LYCEUM-NORTHWESTERN UNIVERSITY

COLLEGE OF NURSING

NAME:

APOLONIO, REYJAN

BORJA, ARMIE JANE

DAUZ, ABEGAIL

PALAGANAS, KYFER

PILAPIL, RHONA RHEZ

RAFAEL, KYRA

ROVILLOS, JOANNA

SORIANO, ALEXANDRA

UNTALAN, FERLIE

VIDEZ, JERAMIL

YEAR/SECTION: II BSN-2D

NURSING CARE PLAN (NCP)

Case Scenario:

A group of preschool-aged children play on the school playground when suddenly Kiara, a 5-year-old child fall on the ground and hurt herself. The other children
go near her and worry about her condition, they called the attention of the school nurse who is nearby. The school nurse assesses Kiara and observes for any
injuries. Kiara cries and shows to the school nurse her knees with bruises and abrasion. She asks the school nurse “Ms. Nurse, what will happen to me? I am
afraid of any wounds and blood. Please help me.” What will be the plan of care for Kiara?
 LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING

Assessment Planning Implementation Rationale Evaluation

Problem: Short-term Goal: Independent Nursing Intervention: Independent Nursing Intervention: Short- term Goal:

A 5-year-old child After 1 hour of nursing 1. Observe the severity of the 1. To know the necessary and After 1 hour of nursing
fall in the ground intervention, the patient abrasions and assess pain scale. appropriate intervention. intervention, goal was met,
and hurt herself. will appear relax and 2. Clean the wound immediately, Pain threshold also varies the patient was able to
report anxiety reduced to stop the bleeding and maintain because she is still a child. relax and report anxiety
Data: a manageable level. bacterial balance-use aseptic 2. For infection control reduced to a manageable
Subjective/Objective technique when performing measure. level.
Long-term Goal: wound procedures, (handwashing, 3. To prevent infection and
Subjective: using a sterile field, sterile prevents healing process Long- term goal:
After 2 days of nursing instruments, sterile dressings). from being disrupted.
“Ms. Nurse, what will intervention, the patient 3. Cover the wound with bandage. 4. This will help to ease and After 2 days of nursing
happen to me? I am will demonstrate 4. Talk to her while cleaning the reduce the child’s fear and intervention, goal was met,
afraid of any wounds improved coping with wound and treating the wound, trust will be gained. It will the patient was able to
and blood. Please anxiety. like asking her favorite color and also divert her attention, demonstrate improved
help me” as her favorite song anything that while treatment is being coping with anxiety.
verbalized by the she could relate with. provided.
child. 5. Assess the child in other parts of 5. To monitor any injuries from
the body, aside from the bruises falling to the ground, to
Objective: and abrasions on the knee. Like prevent any injuries from the
asking her if she hurt her head fall that could lead to worst
- 5-year-old from the fall, or any other parts of case scenario.
child her body. 6. Preschool- age is a good
- Knees with 6. Educate the child about safety, time to educate the children
bruises and including safety with types of play. about their safety.
abrasion. 7. Educate and encourage the child 7. Preschoolers are magical
about some examples of thinkers, giving them an idea
 LYCEUM-NORTHWESTERN UNIVERSITY
COLLEGE OF NURSING

cooperative play. Like playing with about a type of play could

Nursing Diagnosis: puzzles, sand building. establish and be their guide.

Mild anxiety related

to fear of wounds
and blood as Dependent Nursing Intervention:
evidenced by patient
verbalization. Dependent Nursing Intervention: 1. To help relieve the pain.

1. Administer medications as
ordered.
Collaborative Nursing Intervention:
Collaborative Management:
1. For the patient to have
1. Refer to cognitive behavioral opportunity to meet others
group therapy if needed with the same problem