NURSING CARE PLAN

Cues – Nursing Analysis and Goals and Nursing Rationale Evaluation

Diagnosis Implication Objectives Intervention
Risk for irritation Situational Goal: Goal:
related to Analysis: After 4 hours of ___Met
presence of head nursing ___Partially Met
lice The client shows intervention, the Why?
some clinical client will have ___Not met
Subjective: manifestations that reduced head Why?
appears from louse, as
- The client having head louse, manifested by:
verbalized “Opo, such as itchiness
madami nga po in her scalp. Objectives: Supplemental:
ako mga lisa” Lice feed on Effectiveness:
- “makati siya, human blood 1. After 2 minutes 1. Assess the Assessing the 1. Was the client
napapadalas na several times daily. of assessment, client’s hair for the patient is able to know the
nga po eh” They stay close to the client will be extent of in sight essential to degree of present
-“Pag makati po, the skin for able to know the head lice. determine the head lice?
kinakamot ko moisture, food and degree of present quantity of Yes__
nalang po” warmth. They head lice. needed nursing No___Why?
- “busy si mama move freely and care.
at papa sa quickly, that may Reference:
pagtinda eh, kaya be the cause of Fundamentals of
Nursing by Carol
hindi ako itchiness and Taylor pp. 199
nakukutohan” feeling of irritation.
Developmental:
Objective: Health Implication:
2. After 5 minutes 2. Teach the client Teaching is a 2. Was the client
- The client tends A Head louse is of nursing at least 5 risk planned method able to state 4
to scratch her more common in intervention, the factors of Head or series of risk factors of
scalp during the female than male. client will state at Lice. methods used to having head lice?
interview. It infects more least 4 out of 5 help someone Yes___
-presence of nits children than risk factors of learn. No____Wby?
(eggs) in the hair adults. Itching is having Head It is also a
shafts. the first louse. preparation for
-presence of predominant receiving care.
abrasion in the symptom. Reference:
scalp. When neglected, Fundamentals of
Nursing by Carol
varying degrees of Taylor pp. 477-478
irritation,
excoriation, and
crusting ensue Lice on the hair
and a foul-smelling 3. After 5 minutes 3. Identify at least are usually 3. Was the client
mass consisting of of nursing 2 ways to manage treated with able to state 1
matted hair nits, intervention, the Head lice such as medicated way to manage
ova, pus, crusts, client will state at using cream rinses shampoos or head lice?
and pediculi least 1 way to and Nit combs. cream rinses. Nit Yes___
results. This is manage Head lice. combs can be No____Wby?
also known as used to remove
Plica Polonica. nits and lice from
the hair.
Reference: Reference:
Handbook of Common Parasitology and
Communicable and Virology: Clinical
Infectious Diseases Approach
By: Dionesia By Bolo pp.110
Mondejar-Navales
pp. 175-176
Nurses assume
4. After 5 minutes 4. Demonstrate 4. Was the client
They feed the role of
of nursing the proper steps in able to
exclusively on teacher and
intervention, the managing head demonstrate
blood and heavy patients assume
client will be able lice. proper step of
infestations can the role of learner
to demonstrate the managing head
cause severe when patients
said management. lice?
debilitation, have identifiable
Yes___
anemia, and learning needs.
Fundamentals of No____Why?
weakness of the
host. Nursing by Carol
Taylor pp. 477 Adequacy:
Reference: Were the
Parasitology and resources
Virology: Clinical
Approach adequate to
By Bolo pp.109 conduct the
nursing
intervention?
Yes___
No____Why?

Efficiency:
Are the resources
enough to fully
understood by the
client the entire
health teaching?
Yes____
No____Why?

Appropriateness:
Were the nursing
interventions
appropriate to the
client?
Yes___
No___Why?