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CUES/DATA NURSIG RATIONALE GOALS AND NURSING RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES INTERVENTION


Subjective data: Impaired skin Direct person After 3 weeks of -wear gloves -To avoid direct After 3 weeks of
"may sugat siya integrity r/t with is infected nursing when caring for contact and nursing
sa paa ," as invasion of skin of scabies intervention, the client with transmission of intervention,
verbalized by structures by predispose the client will regain lesions infectious agent. goal was met as
the clients pathogenic person to have skin integrity -cleaning the manifested by
mother organism scabies too. As manifested -cleanse the skin will help to -Healed skin
Sarcoptes by skin thoroughly, wash out the rashes
Objective data: scabiei burrows -skin rashes will but gently. mites in the -Moist and less
-rash draining in the skin and heal skin. Cleansing scaly skin
serosanguinous fluid lay eggs. The -dry skin will it gently will
-dry and scaly skin eggs hatch in 3- become moist prevent
on the feet 4days.They and scaly skin excessive
become larvae will lessen -in the case of erosions of the
and burrow in bacterial skin.
the skin causing infections or -kills bacteria
rashes. A lesions with
delayed type IV secondary
hypersensitivity infections, use
reaction cause an antibacterial
pruritus in the soap.
skin which -Gently remove -cleaning the
cause 2nd skin crust, scales, area first before
infection. and traces of putting any
old medication cream makes
before applying the cream
fresh creams or absorbed by the
lotions skin.
-Encourage to
comply to -medications
prescribed are given to
medication if treat infection.
any One must
comply so I it
-apply cream will not become
and lotions worse
-monitor their -it gives
effectiveness moisture to the
skin
-to evaluate the
effectiveness of
management
NURSING CARE PLAN
CUES/DATA NURSIG RATIONALE GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION
Subjective data Acute pain r/t Direct person After 3 weeks of -instruct the -warmth After 3 weeks of
"Makati ang itching, burning with is infected nursing client to keep increases nursing
sugat ko lalo na and infection of scabies intervention, the environment itching intervention,
sa gabi,"as predispose the client will report temperature Goal was metas
verbalized by person to have less pain and cool manifested by
the client scabies too. itching - client will
Sarcoptes -Cleanse skin -Warm water report less pain
Objective data: scabiei burrows lesions with helps kill the and itching
-rash draining in the skin and tepid water not mites -absene of rash
serosanguinous fluid lay eggs. The hot drainage
-dry and scaly skin eggs hatch in 3-
on the feet 4days.They -encourage the -scratching the
become larvae client not to rash leads t 2nd
and burrow in scratch the skin lesion and
the skin causing rash. Explain infection.
rashes. A the
delayed type IV consequences
hypersensitivity of scratching it.
reaction cause
pruritus in the
skin which
cause 2nd skin
infection.
CUES/DATA NURSIG RATIONALE GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION
Subjective data: Risk for Scabies can be After 3 weeks of -Wash the bed -It kills the After 3 weeks of
infection transmitted nursing linens and mites nursing
transmission r/t through man to intervention, clothing with preventing intervention,
Objective data: different modes man contact there was no warm water and further goal was met as
-skin rash on of transmission and dog to man evidence of expose it to transmission to manifested by
the feet contact. It can patient to sunlight others -No evidence of
also spread patient transmission
through indirect transmission of -Prevent patient due to
contact like infection as to patient -Organism that contaminated
contaminated manifested by infection spread are spread equipment
fomites -No evidence of through direct
transmission contact or
due to -Use gloves indirect contact
contaminated when handling are very
equipment any body fluid contagious
from any -gloves provide
patient body effective barrier
fluid protection

-avoid wearing
artificial nails or -Artificial
extenders when fingernails and
providing care extenders
to the client. harbor
Keep natural microorganisms
nail less than ¼
inch long
-encourage
good personal -helps in killing
hygiene the mites and
other bacteria.
CUES/DATA NURSIG RATIONALE GOALS AND NURSING RATIONALE EVALUATION
DIAGNOSIS OBJECTIVES INTERVENTION
Subjective data Impaired skin Direct person After 3 weeks of -wear gloves -To avoid direct After 3 weeks of
"Makati ang integrity r/t with is infected nursing when caring for contact and nursing
sugat ko lalo na scratching of scabies intervention, the client with transmission of intervention,
sa gabi, kaya scabie lesions predispose the client will regain lesions infectious goal was met as
kinakamot as evidenced by person to have skin integrity agent. manifested by
ko,"as open lesions scabies too. As manifested -cleanse the -cleaning the -Healed skin
verbalized by draining Sarcoptes by skin thoroughly, skin will help to rashes
the client serosanguineou scabiei burrows -skin rashes will but gently. wash out the -Moist and less
s fluid, scrabbed in the skin and heal mites in the scaly skin
Objective data: lesions lay eggs. The -dry skin will skin. Cleansing
-rash draining eggs hatch in 3- become moist it gently will
serosanguinous fluid 4days.They and scaly skin prevent
-dry and scaly skin become larvae will lessen -in the case of excessive
on the feet and burrow in bacterial erosions of the
the skin causing infections or skin.
rashes. A lesions with -kills bacteria
delayed type IV secondary
hypersensitivity infections, use
reaction cause an antibacterial
pruritus in the soap.
skin which -Gently remove
cause 2nd skin crust, scales, -cleaning the
infection. and traces of area first before
old medication putting any
before applying cream makes
fresh creams or the cream
lotions absorbed by the
-Encourage to skin.
comply to
prescribed -medications
medication if are given to
any treat infection.
One must
-apply cream comply so I it
and lotions will not become
-monitor their worse
effectiveness -it gives
moisture to the
skin
-to evaluate the
effectiveness of
management