DAVAO DOCTOR COLLEGE

General Malvar St., Davao City

Nursing Program

NURSING CARE PLAN

Name of Patient: M.J Date of Admission: November 9, 2022 Room No: 302 Age: 27-month-old Sex: Male Civil Status: Single Attending Physician: Dr. Lariosa
PROBLEM Nursing Diagnosis GOALS/OBJECTIVES NURSING RATIONALE EVALUATION
CRITERIA INTERVENTIONS
November 9, 2022 Risk for infection related Independent: “GOAL PARTIALLY MET”
@ 10 am to second degree burn.  Within 8 hours span After 8 hours span of care,
of care patient will 1. Remind the 1. The hand is one of the goal was partially met
SUBJECTIVE: Scientific Basis: reduce risk for patient's mother to the worst as evidenced by:
No subjective Susceptible to invasion developing wound avoid touching the contaminants of
and multiplication of infections. wound, only wounds and  Shows reduced risk
OBJECTIVE: pathogenic organisms, touching it during frequent touching for developing
 Irritably which may compromise  Within 8 hours span wound dressings. increases the risk of wound infections.
 Blister health. Burn wound of care maintain infections. Only
 Swollen infections are most aseptic technique in touching it during  Maintained aseptic
 Redness commonly caused by handling wounds. wound dressings technique in
bacteria, fungi, or viruses. would reduce the handling wounds.
VITAL SIGNS:
Burn is one of the most risk for infection
TEMP. 36.3 °C
RR: 38cpm common and devastating dramatically.
HR: 98bpm forms of trauma.
Pain Scale 7/10 2. Prevent the skin 2. Excessive moisture
surfaces from or dryness of the
rubbing together skin can cause
and ensure that the further breaks in
surrounding skin is skin integrity and
kept clean and dry. rubbing skin
surfaces together
may cause micro
lacerations which
can eventually
become a portal of
entry for other
microorganisms.
 3. Educate Patient's 3. Knowledge of ways
mother about to reduce or
appropriate eliminate germs
cleaning, reduces the
disinfecting, and likelihood of
sterilizing items. transmission.

Dependent:

4. Administer 4. Taking medicine as

medication per prescribed or
doctor’s order. medication
adherence is
important for
controlling chronic
conditions, treating
temporary
conditions, and
overall long-term
health and well-
Collaborative: being.

5. Consult a dietitian. 5. Working with a

dietitian is the best
way to get personal
advice about food
and lifestyle
choices that can
affect patient's
health.

REFERENCES: Heather, H., Shigemi, K., Camila, T.L., (2021). NANDA International, Inc. Nursing Diagnoses (12th Ed.).

ADRIAN G. NAKILA
Name of Student