St.

Paul College of Ilocos Sur

Member, St. Paul University System

St. Paul Avenue, 2727 Bantay, Ilocos Sur

DEPARTMENT OF NURSING
BACHELOR OF SCIENCE MAJOR IN NURSING

NSC 103 Microbiology and Parasitology Laboratory

1ST Semester A.Y. 2022-2023

Ms. Katya Amelia A. Valido

(Clinical Instructor)

Name: Kristine Angie Ramos Score:

Section/Course: BSN-2C

Assessment Nursing Planning Interventions Rationale Evalutation

Diagnosis

Subective: Impaired The  Assess  Specific types of The patient

Skin patient will
Dry and flacky skin. skin, noting dermatitis may ables to
Integrity maintain
optimal color, have maintain
related to
skin
Objective: allergens, moisture, characteristic his/her
integrity
- Inflammation evidenced within the texture, and patterns of skin optimal skin
by dry and limits of
- Fissures temperature changes and integrity.
flacky skin. the
disease, ; note lesions.
as
erythema,
evidenced
by intact edema, and
skin.
tenderness.  Flexural areas
 Assess the (elbows, neck,
skin posterior knees)
systematica are common
lly. Look for areas affected by
areas of atopic dermatitis.
irritant and  Open skin lesions
allergic increase the
contact. patient’s risk for
infection.
 Assess skin Thickening occurs
for lesions. in response to
Note the chronic scratching
presence of
excoriations  One of the first
, erosions, steps in the
fissures, or management of
 thickening. dermatitis is
promoting healthy
skin and healing
 Encourage
skin lesions.
the patient
 ation. Moisturizing
to adopt
is the cornerstone
skin care
of treatment.
routines to
Over-the-counter
decrease
moisturizing
skin
lotions include
irritation:
Eucerin,
Lubriderm, and
Nivea. Lotions are
 Apply lighter and less
topical emollient than
steroid creams. If more
creams or moisturizing is
ointments. required than a
lotion can
provide, a cream
is recommended.
These include
Keri cream,
Cetaphil cream
Assessment Nursing Planning Interventions Rationale Evalutation
Diagnosis

Subjective: Risk of With this  Assess the  Proper skin After the
Pain, fatigue, infection nursing skin for assessment nursing
coughing and related to care plan, color, and
mascles aches. Increased texture, documentatio interventions
you can
exposure to elasticity, n facilitates
expect the the patient is
Objective: pathogens, and prevention of
evidenced patient moisture. the now free from
- Fever by fever, to:Remain breakdown of signs of
- Redness muscles free from skin
- Highblood ache, signs of  Routinely breakdown infections.
highblood any monitor the which is the
pressure
pressure. patient’s body’s first
infection
white blood line of
cell count, defense
serum against
protein, and pathogens.
serum  These
albumin. laboratory
 Assess the values are
temperatur closely linked
e of to the
neutropenic patient’s
clients nutritional
every 4 status and
hours. immune
 Monitor the function.
patient for  Neutropenic
any signs of patients may
swelling, not have an
purulent adequate
discharge inflammatory
or presence response. In
of pain from most cases,
wounds, fever is the
injuries, only symptom
catheters or they’ll show.
drains.  These are the
 Encourage classic signs
patient to of infection.
increase  It helps thin
fluid intake out
if not secretions
contraindic and replace
ated. fluid loss
 Encourage during fever.
adequate It also
rest. prevents
stasis of urine
by promoting
diluted urine
and frequent
emptying of
the bladder.
 It can reduce
stress and
boost the
immune
system.