Student Nurses’ Community
NURSING CARE PLAN – Rabies ASSESSMENT SUBJECTIVE: “Nakagat ako ng aso habang pauwi ako” (I got
bitten by a dog on my way home) as
DIAGNOSIS Impaired skin integrity related to disruption of skin surface with destruction of skin layers.
INFERENCE
PLANNING After 8 hours of nursing interventions, the patient will achieve timely wound healing.
INTERVENTION INDEPENDENT: • Assess or document size, color, depth of wound and condition of surrounding skin. • Thoroughly wash the wound as soon as possible with soap and water for approximately five minutes. After washing an antiseptic solution should be applied in the wound such as povidone-iodine and alcohol (ethanol). Keeps skin free from pressure. Implement contact isolation for respiratory secretions, especially saliva in the duration of illness. •
RATIONALE Provide baseline information about the wound and possible clues about the blood circulation in the affected area. Washing the affected area is very effective at reducing the number of viral particles. To hasten the spread of the viral disease in the surrounding area.
EVALUATION After 8 hours of nursing interventions, the patient was able to achieved timely wound healing.
verbalized by the patient. OBJECTIVE: ♦ Facial grimace ♦ Irritability ♦ V/S taken as follows: T: 37.2 P: 81 R: 21 BP: 120/70
Rabies is a zoonotic viral disease which infects domestic and wild animals. It is transmitted to other animals and humans through close contact with saliva from infected animals (i.e. bites, scratches, licks on broken skin and mucous membranes). Once symptoms of the disease develop, rabies is fatal to both animals and humans. The first symptoms of rabies are usually non-specific and suggest involvement of the respiratory, gastrointestinal and/or central nervous systems. In the acute stage, signs of hyperactivity (furious rabies) or
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To promote circulation. To reduce the risk for crosscontamination.
Student Nurses’ Community
paralysis (dumb rabies) predominate. In both furious and dumb rabies, paralysis eventually progresses to complete paralysis followed by coma and death in all cases, usually due to respiratory failure. Without intensive care, death occurs during the first seven days of illness.
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Investigate for change in mentation.
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Deterioration in the level of consciousness may indicate worsening of the patient’s condition. Identifies presence of wound healing.
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Examine the wound daily.
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COLLABORATIVE: • Administer anti tetanus and antirabies immunoglobulin as prescribed. • To provide protection and prevents the spread of the disease.