FAR EASTERN UNIVERSITY

Nicanor Reyes St. Sampaloc, Manila

S.Y 2019-2020

INSTITUTE OF NURSING

GROUP 38 MARCH 6, 2020

BSN SECTION 10 MA’AM ESCOLANO

NURSING CARE PLAN

Patient's Name: A.M.G

Cues Diagnosis Analysis Goals and Objectives Interventions Rationale Evaluation

IMMEDIATE CAUSE: LONG-TERM INDEPENDENT: Was the client

SUBJECTIVE Mite Infestation GOALS: ------------------------ -------------------------- able to fully
CUES: After 3 weeks of Assess skin, noting Specific types of skin regain skin
According to the nursing intervention: color, moisture, infection may have integrity as
client’s mother, the Impaired Skin INTERMEDIATE texture, temperature; characteristic patterns manifested by
itchiness started Integrity CAUSE: -The client will regain note erythema, of skin changes and itchiness and
from her fingers related to Skin The client reports that skin integrity edema, tenderness. lesions. papules?
first which Infection as she and her brother as manifested by: ------------------------- -------------------------- ___Met
widespread in more Evidence by shared the same room. Monitor status of ___Partially met
numbers and Itchiness, a. Itchiness and skin around Individualize plan is ___Unmet
different sizes to Papules and Papules will be healed wound. Monitor necessary according
her wrist, armpits vesicles ROOT CAUSE: patient’s skin care to the client’s skin Was the client
and back within the located at the The higher possibilities -The client will regain condition, needs, able to regain
practices, noting
time frame of one foot and of getting infected by the comfort and absence comfort and
the type of soap or and preferences.
week as stated. finger webs scabies is from outside of itchiness absence of
the house, school or the other cleansing itchiness?
She also neighbourhood. agents used, ___Met
complained of SHORT TERM temperature of ___Partially met
itchiness in her GOALS: water, and ___Unmet
lower extremities After 3 days of frequency of skin
as verbalized by nursing intervention, cleansing. Was the client
the client. the client will be able ------------------------- able to display
--------------------------
PATHOPHYSIOLOGY to display improvement in
: improvement in
The client Scabies is an endemic wound healing as Advise client to This is to prevent wound healing?
verbalized that the infestation caused by the evidence by: report any skin further impaired tissue ___Met
itchiness worsens scabies mite, Sarcoptes a. Minimized presence irritation to integrity ___Partially met
at night and her scabiei. Into the stratum of wound physician or nurse complications. ___Unmet
sleep was ruined by corneum of the b. Papules is less than ------------------------ ---------------------------
intense pruritus for epidermis, lesions are 0.1 to 0.2 cm Rubbing and Was the client
the past two weeks. created as the c. less itching Advise client to scratching can cause able to minimize
impregnated female avoid scratching the further injury and the presence of
OBJECTIVE burrows wherein they OBJECTIVES: infected skin delay healing. the wound?
CUES: have a life cycle of -------------------------- ___Met
female mite of 30 days 1.The client/mother ------------------------- ___Partially met
● Itchiness and the vesicles of will be able to gain ___Unmet
was papules may form and knowledge regarding Educate the client
limited female mite starts to lay scabies skin infection. regarding to scabies,
bilaterally 10 - 25 eggs and after e.g., A Early assessment
between laying eggs they die 2. The client/mother communicable and intervention
the because of the mites will be able to identify disease of the skin help prevent the
fingers, cannot live without their the signs and caused by Sarcoptes development of
wrist, host. The inflammatory symptoms of scabies Scabiei
serious problems.
palm, response causes intense skin infection by: -------------------------
armpit, pruritus that leads to a. Verbalizing Educate the
back and punctate discrete at least 2-3 client/mother on
chest. excoriations secondary to signs and symptoms
itching. Scabies is 3. The client’s family of scabies, e.g.,
● Papules transmitted primarily will be educated on Itching and thin,
and through prolonged close the cause and effects irregular burrow
---------------------------
vesicles personal contact, and it of scabies by: tracks made up of
located at affects persons regardless a. Stating at tiny blister or bumps
the of age, sex, personal least 2-3 on the skin
patient's hygiene, and -------------------------
foot and socioeconomic status. 4. The client will be Educate the family
finger able to gain on the cause and
webs. Reference: knowledge regarding effect of scabies
Hockenbery, M., Wilson the mode of skin infection, e.g.,
● Effloresce D., & Rodgers, C. (2019). transmission of The eight-legged
nce was Wongs Nursing Care of scabies skin infection mite that causes
multiple Infant and Children( 2nd scabies in humans
erythemat Edition). Elsevier( 5. The client/mother and when the eggs
ous Singapore) Pte. Ltd. will be able to identify hatch, and the mite
papules, prevention and control larvae work their
 round Paoran(2011). Scabies of scabies skin way to the surface Accurate
shaped Patho. Retrieved from: infection by: of your skin, where information
with well https://www.scribd.com/d a. Stating at they mature and can increases the
defined oc/37257420/Scabies- least 2-3 spread to other areas patient’s ability to
borders, Patho of your skin or to
manage therapy
discrete 6. The client/mother the skin of other
presentati HEALTH will be able to identify people. The itching independently and
on IMPLICATIONS: the necessary of scabies results reduce the risk for
measuring Upon determining the treatments for skin from your body's infection.
from 0.1 health problems and infection by: allergic reaction to
to 0.2 cm complication of the a. Verbalizing the mites, their eggs
in patient, Scabies 2-3 and their waste.
diameter, infestation may be medication -------------------------
with no complicated by bacterial b. Verbalizing Educate the
scales. infection, leading to the 1-2 client/mother
development of skin alternative regarding the mode
● The sores that, in turn, may home transmission of
papules lead to the development remedies scabies, e.g., skin to
also of more serious skin contact by
appear in consequences such as 7. The family of the infected individuals
multiple septicaemia, heart disease client will be educated and using infected
spherical and chronic kidney in obtaining good clothing.
vesicles disease. personal hygiene -------------------------
with a size Educate the
range Reference: WHO( 2017). 8. The client/mother client/mother
measuring Scabies and other will be able to obtain regarding to prevent
from 0.3 ectoparasites. knowledge regarding re-infestation and to
to 0.5 cm Retrieved from: on applying proper control spreading to
in https://www.who.int/ne medication to scabies other people
diameter glected_diseases/disea regarding to topical regarding to scabies,
with ses/scabies-and-other- creams e.g., Regular
erosion ectoparasites/en/ changing of clean
that has 9. The client will be clothing beddings
already able to report progress and towels and
healed and through diary improving the
crusted. sanitation of the
● There surroundings
were also ------------------------- ---------------------------
a few Demonstrate to the
serpiginou family members on
s papules how to make a To be able to know
that guava decoction to other alternative home
appears apply to the wound remedies
whitish to as alternative
greyish disinfectant
colour and ------------------------- ---------------------------
has a Encourage client to
threadlike demonstrate good
elevated skin hygiene, e.g.,
line on her wash thoroughly
right and pat dry carefully
hand. Accurate information
increases the patient’s
ability to manage
------------------------- therapy independently
and reduce the risk for
Advise client to take infection.
down notes through
diary on the
progress of the
healing of skin
infection

------------------------- ---------------------------
==============
DEPENDENT:
------------------------ Accurate information
Instruct the increases the patient’s
client/mother on ability to manage
applying proper therapy independently
medication on and reduce the risk for
topical creams, e.g., infection.
applying the cream
at bedtime and
covering the
infected area.
------------------------ ---------------------------
Administer
medication of non- Wound infections may
pharmacological and be managed well and
pharmacological more efficiently with
treatment such as topical agents,
topical and systemic although intravenous
medication. antibiotics may be
indicated.

------------------------ ---------------------------
============== ================
COLLABORATIVE
------------------------- ---------------------------
Suggest the family
members and
other close contact
of the patient be
checked for This is to prevent
possible further impaired
symptoms and be tissue integrity
treated if complications.
necessary.
-------------------------
Educate the patient
the need to notify
the physician or
nurse. ---------------------------
REFERENCE:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurses pocket guide: diagnoses, prioritized interventions, and rationales (15th ed.). Philadelphia: F.A.
Davis Company.

Wayne, G., Wayne, G., & Wayne. (2019, March 20). Impaired Tissue (Skin) Integrity – Nursing Diagnosis & Care Plan. Retrieved from
https://nurseslabs.com/impaired-tissue-integrity/