NURSING CARE PLAN #1

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Acute pain related to Short term: Independent: Independent: Short term:
 “Ganina rana swelling of lymph After 1 hour of 1. Maintain the 1. Provides a After 1 hour of
sha ga hilak, nodes and nursing intervention child’s room to conducive nursing intervention
musamot pag inflammation of joints the patient will be be in a environment the patient was able
able to: comfortable to heal and to:
gunitan og
temperature,
ipalihok” as 1. Stop crying clean, free from
promotes 1. Stop crying
verbalized by 2. Experience foul odors, with proper 2. Experience
mother less pain with a minimal noise infection less pain with a
Objective: rating of 4 out and visitors control rating of 2 out
 Facial of 10 2. Apply cool cloths 2. Alleviate skin of 10
grimacing, 3. Be free from to the skin, itching, cools 3. Be free from
Expressive any facial lotion, and soft, down the skin, any facial
behavior of grimacing loose clothing on therefore, grimacing
crying, Wong- Long term: the child. promotes Long term:
After 24 hours of 3. Apply lubricating comfort. After 24 hours of
Baker Faces
nursing intervention lip ointments 3. Moistens dry nursing intervention
Pain Rating and glycerin
Scale of 8 out the patient will be oral mucosa to the patient was able
swabs to the
of 10 able to: oral mucosa lessen to:
1. Feel little to no 4. Offer cool liquids discomfort 2. Feel little to no
pain, 2 out of and soft foods, 4. Maintains pain, 2 out of
10 but avoid acidic hydration and 10
and spicy fluids reduces mouth
Dependent: tenderness, Goal Met
1. Antipyretics acidic or spicy
such as fluids will sting
acetaminophen and cause
2. Administer IV more pain
immunoglobulin
Dependent:
as indicated
1. Reduces pain
and fever
2. Decreases
inflammatory
process
 NURSING CARE PLAN #2

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Impaired oral mucous Short term: Independent: Independent: Short term:
 “Pula kaayo iya membrane related to After 5 hours of 1. Assess for 1. Monitor for After 4 hours of
dila sugod disruption of tissue of nursing intervention changes in the further nursing intervention
ganina buntag, the oral cavity the patient will be lips and oral complications the patient was able
nag crack sad able to: cavity. and provide to:
early
iya lips” as 1. Have moist 2. Provide soft, 1. Have moist
intervention
verbalized by lips, pink and nonirritating lips, pink and
2. Soft food
mother non-tender foods such as requires less non-tender
Objective: tongue gelatin. chewing and tongue
 Dry mouth and 2. Show signs of 3. Provide cool provides less 2. Show signs of
cracked lips, having proper liquids such as irritation to the having proper
Red strawberry hydration ice chips. oral mucosa. hydration
tongue, 4. Instruct the use 3. Moistens dry
Inflamed a soft-bristle oral mucosa to Goal Met
tongue brush or a lessen
padded tongue discomfort
blade during 4. Soft-bristle
brush limits
mouth care. mucosal
5. Provide regular irritation and
oral care with continuing
alcohol-free mouth care
mouthwash. prevents
formation of
lesions and
sores
5. Alcohol-free
mouthwash
limits bacterial
accumulation
and does not dry
the mucosa
 NURSING CARE PLAN #3

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Impaired physical Short term: Independent: Independent: Short term:
 “Galisod man mobility related to After 8 hours of 1. Provide joint 1. Pillows can be After 8 hours of
sha og arsa inflamed joints nursing intervention support using used to stabilize nursing intervention
saiya ulo, pati the patient will be pillows. a joint and to the patient was able
sad sa pag able to: 2. Provide ample minimize the risk to:
of pressure
kulob” as 1. Raise head resting periods 1. Raise head
ulcers.
verbalized by with help and in-between with help and
2. Promotes
mother support activities conservation of support
Objective: Long term: 3. Assist with energy and
 Impaired ability After 1 week of passive range decrease Goal Partially Met
to raise head nursing intervention of movement fatigue.
and turn from a the patient will be exercises as 3. Maintains and
prone position able to: tolerated improves joint
into a supine 1. Raise head 4. Encourage function, muscle
position and change intake of soft strength, and
from prone to foods that are overall stamina.
supine position rich in 4. These food
(vice-versa) antioxidants, items help
freely without Omega-3 Fatty strengthen
difficulty and acids, and anti- mobility and
support inflammatory maximize
properties energy
production.