A nurse is caring for a patient admitted to the medical unit with a diagnosis of pemphigus vulgaris. When writing the care plan for this patient, what nursing diagnoses should be included? Select all that apply
A) Risk for Infection Related to Lesions
B) Impaired Skin Integrity Related to Epidermal Blisters
C) Disturbed Body Image Related to Presence of Skin Lesions
D) Acute Pain Related to Disruption in Skin Integrity
E) Hyperthermia Related to Disruptions in Thermoregulation
Ans: A, B, C, D
Feedback:
Blistering diseases disrupt skin integrity and are associated with pain and a risk for infection. Because of the visibility of blisters, body image is often affected. The patient faces a risk for hypothermia, not hyperthermia.
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