Question

integumentary case study

Integumentary Case Study ONE Nursing Response & Rationale DATE/TIME EVENT 30 September 0900 Pt calls to report that the pain in her back and under her breast what to do Patient arrives at MD office indicate the reason for the orders and describe the nursing response

Answer 1

As mentioned in the case study, the physical assessment focus towards Ms.Diego suffer from Herpes Zoster.

KEY FINDINGS AND NURSING INTERVENTION.

1.Acute / chronic pain related to nerve pain as evidenced by pain localised to affected nerve

Nursing Implication:

• Assess the pain scale, severity, location , quality, precipitating factor and duration

•Educate about wearing loose , non restrictive clothing

•Educate to avoid hot and cold air and water

•Educate to avoid rubbing and scratching the skin

• Advice to stick on to medication regimen

2.Deficient knowledge related to complexity of treatment as evidenced by verbalizing inaccurate information.

Nursing Implication:

•.determine clients and caregivers knowledge level

• determine the vaccination status of client and family memebers

•explain the need of isolation

• encourage herpes zoster vaccination

• Provide necessary information about disease management as leaflet or brochure

3.Risk for infection related to skin lesion as evidenced by assessment

Nursing Implication:

• Assess for severity of skin lesion, its location and presence.

• Assess for pruritis , amount of scratching

• Assess for client and family meembers immunization status and past history of chicken pox

•Obtain culture and sensitivity of infected lesion and blood work as indicated

• Educate on universal precaution to prevent disease transmission.

• Advice to adhere to medication regimen as prescribed

4.Risk for disturbed body image related to visible skin lesion

Nursing Implication:

• Assess the clients perception about her changed body appearence

•Note verbal reference to skin lesion

•Discuss reason for social isolation

• Suggest use of well covered , non irritating loose clothing to help to adjust to body image changes

REASON FOR ORDER AND NURSING RESPONSIBILTY:

1.IBUPROFEN :

Its a nonsteroidal anti inflammatory drug.

Nurses should observe for GI bleeding, anaphylaxis reaction, check for headache, nausea , vomiting and constipation in client, advice patient to avoid alcohol.

2.Cool compress :

It help to provide a mild relief from bothersome itching and inflammation and help to reduce swelling

Nurses should make sure to avoid too cold water for compression as it cause burning sensation, and take client consent as the compress to be provided to the private areas.

3..Acyclovir:

It is an antiviral drug of choice for herpes zoster disease

The nurse should observe for any side effects like vasculitis, anaphylaxis etc

4. Shingrix vaccine provided to avoid reoccurence and prevent varicella episodes.