3.3           Intervention

no

No.

Diagnosis Intervention Rational

1. Acute Pain related

with virus infection

and dermal eruption.

Purpose :

After do the nursing

action, patient show

the pain is gone and

decrease.

Outcome criteria :

1.   Scale of pain

decrease.

2.   Client not scratch

the region with

vesicle, and vital

signs normal

3

1.  Observation the regional

and pain intensity, itch.

2.   Recommend client for

not itch too hard at

region of itch.          

Teach and recommend

client for do the technic

relactation and distraction.

4.   Recommend to change

the underwear as often as

probable.

5.   Colaboration with doctor

in granting :

ü - rinse the m outh

ü – Soak the drugs

ü - Analgetic

1. Know the location and pain

intensity with the result that can

planning further action.

2. Shun beenacted the lesion that

too in.

3. Can cause the muscles become

be as relactation and reduce

stimulation.

4. Can avoid eff loresce

bactery/virus can make heavier

condition of client.

5. Can reduce/kill lamentation

of pain.

2. Disturbance integrity of

skin related with the

lesion, krusta on the

skin, and pruitis.

Purpose:

After do the nursing

action, patient show

the integrity of skin a

good.

Outcome Criteria:

1. Recommend client to

increase personal

hygiene the skin with

take a bath 3x one day

on a regular basis with

clean water.

2. Recommend to repair

nutritional status and

diet.

3. Recommend for wear

mouthwash/soak the

1. restrain distributing virus with

restrain the occurrence of

secunder infection.

2. Nutritional status a good, restrain

the occurrence of the more severe

infections.

3. Restrain wide spreading and

1. No lesion  

2. the skin looks

intact

3. The vesicles

gone

2

drugs in accordance

with the infection

suffered.

4. Teach manner oral

hygiene and vulva

hygiene appropriate

procedures.

4

getting in of lesion.

4. Restrain spreading infection.

3. Hipertermia related

with infection process

herpes virus.

Purpose:

After do the nursing,

patient show body

temperature in normal

range (36,5 – 37,50C)

Outcome Criteria:

1. body temperature

in normal (36,5 –

37,50C)

2. vital signs normal.

3. Colour the skin

florid (normal)

4. Do not experience

distress respiration,

nervous or

lethargy.

3.      

1.    monitor the

existence of signs

of seizures and

hydration.

2. monitor the vital

signs.

3. remove the excess

clothing.

4.    Use a cold/warm

compress

corresponding

increase in body

temperature.

5. recommend liquid

one oral.

6.    collaboration

giving a antipyretic,

with indication.

1. shun the risk of

enhancement body

temperature.

    

2.  know development of

patient.

3.  substract production the

over warm.

4.     go down the body

temperature.

5. Shun the dehydration

consequence raising of body

temperature.

6. Go down the body

temperature.