ASSEESSMENT Subjective: Nangangati ako. Kanina ko pa to kinakamot eh.

As verbalized by the patient Objective: -Irritable - Redness of the skin - Hermans rash

NURSING DIAGNOSIS Risk for impaired skin integrity related to altered circulation

INFERENCE Aedes Aegypti (Dengue virus carrier)

EXPECTED OUTCOME Short Term Goal: After 1 hour of nursing intervention, patient will demonstrate behavior in preventing skin impairment as evidenced by:

NURSING INTERVENTION Independent: -Monitor vital signs

RATIONALE Independent: - Serves as baseline data to determine any discrepancies - Early recognition of signs of impaired skin integrity allows prompt intervention - The outermost layers of the skin can be damaged when dragged along or rubbed against another surface -To maintain Skin integrity at Optimal level. Keeping skin clean removes many surface microorganisms, which, if allowed to accumulate, increase the risk for irritation or infection and

EVALUATION After 1 hour of rendering effective nursing intervention the goals are fully met as evidenced by patients demonstration of behavior in preventing skin impairment by applying measures in preventing friction of the skin and how to prevent the drying of the skin.

Bite from mosquito

Dengue Virus Type I

- Inspect the skin for pallor, redness and breakdown.

a. application of IgG adheres to the measures in platelet preventing friction of the skin as well as Thrombocytopenia scratching. b. Following measures to prevent drying of the skin

- Implement measures to reduce friction between the skin and another surface.

Increased potential for hemorrhage

Stimulates intense inflammatory response

-Provide skin hygiene through sponge bathing & changing regularly

Hermans rash

subsequent skin breakdown. - Keep bed clothes dry, use nonirritating materials, & keep bed wrinkled free - Implement measures to prevent drying of the skin such as encourage a fluid intake of 2500ml/day and apply moisturizing lotion at least once a day - Provide information to the client about the importance of regular observation & effective skin care -To avoid lesions, scratching of skin & harboring of Microorganism. - Dry skin is more prone to cracking and has decreased elasticity, which make it susceptible to damage.

- To promote wellness by gaining knowledge on treatment/ therapy

ASSEESSMENT Subjective: -Medyo nalulungkot ako dahil sa kalagayan ko ngayon As verbalized by the client. Objective: -Patient is conscious and coherent. - irritability -Restlessness -facial grimace

NURSING DIAGNOSIS Anxiety related to change in health status and associated changes in role function.

INFERENCE Change in health status

EXPECTED OUTCOME Short Term Goal: After 8 hrs. of nursing care, the client will appear relaxedand the level of anxiety is reduced

NURSING INTERVENTION Independent: -Assess patients Coping mechanisms in handling anxiety.

RATIONALE Independent: -This assessment helps determine the effectiveness of coping strategies currently used by patient -Acknowledgement of patients feeling and validates the feelings and communicates acceptance of those feelings.

EVALUATION After of 3 hrs. nursing care, the client was relaxed and the level of anxiety was reduced.

Worried in his limitation (e.g.activity, diet, role)

Anxiety -Acknowledge awareness of patients anxiety.

-Encourage patient -Recognize to talk about level of anxious anxiety. feelings and examine the anxiety, provoking situation.