CUES/DATA NURSIG DIAGNOSIS RATIONALE GOALS AND NURSING RATIONALE EVALUATION

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

-avoid wearing -Artificial fingernails

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