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    20 NCP Impaired Skin Integrity

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    Steffi Muriel
    The patient presented with a rash characterized by erythematous plaques and white scale on their face, abdomen, arms, legs, feet, and hands caused by syphilis. The diagnosis was impaired skin integrity secondary to the rash. The nursing interventions included daily skin assessment, good skin hygiene, clean linen, ambulation, filing nails, and administering prescribed antibiotics and steroids. Collaboration with other healthcare providers was also required.

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    20 NCP Impaired Skin Integrity

    Uploaded by

    Steffi Muriel
    65 views4 pages
    The patient presented with a rash characterized by erythematous plaques and white scale on their face, abdomen, arms, legs, feet, and hands caused by syphilis. The diagnosis was impaired skin integrity secondary to the rash. The nursing interventions included daily skin assessment, good skin hygiene, clean linen, ambulation, filing nails, and administering prescribed antibiotics and steroids. Collaboration with other healthcare providers was also required.

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    NCP

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    The patient presented with a rash characterized by erythematous plaques and white scale on their face, abdomen, arms, legs, feet, and hands caused by syphilis. The diagnosis was impaired skin integrity secondary to the rash. The nursing interventions included daily skin assessment, good skin hygiene, clean linen, ambulation, filing nails, and administering prescribed antibiotics and steroids. Collaboration with other healthcare providers was also required.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    65 views4 pages

    20 NCP Impaired Skin Integrity

    Uploaded by

    Steffi Muriel
    The patient presented with a rash characterized by erythematous plaques and white scale on their face, abdomen, arms, legs, feet, and hands caused by syphilis. The diagnosis was impaired skin integrity secondary to the rash. The nursing interventions included daily skin assessment, good skin hygiene, clean linen, ambulation, filing nails, and administering prescribed antibiotics and steroids. Collaboration with other healthcare providers was also required.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 4

    Impaired Skin Integrity

    Assessment

    Subjective:

    Objective:
    - (+) HIV infection
    - Rash characterized
    by erythematous
    plaques and
    overlying white
    scale involving the
    face, abdomen,
    arms, legs, feet,
    and hands,
    including palms

    Diagnosis

    Impaired skin
    integrity evident by
    skin rashes secondary
    to syphillis

    Nursing Intervention

    Independent:
    1. Assess skin daily. Note color, turgor, circulation,
    and sensation. Describe and measure lesions and
    observe changes. Take photographs if necessary.
    2. Assess bony prominences, perineum, and
    dependent and pruritic areas for pallor, redness,
    and breakdown.
    3. Maintain and instruct in good skin hygiene:
    wash thoroughly, pat dry carefully, and gently
    massage with lotion or appropriate cream.
    4. Maintain clean, dry, wrinkle-free linen,
    preferably soft cotton fabric.
    5. Position client properly; use pressure-reducing
    or pressure-relieving devices
    6. Instruct or assist client to shift weight at least
    every 30 minutes
    7. Encourage ambulation as tolerated.
    8. File nails regularly.
    9. Apply and administer medications as indicated.

    10. If tissue breakdown occurs notify appropriate


    health care provider

    Collaborative:
    1. Administer prescribed antibiotics (IV penicillin)
    2. Administer prescribed Glucocorticoid
    (prednisone) for inflammation
    4. Assist in procedures
    3. Collaborate with other involved health care
    team members

    Assessment

    Diagnosis

    Nursing Intervention

    Subjective:

    Objective:
    - (+) HIV infection
    - Rash characterized
    by erythematous
    plaques and
    overlying white
    scale involving the
    face, abdomen,
    arms, legs, feet,
    and hands,
    including palms

    Impaired skin
    integrity evident by
    skin rashes secondary
    to syphillis

    Independent:
    1. Assess skin daily. Note color, turgor,

    circulation, and sensation. Describe and


    measure lesions and observe changes. Take
    photographs if necessary.
    2. Maintain and instruct in good skin
    hygiene: wash thoroughly, pat dry
    carefully, and gently massage with lotion or
    appropriate cream.
    3. Maintain clean, dry, wrinkle-free linen,
    preferably soft cotton fabric.
    4. Encourage ambulation as tolerated.
    5. File nails regularly.
    6. Apply and administer medications as
    indicated.
    Collaborative:
    1. Administer prescribed antibiotics (IV penicillin)
    2. Administer prescribed Glucocorticoid
    (prednisone) for inflammation
    4. Assist in procedures
    3. Collaborate with other involved health care

    team members

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