Pemphigus vulgaris is a chronic blistering skin disease with skin lesions that are rarely pruritic, but which are often painful.
Pemphigus vulgaris is an autoimmune, intraepithelial, blistering disease affecting the skin and mucous membranes.
1. Acute Pain related to damage to the soft tissue, soft tissue erosion.
Goal: Pain is reduced / lost or adapted.
Expected outcomes:
- Subjectively reported reduced pain or can be adapted. Pain scale: 0 -1.
- Can identify activities that increase or decrease the pain.
- The patient is not restless.
1. Assess PQRST approach (P = Provocation / Palliation, Q = Quality / Quantity, R = Region / Radiation, S = Severity Scale, T = Timing)
Rationale: Being a basic parameter to determine the extent of intervention required and as the evaluation of the success of the intervention pain management.
2. Explain and help the patient with pain relief action nonpharmacological and noninvasive.
Rationale: The approach by using relaxation and other nonpharmacological have shown effectiveness in reducing pain.
3. Perform nursing management of pain:
a. Set the physiological position.
Rationale: It would increase the intake of oxygen into the subcutaneous tissue inflammation. Setting ideal position is in the opposite direction to the lesion pemphigus.
b. Perform maintenance of oral hygiene.
Rationale: Overall patient's oral cavity can be eroded and exposed surfaces. Necrotic tissue can form in this area so that adds to the suffering of patients and interfere with food intake. Weight loss and hypoproteinemia may occur. Careful oral hygiene care is very important to keep the oral mucosa is kept clean and allow the regeneration of the epithelium. Rinse the mouth that often must be done to cleanse the mouth and reduces pain in the area of ulceration. Be kept moist lips by applying a lip moisturizer.
c. Rest client
Rationale: Rest is needed during the acute phase. This condition will increase the supply of blood to the inflamed tissue.
d. If necessary premedication before performing wound care.
Rationale: wet and cool compresses or immersion therapy is protective measures that can reduce pain. Patients with extensive lesions and pain should receive premedication prior to the preparation of an analgesic before the skin care began.
e. Environmental management: calm environment and limit visitors.
Rationale: Tranquil environment will decrease the pain stimulus of external and visitor restrictions will help increase oxygen conditions of the room, which will be reduced if many visitors who were in the room.
d. Teach deep breathing relaxation techniques.
Rationale: Improve input oxygenation in patients, resulting in lower secondary pain from inflammation.
e. Teach technique of distraction during painful.
Rationale: Distraction can reduce internal stmulus.
f. Perform touch management.
Rationale: It can help reduce pain. Light massage can increase blood flow and automatically helps the blood supply and oxygen to the painful area, and reduce the sensation of pain.
4. Collaboration with physicians for providing analgesic.
Rationale: Analgesics block the path of pain so the pain will be reduced.
2. Impaired Skin Integrity related to local necrosis secondary to tissue accumulation of pus in the hair follicles.
Goal: Improved skin integrity optimally.
Expected outcomes:
- Increased tissue growth, improved wound state, spending pus in the wound no longer exists, the wound closed.
1. Assess soft tissue damage that occurs on the client.
rationale:
Being the basic data to provide information about wound care interventions, what tools will be used, and the type of solution that will be used.
2. Perform maintenance bullae.
Rationale: The patient with bullae broad area, has a characteristic odor which will be reduced after secondary infection under control. The patient's skin after a bath, the skin is dried carefully and sprinkled with powder that is not irritating so that the patients can move more freely in bed. The amount of powder that is pretty much it may be necessary to keep the patient's skin is not sticky on the sheets. Hypothermia often happens and actions for keeping the patient warm and comfortable is a priority in nursing activity.
Increased tissue growth, improved wound state, spending pus in the wound no longer exists, the wound closed.
3. Increase the intake of nutrients in patients.
Rationale: Nutrition is necessary to increase the intake of the needs of the body's tissues.
4. Evaluation of tissue damage and the development of tissue growth.
Rationale: If still not reached of the evaluation criteria, then it needs to be re-examined factors that can inhibit the growth of the wound.
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