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ASSESSMENT NSG.

DX RATIONALE PLAN INTERVENTIONS RATIONALE EVALUATION


S>”makati sya Impaired A skin After 2 days of 1.identify 1. to assess causative After 2 days of
meron ako sa Skin infection NI, patient will underlying cause of factor NI, there will be
buong katawan.” Integrity r/t caused by the be able to skin disruption no further skin
presence of itch mite. prevent (communicable dse.) breakdown will
O> observed invasive Scabies is further skin be noted and
patient constantly parasites typified by breakdown 2. note 2. to assess extent of patient will
scratches whole severe itching, and remained characteristic of involvement of skin remain free from
body. red papules. to be free from lesions, inspect disruption. s/sx of infection
Presence of red Itching is a signs and extent of skin
papules over upper allergic symptoms of affection.
and lower reaction to the infection.
extremities, nape mite, its egg 3. provide skin care, 3. to prevent transfer of
area, observed and feces. In keeping areas clean/ microorganism and
poor hygiene and this which may dry. further extension of skin
grooming cause disruption.
(+) capillary refill disruption of
Temp: 36.8 C skin surface. 4. Monitor vital 4. may indicate an
signs especially infection
temperature

5. Assist the client 5. enhances commitment


in understanding to plan, optimizing
proper daily skin outcomes
maintenance

ASSESSMENT NSG.DX RATIONALE PLAN INTERVENTIONS RATIONALE EVALUATION


S> Araw-araw ako Self-care After 2 days of After 2 Days of
naliligo, hindi ako deficit: NI, client will NI, Px will be
nagsha-shampoo at grooming/h be assisted in 1. Assess current 1. Provides information able to be
nagsisipilyo.” ygiene r/t proper level of functioning; about changes in assisted in
lack of grooming and reevaluate daily. individual proper grooming
O> noticed client concern hygiene abilities necessary for and hygiene
constantly and planning/altering care.
scratches her body, inattention 2. Provide physical
poor grooming and to ADLs assistance, 2. Helps focus attention
hygiene, unable to supervision and on task.
combed hair, and simple Providing
yellowish teeth, only
presence of scabies directions/reminder
all over the s, encouragement
extremities, nape and support,
area required assistance
fosters autonomous
as needed.

3. Assist in
grooming and 3. in able patient to
Hygiene attend to own activities of
daily living

4. Instruct client of 4. redirects client to daily


proper grooming routines
and hygiene

ASSESSMENT NSG.DX RATIONALE PLAN INTERVENTIONS RATIONALE EVALUATION


S>”meron Risk for After 2 days of 1. ask directly if 1. determines intent After 2 days of
nagsasabi sa akin Suicide r/t NI, client will thinking of suicide NI, client will be
na boses na loss of be involved in able to be
papatayin daw nya important planning 2. develop 2. promote sense of trust, involve in the
ako.”, “dati relationship course of therapeutic nurse- allowing individual to plan ofaction to
sinubukan ko ng action to client relationship discuss feeling openly correct existing
magpakamatay.” correct existing problems
“yung ka live-in ko problems 3. encourage 3. acknowledge reality of
One year na expression of feelings and that they are
kaming nagsasama feelings and make okay.
nun, 6years ko na time to listen to
syang boyfriend, concerns
me chismis na me
babae sya, 4. help client 4. to lessen sense of
tapos sinasaktan identify more anxiety
nya ako.” appropriate
solutions, behavior
O> patient with flat
affect, loss of an 5. Engage client in 5. promotes feelings of
important psychotherapy self-worth and improves
relationship, program sense of well-being