DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program
NURSING CARE PLAN

Name of Patient: _Patient MJ___________ Date of Admission: _November 8, 2021 @8:00AM Room: __P302_
Age: _27 months old_ Sex: _Male_ Civil Status: _N/A_ Chief Complaint: 2nd degree burn
Religion: ___N/A___________ Attending Physician: ___Dr. Lariosa____

PROBLEM SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTIONS
November 8, 2021 Anxiety related emotional After 8 hours of providing November 8, 2021
@8:00AM impact of burn injury nursing interventions, the 1. Monitor vital signs 1. For baseline data. @8:00AM
patient will be able to:
2. Introduce diversional 2. To divert the client GOAL MET
Objective: BASIS: a. Appear relaxed and activities such as attention.
 Irritable The emotional impact of burn reduced anxiety playing toys or After 8 hours of providing
 Crying and injury to a toddler is feeling instruments nursing interventions, the
pointing towards scared, frightened or shocked patient was able to:
his right hand accompanied by the pain 3. Give medication with 3. To lessen the a. Appeared relaxed
they felt. So, this then makes role playing. client’s anxiety. and reduced
Vital signs: the toddler cry uncontrollably, anxiety as
BP: 100/60 irritable and anxious. 4. Modify procedures as 4. To limit the degree evidenced by not
PR: 96 much as possible. of stress and crying and not
RR: 20 avoid feeling irritable
overwhelming the
client.

5. Be truthful, avoid 5. To soothe fears

bribing, and provide and provider
physical comfort when assurance.
dealing the client.

6. Encourage the 6. Promotes

involvement of participation in
parents in and reduces
interventions; allow anxiety of the
them to hold or cuddle client.
the client.
REFERENCES:
Doenges, M., Moorhouse, M.
F., & Murr, A. (2019). Nurse’s
Pocket Guide diagnoses,
Prioritized Interventions and
Rationales. Philadelphia,
Pennsylvania: F. A Davis
Company
7. Inform the parents 7. Prevents feeling
that the client’s of adequacy of the
behavior caused by parents.
anxiety is expected.
8. Provide health 8. Help lessen
teaching to the anxiety on the
parents the client.
importance of good
communication to the
client.

Edelyn Santoyo
Name of Student
DRUG STUDY
 Medication Mode of Action Dosage Indication(s) Contraindication(s) Side Effects Adverse Effects Nurses Responsibilities
Generic Name: The vaccine 0.5mL IM 4th Provide - Patients who have had CNS:  CNS:  Be prepared for life
Dtap vaccine produces an dose protection a severe allergic Feeling Fussiness, threating reaction
active immune (immunity) reaction (e.g., tired seizures, high when ever
Brand Name: response of the against anaphylaxis) after a fever immunizing children.
Adacel body by diphtheria, previous dose  At every
developing tetanus -Hypersensitivity to any Injection  visit/encounter child’s
Classification: antibodies and (lockjaw), and of the vaccine site: immunization record
Soreness, GI:
antitoxins against pertussis components Loss of appetite, should be reviewed.
the toxoids and (whooping redness,  Review child’s
swelling, vomiting
acellular pertussis cough) in allergies (food and
antigens children pain medicine).
between 6  Review potential
weeks and 7 contraindications to
years old. each vaccine.
 Review past
immunization history
for past reactions.
 Assess child for
anxiety and fear
related to
administration.
 Obtain informed
consent.
 Use the same brand
whenever possible.
 Inform parents of
increased risk of
reaction to dose 4 &
5.
 Instruct parents to
report and bring child
to hospital if any
adverse effects
occurred.
 If child had a serious
adverse reaction to
any previous dose,
the next doses should
be deferred.
 Give parent current
VIS (vaccine
information
statement) in
REFERENCES:
CDC. (August 6, 2021). DTaP (Diphtheria, Tetanus, Pertussis) Vaccine: What you need to know. https://www.cdc.gov/vaccines/hcp/vis/vis-statements/dtap.html

Weaver, B. (2014). Vaccines and Vaccine Preventable Communicable Illness of Childhood. https://slideplayer.com/slide/5884445/
FDAR:

F 2nd degree burn

D Irritable, crying uncontrollably and pointing towards right hand

A Administered Ibuprofen Oral Suspension 100mg/5ml PO 5 ml, as

ordered; Monitored vital signs recorded; Elevated right hand;
Watched out for fever, fluid leaking, increased redness of the area.

R After 8 hours

Patient pain was relieved. Wong Baker face pain scale 0/10, no
irritability, and crying noted. Wound care is continued.

CUS:

Collaboration:

C I am concerned that the mother had to bring her child her despite not
knowing what was chewed by the child.

U I am uncomfortable since it is not the best action, it may cause

aspiration if the child accidentally ingests what she was chewing.

S It is a safety concern. Can you educate the mother of what should be

done to ensure that the child will be much safer?

Ethico-Moral-Legal Consideration:

Nursing Action  Educate the mother the difference between

discipline and punishment.

 Educate parent that she should be consistent,

and the child will learn the rules if correct
behavior is praised rather than wrong
behavior is punished.

 Encourage the “time-out” technique to the

mother, this is to help child learn that actions
have consequences.
Beneficence. It is about doing good.
Ethical Principle
Upheld Encouraging the mother about the best action for her
child’s behavior is essential. Thus, addresses the
idea that a nurse's actions should promote good.