ASSESSMENT O- Demonstrates itchiness of the affected area.

(+)dry skin (+)Scabies (+)

DIAGNOSIS Impaired skin integrity r/t

PLANNING After the rotation, the patient will verbalize feelings of increased self esteem and ability to manage the situation.

INTERVENTION Evaluate client with impaired cognition, developmental delay and need for/ use of restrains. Periodically, re measure wound and observe for complications. Keep the area clean and dry, prevent infection, manage incontinence and stimulate circulation of the surroundings areas. Apply appropriate dressing. Limit/avoid use of plastic material.

RATIONALE To identify risk for injury/ safety requirements.

EVALUATION Goal was partially met After nursing interventions, the client verbalized feelings of increased self esteem and ability to manage the situation. And she has still skin rashes and lesions but it lessened the itchiness.

To monitor the progress of wound healing. To assist body natural process of repair.

For wound healing and to best meet needs of client and caregiver/care setting. Moisture potentiates skin breakdown.