ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Subjective: namamaga yung paa ko at may mga pantal pantal As verbalized by the patient. Objective: -palpable Purpuric rashes -lower extremities edematous (especially feet)

Impaired tissue integrity related to increase vascular per meability secondary to bacterial infection. There is tissue deposition of IgA containing immune complexes especially within the small vessels. The abnormal response of the immune system is unclear why it occurs, but it seems to represents an unusual reaction of the bodys immune system that is response to infection (either bacterial or virus). Small vessels called capillaries in the skin are affected due to increase vascular permeability resulting to skin rash which Is most prominent over the buttocks and behind the lower extremities

After 8 hours of nurse patient intervention the patient will be able to:-Prevent/ minimize occurrence ofcomplicationsmaintain nor m al range of temperaturedemonstrate tiss ue regeneration

-Assess environmental location of home and work or school, as well as recent travel.

-Some areas of a country or city may be susceptible to certain disease conditions or environmental problems. -That may be impacting tissue health. -For comparative baseline.

-Note poor hygiene or health practices.

-Assess skin and tissues, bony prominences, pressure areas and wounds like note for the color, texture and turgor. Assess areas of least pigmentation for color change. Note presence, location and degree of edema. Record the size, color, location texture of the wounds or lesions. Observe for other distinguishing characteristics of surrounding tissue. -Inspect lesions or wounds daily, or appropriate, for changes.

-Promotes timely intervention and revision of plan of care. -To facilitate healing.

-Promote optimum nutrition with high-quality protein and sufficient calories, vitamins, and mineral supplements. -Discuss importance of early detection and reporting of changes in condition or any unusual physical discomforts or changes in pain characteristics. -Help client and family identify effective successful coping mechanisms and implement them.

After 8 hours of nurse patient intervention the patient was able to: -Prevent occurrence of co mplications as evidenced by absence of signs and manifestations of any complicatio n such as (dermatitis) therefore goal met partially demons trate tissue regeneration due to lack of medicine. Therefore goal partially met

-Promotes early intervention and reduces potential for complications.

-To reduce pain or discomfort and to improve quality of life.

ASSESSMENT

DIAGNOSIS

PLANNING

IMPLEMENTATION

RATIONALE

EVALUATION

Subjective: hindi ako makatulog As verbalized by the patient. Objective: -Irritability -Fatigue -Weakness

Sleep pattern disturbances related to pruritus and discomfort secondary to disease process Pruritus and hyper irritability are related to large amounts of histamine in the skin. This occursinresponse toimmediate immunologic response between specific antigen and antibody. The interaction of foreign antigen which specific antibodies causes subsequent release of histamine and other mediators. Medsurg. Smeltzeret. Al Vol.2 pp 19701865

After 8 hrs of nurse patient interaction the patient will be able to: -minimize pruritus and discomfort -Obtain adequate sleep as evidence by minimize fatigue

-Identify presence of factors known to interfere with sleep.

-Sleep problems can arise from internal and external factors and may require assessment over time to differentiate specific cause(s). -These factors can reduce clients ability to rest and sleep at a time when more rest is needed.

After 8 hours of nurse patient interaction the patient was able to: Minimize discomfort and pruritus as evidenced by absence of scratching therefore goal met. Obtain adequate sleep as evidenced by 7 - 8 hours of sleep and absence of eye bags therefore goal met.

-Note environmental factors, such as unfamiliar or uncomfortable room; excessive noise and light, uncomfortable temperature; frequent medical and monitoring interventions; and roommate actions- snoring, watching television late at night, wanting to talk. -Assess clients usual sleep patterns and compare with current sleep disturbance, relying on client report of problem. -Listen to reports of sleep quality and response from lack of good sleep.

-To ascertain intensity and duration of problems.

-Helps clarify clients perception of sleep quantity and quality and response to inadequate sleep. -to maintain daytime light and nighttime dark. -To promote readiness for sleep, and improve sleep duration and quality.

-Adjust ambient light.

-Minimize sleep-disturbing factors (shut room door, adjust room temperature as needed, reduce talking and other disturbing noises such as phones and alarms). -Encourage appropriate indoor light settings during day and night, avoidance of daytime napping as appropriate for age and situation, being active during day and more passive in evening.

-Helps in promotion of normal sleep-wake patterns.