Nursing Diagnosis and Nursing Interventions

Nursing Diagnosis and Nursing Interventions for Erythroderma

Erythroderma is the term used to describe intense and usually widespread reddening of the skin due to inflammatory skin disease. It often precedes or is associated with exfoliation (skin peeling off in scales or layers) when it may also be known as exfoliative dermatitis (ED).

Symptoms
  • Severe redness and shedding of skin over a large area of the body.
  • Exfoliation often occurs in large "sheets" instead of smaller scales.
  • Skin looks as if it has been burned.
  • Heart rate increases.
  • Severe itching and pain.
  • Body temperature goes up and down, especially on very hot or cold days.

Nursing Diagnosis and Nursing Interventions for Erythroderma

1. Impaired skin integrity related to the lesion and the inflammatory response

Expected results:
  • Shows an increase of of skin integrity
  • Avoid skin injury

Plan of actions:
  • Assess the skin in general circumstances
  • Instruct the patient to not pinch or scratch the skin area
  • Maintain skin moisture
  • Reduce the formation of scales with the provision of bath oil
  • Motivate patients to eat high nutrition

2. Risk for infection related to hipoproteinemia

Goal:
No infection

Expected results:

  • No signs of infection (rubor, color, dolor, functional laesa)
  • Does not arise a new wound

Plan of actions:
  • Assess for presence, existence of, and history of risk factors Such as open wounds and abrasions
  • Monitor white blood count (WBC)
  • Monitor signs of infection
  • Assess nutritional status
  • Keep the wound clean
  • Collaboration antibiotics

Share :

Facebook Twitter Google+

Nursing Diagnosis - Nursing Interventions

NANDA NURSING

Powered by Blogger.
Back To Top