Nursing Care Plan for Pyoderma (NIC – NOC)

Nursing care plan for pyoderma (nic - noc) 1

Pyoderma Definition

Pyoderma is a skin disease caused by Staphylococcus, Streptococcus, or by both.

Etiology

The main cause is Staphylococcus aureus and Staphylococcus B hemolytic, whereas Staphylococcus epidermidis is a normal inhabitant of the skin and rarely cause infections.

Predisposition Factor

1. Poor hygiene.
2. Immune deficiencies.
For example: malnutrition, anemia, chronic disease, malignant neoplasm, diabetes mellitus.
3. There has been other skin diseases.
Because there is damage in the epidermis, the skin functions as a protective be disturbed so as to facilitate infection.

Various forms Pyodema:

1. Impetigo
Impetigo is superfisialis pyoderma (limited to the epidermis). There are 2 forms of impetigo is impetigo krustosa and bulosa.

2. Folliculitis
An inflammation of the hair follicles, usually caused Staphylococcus aureus.

3. Furunkel / carbuncle
An inflammation of the hair follicle and surrounding areas. If more than an Furunkulosis mentioned, carbuncle is Furunkel group. Usually caused by Stapyhlococcus aureus, complaints usually painful.

4. Ecthyma
Ecthyma is superficial ulcers with krusta on it due to infection by Streptococcus.

Nursing Care Plan for Pyoderma (NIC – NOC)

1. Impaired skin integrity

Definition
Changes in the dermis and epidermis

Related factors:
Hyperthermia, skin moisture, mechanical factors, drugs, radiation, extreme age, immunologic deficits, changes in sensations, changes in fluid status, changes in pigmentation, changes in circulation.

NOC:

1. Tissue Integrity: Skin and mucous membranes
Definition: the completeness of structure and physiological function of the skin and mucous membranes
Indicators:

  • Tissue temperature as expected
  • Sensation as expected
  • Elasticity as expected
  • Hydration as expected
  • Pigmentation as expected
  • Perspiration as expected
  • Color as expected
  • Texture as expected
  • Thickness as expected
  • Free tissue lesions
  • tissue perfusion
  • Hair growth on skin
  • Leather intake

Description:
1: very problematic
2: problematic
3: moderate
4: a little problematic
5: no problem

NIC:

1. Topical Skin curry

  • Prevent the use of coarse-textured linen.
  • Avoid lesions of manipulation and contamination.
  • Make skin care aseptically 2 times a day.
  • Give the topic of therapy, based on the program.
  • Give antibiotic / anti-inflammatory appropriate program.
  • Encourage intake of high calorie and high protein.

II. Risk for Infection

Definitions :
Increased risk of entry of pathogenic organisms

Related factors :
Invasive procedures, trauma, tissue damage and increased exposure, malnutrition, immunosuppression, inadequate primary defenses (skin damage), inadequate secondary defenses (decreased hemoglobin, leukopenia)

NOC :
1. Knowledge : Control of infection
Definition : the level of knowledge on the prevention and control of infection
Indicators :

  • Describe the ways the spread of infection.
  • Describe the factors that contribute to the spread.
  • Explain the signs and symptoms.
  • Describing the activities that can increase resistance to infection.

Description :
1 : never
2 : limited
3 : moderate
4 : often
5 : always

2 . Nutritional Status
Definition : the level of nutritional needs in accordance with the requirement for metabolic
Indicators :

  • Nutritional intake
  • Food and fluid intake
  • Energy
  • Body mass
  • Weight loss

Description :
1 : very problematic
2 : problematic
3 : moderate
4 : a little problematic
5 : no problem

NIC:
1. Infection control
Definition: get the infection and minimize the transmission of infectious agents
Intervention:

  • Clean up the environment after use by patients.
  • Replace equipment after each patient action.
  • Limit the number of visitors.
  • Teach hand washing to maintain the health of the individual.
  • Instruct the patient to wash hands properly.
  • Use antimicrobial soap for hand washing.
  • Encourage visitors to wash their hands before and after leaving the patient’s room.
  • Wash hands before and after patient contact.
  • Perform universal precautions.
  • Use sterile gloves.
  • Perform aseptic care, in all IV lines.
  • Perform proper wound care techniques.
  • Teach the patient to capture urine midstream.
  • Increase the intake of nutrients.
  • Encourage adequate fluid intake.
  • Instruct the rest.
  • Give antibiotic therapy.
  • Teach patients and families about the signs and symptoms of infection.
  • Teach patients and family members how to prevent infection.

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