NURSING CARE PLAN

CUES NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS EXPLAINATION INTERVENTION

Objective: Pain related Unpleasant Short 1. Position the 1.To be more After 30mins of
to sensory and Term: client in a comfortable Nursing Intervention
>Grimace inflammation emotional After 30mins comfortable the patient
face(+) as evidence experience of nursing position. experience :
>irritability by grimaced arising Intervention 2.To divert >pain scale 4/10
(+) from actual or the patient 2. Diversion of attention of >comfortable
face and
>crying potential tissue activities like >(-)irritability
irritability. will: pain.
>pain scale damage, reading books, >(-)grimaced face
>Pain scale
7/10 sudden or slow drawing, coloring
>128bmp >Pain scale 4/10 etc.
7/10. onset of any >Comfortable GOAL WAS
>RR-41 intensity MET.
>Temp.36.6 >Grimaced 3. Provide rest,
from mild to face(-) 3.To provide
severe with sleep, And
>irritability Comfort.
anticipated or relaxation.
(-)
predictable end
4. Instruct family
a duration of 4.To provide
member to
less than 6 rest and
eliminate any
months. comfort
positive stressor or
discomfort.

5. Administer pain
reliever as per
5. To relieved
doctor’s advice.
pain and
discomfort.
CUES NURSING SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS EXPLAINATION INTERVENTION

Objective: Impaired Skin is the Short Term: 1.Assess skin 1.To established After 8hrs of nursing
>noted skin integrity primary defense After 8hrs. noted color, baseline for intervention the
swelling related to or the body it Of nursing turgor sensation Providing timely patient understand
of the mass Intervention describe and intervention.
presence of protects against the health teaching.
>irritable The patient measure the
>itchiness swelling at infections and wounds or mass
will verbalize 2. For baseline
>skin the left diseases that and observed data.
understandi
redness at lumbar brought about by changes.
ng of health
the sacral area the invasive 3. To make
teaching. 2.Monitor VS
back with the microbes in the patient
lumbar presence of body. A normal (temp. RR,BP,
HR) comfortable.
area mass. skin is moist and
>decrease intact, dryness
peristalsis 3. Counter 4. Maintain clean
of the skin is
more to friction Irritation and and dry skin
that may result touch therapy provides barrier
to skin impair- to infection.
ment of the skin 4. Demonstrate
Patting skin dry
integrity as com- good skin hygiene
(e.g wash instead of
pared with moist
thoroughly and pat rubbing reduces
normal skin.
dry carefully. risk of dermal
trauma to fragile
5.Place the patient skin.
in comfortable
position(right side
5. To make more
lying position)
comfortable and
 minimized the
swelling of mass.
6. Instruct family
member to
maintain clean
and dry skin
preferably soft 6. Skin friction
cloth such as caused by stiff or
cotton fabric or t- rough clothes
shirt. leads to irritation
of fragile skin in-
7.Instruct family
crease risk for
member to do
hand washing. infection.

8. Administer 7. To prevent
oxacillin and spreading of
cefuroxime (q8) bacteria that
antibiotic as per causes infection.
doctor’s advice.
8. To lower
9. Schedule for bacterial growth
I&D and waiting and minimized
for the clearance infection by
from pediatrician. administering
antibiotic.

9. To drain the
abscess that
present in the
mass that
causes infection
and pyomyositis.