• Impaired skin integrity
• Acute pain
• Imbalanced nutrition: less than body requirements
• Risk for infection
• Impaired physical mobility
• Deficient knowledge
• Disturbed body image
• Ineffective coping
III.Planning and Outcome Identification
• The major goals may include maintenance of skin integrity; relief of discomfort; absence of complications, such as altered nutrition, infection, and impaired mobility; understanding the condition to enhance compliance with prescribed therapy; and improved body image and coping.
Enhance skin integrity
• Assess the entire skin area, including the mucous membranes, scalp and nails for evidence of irritation or breakdown.
• Keep intact skin clean and dry, clean the skin with mild soap at least once daily
• Protect the skin folds and surfaces that rub together
• Keep clothing and linen clean and dry
• Protect hands by wearing gloves when using strong soaps, solvents, detergents and other chemicals
Provide pain relief.
• To help relieve pruritus, humidify the room, maintain a cool temperature, remove excess bedding and clothing, and use soaps for sensitive skin.
• Encourage diversionary activities and relaxation techniques to ensure restful sleep and to alleviate discomfort.
Promote nutritional balance
• Encourage the client to consume foods rich in protein and vitamins A,B complex C & K.
• Encourage the client to increase fluid intake to 2 to 3 L per day, unless contraindicated.
• Maintain careful handwashing and wear gloves when handling or dressing any type of skin disorder.
• Implement standard precautions when applicable, and collaborate with the infection control nurse.
Improve physical mobility. Perform passive-range-of-motion exercises and encourage the client to perform active range-of-motion exercises at least three times daily.
Provide client and family teaching.
• Instruct the client on the principles of good nutrition and the importance of exercise, rest, and sleep in maintaining healthy intact skin.
• Instruct the client to report any changes in skin lesions, including a change in seize, texture or contour
• Instruct the client on the cause of the disorder and interventions aimed at preventing complications. Discuss medication administration.
Improve coping and body image.
• Encourage the client to verbalize feeling and identify effective coping strategies to deal with the illness.
• Encourage the client to ventilate feelings about the impact that the body change has had on self-concept and his relationships with others.
• The client exhibits intact or only minimally disrupted skin integrity.
• The client’s skin heals without inflammation or vesicular eruption and exhibits no sign of infestation.
• The client reports no pain or discomfort
• The client maintains optimal nutritional balance to promote healing
• The client remains free from infection.
• The client participates in physical therapy to maintain an optimal range of motion and function and to prevent contractures.
• The client verbalizes important preventive measures to avoid complications associated with disorders of the integumentary system.
• The client exhibits healthy adaptation to body image changes.
• The client verbalizes feelings and is ale to cope effectively with disorders of the integumentary system.