REPUBLIC of the PHILIPPINES

City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING

NURSING CARE PLAN

NAME OF STUDENT: Antonette E. Taguibao YEAR/GROUP: 2-BN CONCEPT: NP9 AREA: Pediatric Ward DATE: March 3, 2021
Assessment Nursing Inference Planning Intervention Rationale Evaluation
Diagnosis
Thermal insult Long Term Objective
Subjective Risk for fluid and results in Long Term Objective Independent
Cues electrolyte coagulative After 7-21 days of nursing
balance as necrosis of the After 7-21 days of Educate and make the patient understand her situation in The patient is child, and intervention the patient has:
“Natapunan ng evidenced by skin nursing intervention layman’s term. making her understand her
kumukulong the examination the patient will: condition is a big help for Returned and maintained
tubig.” As done to the Educate the patient regarding the danger of touching and cooperation, especially at her fluid and electrolyte balance.
patient. Hot object/liquid Return and maintain holding hot objects without proper protection or supervision age.
verbalized by the
mother
affects skin (if fluid and electrolyte of the guardian, make her situation as an example. Further infection is
poured, splashed, balance. Educating Young/children prevented.
touched or held) Advise parents to support their daughter while medication is about it will help her and her
Further infection is ongoing. parents to not get involve Able to move her extremities
Objective Affects the outer prevented. with it again, especially that better or back to normal.
Cues layer of skin Advise the guardians and the patient to make her the child already experienced
(epidermis) and Able to move her movements less than normal. its consequence. Wounds from burnt site is
Presence of part of the inner extremities better or almost healed (if not fully).
blisters, wet layer of back to normal. Advise parents to keep her entertained without her making Support from parents or love
looking wound, large movements. ones gives factor in coping Understood and verbalized
skin (dermis).
irregular white Wounds from burnt up with anxiety. why should we not touch or
and deep red site will be almost Assess the IV site and line from time to time. hold hot objects without
Resulting to healed (if not fully). Less movements will reduce proper protection or
pattern.
blisters, redness Assess vital signs. the chance of popping guardian.
Facial Grimace: and white Understand why blisters and ruining of wound
Crying face irregularity should we not touch or Monitor Fluid and electrolyte results. bandages/dressing.
pigment and pain. hold hot objects
Pain scale of 8/10 without proper Clean the wound and instruct guardians how to properly do Keeping a child entertained
protection or guardian. it. without making large

NAME OF PATIENT: Franchesca R. Vasquez AGE: _7_____________

CLINICAL IMPRESSION/DIAGNOSIS: Second degree burn 30% BSA CHIEF COMPLAINT: “Natapunan ng kumukulong tubig.” As verbalized by the mother
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING

Vital signs movements are one of the

Reference: essential things to avoid her Short Term Objective
BP: 110/70mmHg Sadoway, R. (2019). from feeling of anxiety.
RR: 23 bpm Case Report: Burns. Short Term Objective After 1-3 days of nursing
Emergency Assessing IV site will ensure intervention the patient has:
PR: 110 bpm Medicine, Dalhousie. After 1-3 days of the patency, and if the site is
(awake) Retrieved from nursing intervention still fine. Reduced pain felt.
the patient will:
Temperature: 38
http://sjrhem.ca/wp- Assessing and monitoring Returned fluid and
content/uploads/201 Reduce pain felt. vital signs and electrolyte electrolyte balance
5/04/CaseReport.pdf results will help the physician
Return fluid and about diagnosis and if there Fall down temperature within
electrolyte balance are any complications. normal limits
Oxfore medicine, Fall down temperature Cleaning the wound properly Anxiety felt is reduced.
(2016). Retrieved within normal limits will reduce the risk for
from infection. Improved range of motion.
https://oxfordmedicin Anxiety felt will be
e.com/view/10.1093/ reduced.
med/978019960083
0.001.0001/med- Improve range of Dependent
9780199600830- motion.
chapter-346 Administer pain and fever medication as ordered by the Administering right drug and
physician. dose at the right time is
important for its effectivity.
Regulate and Administer IVF as ordered by the physician.
Stanford Children’s Regulating IVF correctly
health, (nd). Second- based from the order of the
degree burn. physician is important for its
Retrieved from effectivity.
https://www.stanford
childrens.org/en/topi
c/default?id=second-
NAME OF PATIENT: Franchesca R. Vasquez AGE: _7_____________
CLINICAL IMPRESSION/DIAGNOSIS: Second degree burn 30% BSA CHIEF COMPLAINT: “Natapunan ng kumukulong tubig.” As verbalized by the mother
 REPUBLIC of the PHILIPPINES
City of Makati
UNIVERSITY OF MAKATI
COLLEGE OF ALLIED HEALTH STUDIES
J. P. Rizal Extension, West Rembo, Makati City 1215
Telephone No. : (+632) – 881 – 1571
CENTER OF NURSING

degree-burn-in-
children-90-P01757

NAME OF PATIENT: Franchesca R. Vasquez AGE: _7_____________

CLINICAL IMPRESSION/DIAGNOSIS: Second degree burn 30% BSA CHIEF COMPLAINT: “Natapunan ng kumukulong tubig.” As verbalized by the mother