PHINMA - Cagayan de Oro College

College of Nursing

NURSING CARE PLAN

NAME OF STUDENT: _____________________________ SECTION: FC2-BSN1-04 D DATE: _________________ C.I.: __________________

NAME OF PATIENT: ______________________________ ATTENDING PHYSICIAN: ______________ DIAGNOSIS: ______________________ HOSPITAL/ROOM: _________

ASSESSMENT NURSING DIAGNOSIS PLANING INTERVENTION EVALUATION

SUBJECTIVE
“katol kaayo akong lawas murag
gatusokon og dagom” verbalized by
the patient.
Acute Pain related to cutaneous SHORT TERM GOALS
inflammation and irritation as At the end of 30 minutes nursing
evidenced by verbal reports, intervention the patient will be able
irritability, and scratching. to:
• Identify trigger foods
causing allergic reactions.
INDEPENDENT SHORT TERM GOALS
• Educate the patient on At the end of 30 minutes nursing
identifying and avoiding intervention the patient was able
trigger foods, including to:
seafood, poultry, talong, • Identify trigger foods
and kalabasa. causing allergic reactions.

• Demonstrate proper use of • Instruct the patient to keep • Demonstrate proper use of
prescribed topical a food diary to track prescribed topical
medications for rash potential allergens and medications for rash
management. reactions. management.

• Verbalize understanding of • Provide topical treatments • Verbalize understanding of

preventive measures to
minimize skin irritation.
• Report a decrease in
irritation level to 4 out of 10
or lower.
such as soothing creams or preventive measures to
antihistamine lotions to minimize skin irritation.
alleviate itching and
discomfort. • Report a decrease in
irritation level to 4 out of 10
• Encourage the patient to or lower.
wear loose, breathable
clothing to minimize skin
irritation.

• Promote proper hydration

and moisturization to
maintain skin integrity.
OBJECTIVE
• Dry skin and has a presence
of skin lesions
• Frequent scratching
• Skin pigmentation
present
• Presence of scar from
rashes
• Irritation level 8 out of 10
Vital Signs:
Temperature: 36.2°c
Oxygen saturation: 97%
Pulse rate: 79 bpm
Respiratory rate: 19 bpm
BP: 110/60 mmHg
LONG TERM GOALS DEPENDENT LONG TERM GOALS
At the end of 1 week of nursing • Collaborate with the At the end of 1 week of nursing
intervention the patient will be able healthcare provider to intervention the patient was able
to: prescribe antihistamines or to:
is • Maintain skin integrity with corticosteroids for severe • Maintain skin integrity with
no new rashes or lesions allergic reactions. no new rashes or lesions
present. • Consult with a present.
dermatologist for
• Adhere to a modified diet specialized skin care and • Adhere to a modified diet
plan free of trigger foods treatment options. plan free of trigger foods
identified. • Coordinate with a dietitian identified.
to develop a customized
• Utilize effective coping meal plan that eliminates • Utilize effective coping
strategies to manage trigger foods while ensuring strategies to manage
anxiety and stress related to proper nutrition. anxiety and stress related to
food allergies. food allergies.
• Demonstrate proficiency in • Demonstrate proficiency in
self-care techniques to INTERDEPENDENT self-care techniques to
prevent future allergic • Communicate with other prevent future allergic
reactions and skin healthcare team members reactions and skin
irritations. to ensure consistent irritations.
monitoring of skin condition
and response to
interventions.
• Collaborate with
occupational therapy to
assess and implement
strategies for minimizing
skin irritation during daily
activities.
• Involve the patient's family
members or caregivers in
education and support to
promote adherence to
allergen avoidance
strategies.