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    NCP - Module 8

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    adrian nakila
    The patient, M.J., a 27-month-old male, was admitted to the hospital with second degree burns on his hand. He shows signs of irritation, blistering, swelling, and redness. His temperature is elevated and he reports a pain level of 7 out of 10. The nursing student created a care plan to address the risk of infection with the goal of reducing this risk within an 8 hour period. The plan includes reminding the mother to only touch the wound during dressings, keeping the skin clean and dry, educating on proper cleaning and disinfecting, administering medications as prescribed, and consulting a dietitian.

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    NCP - Module 8

    Uploaded by

    adrian nakila
    19 views2 pages
    The patient, M.J., a 27-month-old male, was admitted to the hospital with second degree burns on his hand. He shows signs of irritation, blistering, swelling, and redness. His temperature is elevated and he reports a pain level of 7 out of 10. The nursing student created a care plan to address the risk of infection with the goal of reducing this risk within an 8 hour period. The plan includes reminding the mother to only touch the wound during dressings, keeping the skin clean and dry, educating on proper cleaning and disinfecting, administering medications as prescribed, and consulting a dietitian.

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    NCP_MODULE 8

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    The patient, M.J., a 27-month-old male, was admitted to the hospital with second degree burns on his hand. He shows signs of irritation, blistering, swelling, and redness. His temperature is elevated and he reports a pain level of 7 out of 10. The nursing student created a care plan to address the risk of infection with the goal of reducing this risk within an 8 hour period. The plan includes reminding the mother to only touch the wound during dressings, keeping the skin clean and dry, educating on proper cleaning and disinfecting, administering medications as prescribed, and consulting a dietitian.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    19 views2 pages

    NCP - Module 8

    Uploaded by

    adrian nakila
    The patient, M.J., a 27-month-old male, was admitted to the hospital with second degree burns on his hand. He shows signs of irritation, blistering, swelling, and redness. His temperature is elevated and he reports a pain level of 7 out of 10. The nursing student created a care plan to address the risk of infection with the goal of reducing this risk within an 8 hour period. The plan includes reminding the mother to only touch the wound during dressings, keeping the skin clean and dry, educating on proper cleaning and disinfecting, administering medications as prescribed, and consulting a dietitian.

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    © All Rights Reserved
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    of 2

    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

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