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