Nursing Care Plan

Week 10
Name: Jordan
Age: 4 years old
Address: Prk. 5, Brgy. Malativas, Panabo City, Davao del Norte, Philippines

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Explanation
Subjective: Impaired skin Impaired skin After nursing Note presence of That may impact After nursing
“He got burns on his integrity r/t integrity altered intervention, the compromised client’s self-care as intervention, the
arms up to his external factor of epidermis and/or patient will: mobility, sensation, relates to skin care. patient:
shoulder. And it’s chemical injury dermis. vision, hearing, or
about 2nd degree or 3rd agent as  Display timely speech.  Response to
degree burn.” evidenced by Burn injury is healing of skin intervention,
destruction of damage to your lesions, wounds, Determine degree actions
Objective:
skin layers with body’s tissues or pressure sore and depth of injury performed, or
Alteration of skin
3rd degree (full caused by heat, without any or damage to teachings.
integrity
thickness) burn. chemicals, further integumentary  Have shown any
Destruction of skin
electricity, sunlight complications. system. progress toward
layers
or radiation. Scalds  Participate desired
Vital signs:
from hot liquids and treatment Photograph burns, as To document status outcome(s).
 Temp: 36.5◦C
steam, building fires program. appropriate. and provide visual
 RR: 22 bpm
and flammable baseline for the
 PR: 84 bpm
liquids and gases are future comparisons.
the most common
causes of burns. A Determine patient’s To clarify
major burn is a level of discomfort. intervention needs
catastrophic injury, and priorities.
requiring painful
treatment and long Assist patient to To control feelings
period of learn stress- of helplessness and
rehabilitation. It’s reduction and engage deal with situation.
commonly fatal or in alternate therapy
permanently techniques.
 disfiguring and
incapacitating (both
emotionally and
physically).

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Explanation
Subjective: Impaired physical Limitation in After nursing Assess patient’s To determine After nursing
“He wasn’t walking..” mobility r/t pain independent, intervention, the developmental level, presence of intervention, the
“He was just lame.” and purposeful physical patient will: motor skills,, ease characteristics of patient will:
“He was not able to musculoskeletal movement of the and capability of patient’s unique
talk. He’s horrible” impairment body or of one or  With supervision movement, posture. impairment and to  Response to
possibly more extremities. of caregiver the guide choice of intervention,
Objective:
evidenced by patient will intervention. actions
Engages in
inability to provide performed, or
substitutions for
purposefully understanding of Assess degree of To determine if pain teachings.
movement
move caused by situation and pain, listening to management can  Have shown any
Decrease in range
burn injury. individual patient’s description improve mobility. progress toward
of motion
treatment about manner in desired
Decrease in gross
regimen and which pain limits outcome(s).
and fine motor
safety measures mobility.
skills
(verbal or non-
Vital signs:
verbal cues). Determine degree of Identifies strength
 Temp: 36.5◦C
 Maintain or immobility in and deficits and may
 RR: 22 bpm
increase strength relation to 0-4 scale, provide information
 PR: 84 bpm
and function of noting muscle regarding potential
affected and/or strength and tone, potential for
compensatory joint mobility, recovery.
body part. balance, and
endurance.
 Note Feelings of
emotional/behavioral frustration or
responses problems powerlessness may
of immobility. impede attainment
of goals.

Provide regular skin

care to include
pressure area
management.

Assessment Nursing Scientific Planning Intervention Rationale Evaluation

Diagnosis Explanation
Subjective: Acute pain r/t An unpleasant After nursing Determine and Acute pain is that After nursing
“He got burns on his destruction of sensory and intervention, the document presence which follows an intervention, the
arms up to his skin/tissue caused emotional patient or caregiver of possible cause of injury onset of a patient will:
shoulder. And it’s by physical injury experience will: pain. painful condition.
about 2nd degree or 3rd agent possibly associated with  Response to
degree burn.” evidenced by actual or potential  Report pain is Note patient’s age Affecting ability to intervention,
reports of pain, tissue damage, or relieved or and developmental report pain actions
Objective: verbal and non- described in terms of controlled. level and current parameters. performed, or
Facial grimace verbal cues by the such damage.  Show timely condition. teachings.
 9/10 pain patient and wound healing  Have shown any
scale alteration of Sudden or slow process. Discuss with Family members or progress toward
Expressive behavior muscle tone. onset of any caregivers ways in significant other(s) desired
by crying intensity from mild which they can assist may provide outcome(s).
Evidence of pain to severe with an patient with pain assistance by
using standard pain anticipated or management. transporting patient
behavior checklist predictable end. to prevent walking
for those unable to
communicate long distances,
verbally supporting timely
Vital signs: pain control,
 Temp: 36.5◦C encouraging eating
 RR: 22 bpm nutritious meal to
 PR: 84 bpm enhance wellness.