both forearms and skin breakdown.
anterior lower legs. Encourage adequate
- Scalp hair is dry nutrition and hydration.
and dull and Sufficient hydration and
breaks easily, nutrition help maintain
scaling. skin turgor, moisture, and
- Sparse hair is suppleness, which
noted in the axillae provide resilience to
 and the pubic area. Dependent: damage caused by
- Fingernails are Encourage continuation of pressure.
short and dry; regular exercise program. Dependent:
cuticles are dry Stimulates circulation,
and torn. enhancing cellular
- Toenails are thick nutrition and oxygenation
and yellow Massage and lubricate to improve tissue health.
skin with bland oil or
lotion. Enhances circulation and
protects skin surfaces.
Provide comfort measures
like judicious touch and
cool showers. May decrease nervous
energy, promoting
Collaborative: relaxation.
Administer medications
as indicated. Collaborative:
Collaboration promotes
the best long-range plan
Help patient understand for management of pain.
diet modification plan
along with dietitian, if To encourage compliance
appropriate. with prescribed diet.

Communicate with a
dietician as appropriate.
The dietician can aid the
patient and family in
food preferences to meet
adequate nutritional and
hydration goals.