1. Acute Pain / Chronic Pain related to the inflammatory process
- Observation of the patient's pain level (0-10 scale)
- Teach patient distraction techniques, relaxation
- Give a comfortable position
- Collaboration of analgesic
- Knowing the degree of pain
- Distraction, relaxation can help relieve pain
- Provide comfort to the patient so as to reduce the perceived pain
- Giving analgesics can help relieve the patient's degree of pain.
2. Disturbed Body Image related to the state of the wound
- Observation meaning changes experienced by the patient.
- Involve the family or significant others in care.
- Note the withdrawn behavior: increased dependency, manipulation or not involved in treatment.
- Knowing the patient's feelings about the situation and control his emotions.
- Support the family and those closest to accelerate the healing process.
- Alleged problems with that assessment may require further evaluation and more rigorous therapy.
3. Knowledge Deficit related to lack of information about the disease
- Discuss about skin care, for example: use a moisturizer and sun protection.
- Provide information about hygiene, disease prevention and treatment.
- Emphasize the importance of evaluating treatments.
- Improve self-care after discharge and independence.
- Increase patients' knowledge.
- Continue long-term support and therapy changes are needed to achieve optimal healing.
4. Anxiety related to disability
- Observation degree of patient anxiety.
- Inform patients that the normal feelings.
- Berkan physical comfort, environmental tenag and rest.
- Knowing the patient's anxiety level so as to provide appropriate health information.
- Understanding that the normal feelings can help patients improve some feeling of control emotions.
- Sense of comfort to increase relaxation which helps reduce anxiety.
5. Impaired Skin Integrity related to damage to the skin surface
- Observation, or write down the size, condition warnadan skin around the wound in fig.
- Change positions frequently.
- Give frequent skin care to prevent dry or moist.
- Determine the development of the patient's wound and surrounding skin.
- Improve blood circulation.
- Going dry / humid may damage the skin and accelerate the damage.
Risk for Infection related to Acne