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Monthly Archives: November 2012

Risk for Infection – Dermatitis

Risk for Infection – Dermatitis Nursing Care Plans

Common Risk Factors
Impaired skin integrity Severe inflammation Excoriation
Common Expected Outcome Patient remains free of secondary infection. NOC OutcomesRisk Detection; Risk Control; Tissue Integrity: Skin and Mucous MembranesNIC Interventions Skin Surveillance; Infection Control; Infection Protection

Ongoing Assessment

Actions/Interventions Rationale
Assess skin for severity of skin integrity compromise. The skin is the body’s first line of defense against infection. Disruption of the integrity of skin increases the patient’s risk of developing an infection or of scarring.
Assess for signs of infection. Patients with dermatitis are at highest risk for developing skin infections caused byStaphylococcus aureus. Purulent drainage from skin lesions indicates infection. With severe infections, the patient may have an elevated temperature.

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Disturbed Body Image – Dermatitis

Disturbed Body Image – Dermatitis Nursing Care Plans

Common Related Factor Defining Characteristics
Visible skin lesions Verbalizes feelings about change in body appearance Verbalizes negative feelings about skin condition Fear of rejection or reactions of others
Common Expected Outcome Patient verbalizes feeling about lesions and continues daily activities and social interactions. NOC Outcome Body Image NIC InterventionBody Image Enhancement

Ongoing Assessment

Actions/Interventions Rationale
Assess the patient’s perception of changed appearance. The nurse needs to understand the patient’s attitude about visible changes in the appearance of the skin that occur with dermatitis.
Assess the patient’s behavior related to appearance. Patients with body image issues may try to hide or camouflage their lesions. Their socialization may decrease based on anxiety or fear about the reactions of others.

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Impaired Skin Integrity – Dermatitis

 Impaired Skin Integrity – Dermatitis Nursing Care Plans

Common Related Factor Defining Characteristics
Contact with irritants or allergens
  • Inflammation
  • Dry, flaky skin
  • Erosions, excoriations, fissures
  • Pruritus, pain, blisters
Common Expected Outcome Patient maintains optimal skin integrity within limits of the disease, as evidenced by intact skin. NOC OutcomesKnowledge: Treatment Regimen; Tissue Integrity: Skin and Mucous MembranesNIC Interventions Skin Care: Topical Treatments; Skin Surveillance; Teaching: Procedure/Treatment

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Dermatitis Nursing Care Plans

Dermatitis is a general term that describes an inflammation of the skin. There are different types of dermatitis, including seborrheic dermatitis and atopic dermatitis (eczema). Although the disorder can have many causes and occur in many forms, it usually involves swollen, reddened and itchy skin.
Dermatitis is a common condition that usually isn’t life-threatening or contagious. But, it can make you feel uncomfortable and self-conscious. A combination of self-care steps and medications can help you treat dermatitis.
  1. Impaired Skin Integrity -Dermatitis
  2. Disturbed Body Image  -Dermatitis
  3. Risk for Infection  -Dermatitis
  4. Risk for Impaired Skin Integrity  -Dermatitis
Source:
 http://ncplist.blogspot.com/search/label/Dermatitis

Fatigue — Diabetes Mellitus

Diabetes Mellitus Nursing Care Plans

Nursing Diagnosis:  Fatigue
May be related to
  • Decreased metabolic energy production
  • Altered body chemistry: insufficient insulin
  • Increased energy demands: hypermetabolic state/infection
Possibly evidenced by
  • Overwhelming lack of energy, inability to maintain usual routines, decreased performance, accident-prone
  • Impaired ability to concentrate, listlessness, disinterest in surroundings

Deficient Fluid Volume — Diabetes

Deficient Fluid Volume Diabetes Mellitus Nursing Care Plan

Nursing Diagnosis: Deficient Fluid Volume
May be related to
  • Osmotic diuresis (from hyperglycemia)
  • Excessive gastric losses: diarrhea, vomiting
  • Restricted intake: nausea, confusion
Possibly evidenced by:
  • Increased urinary output, dilute urine
  • Weakness; thirst; sudden weight loss
  • Dry skin/mucous membranes, poor skin turgor
  • Hypotension, tachycardia, delayed capillary refill

Imbalanced Nutrition Less Than Body Requirements — Diabetes Mellitus

 Imbalanced Nutrition Less Than Body Requirements — Diabetes Mellitus Nursing Care Plans

Nursing Diagnosis: Imbalanced Nutrition Less Than Body Requirements
May be related to:
  • Insulin deficiency (decreased uptake and utilization of glucose by the tissues, resulting in increased protein/fat metabolism)
  • Decreased oral intake: anorexia, nausea, gastric fullness, abdominal pain; altered consciousness
  • Hypermetabolic state: release of stress hormones (e.g., epinephrine, cortisol, and growth hormone), infectious process
Possibly evidenced by:
  • Increased urinary output, dilute urine
  • Reported inadequate food intake, lack of interest in food
  • Recent weight loss; weakness, fatigue, poor muscle tone
  • Diarrhea
  • Increased ketones (end product of fat metabolism)

Powerlessness — Diabetes Mellitus

 Powerlessness — Diabetes Mellitus Nursing Care Plan

Nursing Diagnosis: Powerlessness
May be related to
  • Long-term/progressive illness that is not curable
  • Dependence on others
Possibly evidenced by
  • Reluctance to express true feelings; expressions of having no control/influence over situation
  • Apathy, withdrawal, anger
  • Does not monitor progress, nonparticipation in care/decision making
  • Depression over physical deterioration/complications despite patient cooperation with regimen

Risk for Disturbed Sensory Perception — Diabetes Mellitus

 Risk for Disturbed Sensory Perception — Diabetes Mellitus Nursing Care Plan

 Image Courtesy: http://nurseslabs.com
Nursing Diagnosis: Sensory Perception, risk for disturbed (specify)
Risk factors may include
  • Endogenous chemical alteration: glucose/insulin and/or electrolyte imbalance

Risk for Infection — Diabetes Mellitus

Risk for Infection — Diabetes Mellitus Nursing Care Plans

 Image Courtesy: http://nurseslabs.com
Nursing Diagnosis:  Risk for Infection
Risk factors may include:
  • High glucose levels, decreased leukocyte function, alterations in circulation
  • Preexisting respiratory infection, or UTI