NURSING CARE PLAN

CUES

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLAINATION

PLANNING

NURSING
INTERVENTION

RATIONALE

EVALUATION

Objective:

Pain related
to
inflammation
as evidence
by grimaced
face and
irritability.

Unpleasant
sensory and
emotional
experience
arising
from actual or
potential tissue
damage,
sudden or slow
onset of any
intensity
from mild to
severe with
anticipated or
predictable end
a duration of
less than 6
months.

Short
Term:
After 30mins
of nursing
Intervention
the patient
will:
>Pain scale
4/10
>Comfortable
>Grimaced
face(-)
>irritability
(-)

1. Position the
client in a
comfortable
position.

1.To be more
comfortable

After 30mins of
Nursing Intervention
the patient
experience :
>pain scale 4/10
>comfortable
>(-)irritability
>(-)grimaced face

>Grimace
face(+)
>irritability
(+)
>crying
>pain scale
7/10
>128bmp
>RR-41
>Temp.36.6

>Pain scale
7/10.

2. Diversion of
activities like
reading books,
drawing, coloring
etc.
3. Provide rest,
sleep, And
relaxation.

2.To divert
attention of
pain.

GOAL WAS
MET.
3.To provide
Comfort.

4. Instruct family
4.To provide
member to
rest and
eliminate any
comfort
positive stressor or
discomfort.
5. Administer pain
reliever as per
doctors advice.

5. To relieved
pain and
discomfort.

CUES

NURSING
DIAGNOSIS

SCIENTIFIC
EXPLAINATION

PLANNING

NURSING
INTERVENTION

RATIONALE

EVALUATION

Objective:
>noted
swelling
of the mass
>irritable
>itchiness
>skin
redness at
the
back
lumbar
area
>decrease
peristalsis

Impaired
skin integrity
related to
presence of
swelling at
the left
lumbar
sacral area
with the
presence of
mass.

Skin is the
primary defense
or the body it
protects against
infections and
diseases that
brought about by
the invasive
microbes in the
body. A normal
skin is moist and
intact, dryness
of the skin is
more to friction
that may result
to skin impairment of the skin
integrity as compared with moist
normal skin.

Short Term:
After 8hrs.
Of nursing
Intervention
The patient
will verbalize
understandi
ng of health
teaching.

1.Assess skin
noted color,
turgor sensation
describe and
measure the
wounds or mass
and observed
changes.

1.To established
baseline for
Providing timely
intervention.

After 8hrs of nursing

intervention the
patient understand
the health teaching.

2.Monitor VS
(temp. RR,BP,
HR)
3. Counter
Irritation and
touch therapy
4. Demonstrate
good skin hygiene
(e.g wash
thoroughly and pat
dry carefully.
5.Place the patient
in comfortable
position(right side
lying position)

2. For baseline
data.
3. To make
patient
comfortable.
4. Maintain clean
and dry skin
provides barrier
to infection.
Patting skin dry
instead of
rubbing reduces
risk of dermal
trauma to fragile
skin.
5. To make more
comfortable and

6. Instruct family
member to
maintain clean
and dry skin
preferably soft
cloth such as
cotton fabric or tshirt.
7.Instruct family
member to do
hand washing.

minimized the
swelling of mass.

6. Skin friction
caused by stiff or
rough clothes
leads to irritation
of fragile skin increase risk for
infection.

8. Administer
oxacillin and
cefuroxime (q8)
antibiotic as per
doctors advice.

7. To prevent
spreading of
bacteria that
causes infection.

9. Schedule for
I&D and waiting
for the clearance
from pediatrician.

8. To lower
bacterial growth
and minimized
infection by
administering
antibiotic.
9. To drain the
abscess that
present in the
mass that

causes infection
and pyomyositis.