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Sakamoto, Karen S.

July 28, 2009

BSN – 4B Rot 3 PCMC

NURSING CARE PLAN

I. Mr. AA, 3yo


Dx: Acute symptomatic seizure 2̊ to metabolic encep. 2̊ to AGE

Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation

O: Risk for Ingestion of Short term >assess the >to obtain After 5 hours
aspiration milk goal: After condition of baseline of nursing
>The patient related to formula 5hours of the patient. data interventions
consume his body passing to nursing , the goal
bottle while positioning the normal interventions >identify at- >to manage was met as
lying down while bottle ingestion , the patient risk client different evidenced by
fed. pathway will be able according to intervention patient able
that has a to condition. to consume
possibility demonstrate his milk
>educate the
to obstruct techniques to >normal formula
patient and
or block the prevent gravity properly and
relative to
pathway aspiration. helps the the absence
elevate client
because of food go of the risk
to highest or
poor body down to for the
best possible
positioning your patient to
position
that result digestive experience
(e.g., sitting
to risk of tract aspiration.
upright in
aspiration. smoothly
chair)
thus
preventing
aspiration

>it may just


>educate the add up to
patient and aspiration if
relative to present
avoid
washing
solids down
with liquids

>advice the
patient and
>to let the
relative not
food be
to jump
absorbed
around when and
the stomach digested. It
is full. will also
help the
patient not
to vomit.

>Refer to
physician

II. Mr. LA, 7yo


Working dx: Myositis

Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation

S: “di ko Acute pain Pain is caused After 8 hours of >assess the >to obtain After 8 hours
magalaw e. related to by underlying nursing condition of the baseline of nursing
Masakit pa underlying rare condition interventions, patient data interventions
din (pointing physical of the muscle the patient will , the goal
his L leg)” as agents of that makes the be able to >determine and >to lessen was met as
verbalized by the muscle person follow document and avoid evidenced by
the patient. uncomfortabl prescribed presence of the pain by the patient
e because of pharmacologica possible proper was able to
the discomfort l regimen and pathophysiological managemen follow the
that it gives. level of pain be / psychological t prescribed
O: causes of pain
decrease to therapeutic
6/10. (e.g. management
>Observed
inflammation, to his case
evidence of
infections, etc) and level of
pain
pain
>Observe
>Guarding decreased to
nonverbal cues
behavior 6/10.
behaviors (e.g.
>Expressive how client walks,
behavior sits, etc)
>to
(Restlessness >Ascertain client’s anticipate
) knowledge of and pain and
expectations about provide
>Diaphoresis pain management proper care
>Pain scale >to be able
of 7/10 to respond
>Determine to
client’s acceptable therapeutic
level of pain managemen
t

>to be able
to establish
patient’s
trust in you
and not to
give further
pain to the
>Provide comfort patient
measures such as
>to lessen
touch,
the pain
repositioning, etc.

>Encourage use of
relaxation
techniques such as
breathing, >to divert
imaging, etc. attention of
pain
>refer to physician

III. Ms. RAM, 2yo


Adm dx: hepatic abscess

Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation


O: Impaired Impaired Short term >assess the >to obtain After 8 hours
skin skin goal: After 8 condition of baseline data of nursing
>Disruption integrity integrity hours of the patient interventions
of skin related to caused by nursing , the goal
surface external faulty / interventions >identify was partially
underlying >to manage
factor: dislodgmen , the patient met as
>Destructio condition appropriate
hyperthermi t of IV will be able evidenced by
n of skin involved intervention
a catheter to to maintain the patient
layer
the IV site optimal was able to
[dermis] >Assess
causing nutrition, maintain
blood supply
>Invasion of physical physical well >to promote optimal
and sensation
body trauma to being healthy well nutrition by
to the
structures the skin being shifting NPO
affected area
to DAT and
>Review new line of
medication IV was
regimen inserted
>to promote
>Note skin optimum
color, texture health
and turgor
>to able to
differentiate
with baseline
>inspect skin
data
on a daliy
basis, >to note
describing changes
wound whether it
characteristic worsen or heal
s and changes
observed

>keep the
area clean
and dry
>refer to
physician
>wetness
harbour
microorganis
m
IV. Ms. RAM, 2yo
Adm dx: hepatic abscess

Assessment N.Diagnosis Inference Planning Intervention Rationale Evaluation

O: Risk for Ingestion of Short term >assess the >to obtain After 5 hours
aspiration dry crackers goal: After condition of baseline of nursing
>The patient related to passing to 5hours of the patient. data interventions
consumed body the normal nursing , the goal
her dry positioning ingestion interventions >identify at- >to manage was met as
crackers by while eating pathway , the patient risk client different evidenced by
herself in a and limited that has a will be able according to intervention patient able
fast manner interval of possibility to condition. to consume
because of food intake to obstruct demonstrate her dry
hunger >educate the
due to or block the techniques to >normal crackers
patient and
hunger pathway prevent gravity properly and
relative to
because of aspiration. helps the the absence
elevate client
poor body food go of the risk
to highest or
positioning down to for the
best possible
and also your patient to
position
due to digestive experience
(e.g., sitting
limited tract aspiration.
upright in
interval of smoothly
chair)
food intake thus
that result preventing
to risk of aspiration
aspiration.
>it may just
>educate the add up to
patient and aspiration if
relative to present
avoid
washing
solids down
with liquids

>advice the
patient and
>to let the
relative not
to jump food be
around when absorbed
the stomach and
is full. digested. It
will also
help the
patient not
to vomit.
>Refer to
physician