DAVAO DOCTORS COLLEGE

General Malvar St., Davao City

Nursing Program
NURSING CARE PLAN

Name of Patient: _Patient NDJJ___________ Date of Admission: _October 21, 2021 @8:00AM Room: __203-A_
Age: _11 months old_ Sex: _Male_ Civil Status: _N/A_ Chief Complaint: vomiting and loose bowel movement of 5x/day with color of greenish brown stool
Religion: ___N/A___________ Attending Physician: ___Dr. Gin Min Who________

PROBLEM SCIENTIFIC BASIS GOALS/OBJECTIVES NURSING RATIONALE EVALUATION

INTERVENTIONS
October 21, 2021 @ Acute pain related to Within 8 hours of providing 1. Review factor that 1. To lessen/alleviate October 21, 2021 @
12:00PM inflammation as evidenced nursing interventions, the aggravates or pain caused by 3:00PM
by Wong Baker face pain patient will be able to: alleviate pain various factors
scale of 6/10 GOAL MET
Objective: a. Be free from pain as 2. Collaborate in 2. To assist client’s
 Facial grimace evidenced by Wong treatment of family to explore Within 8 hours of providing
 Wong Baker BASIS: Baker Face pain scale underlying condition methods for nursing interventions, the
face pain scale Acute gastroenteritis occurs of 0/10. disease process alleviation/control of patient was able to:
of 6/10 when food or water that is causing pain and pain.
 Always crying contaminated with bacteria or proactive a. Be free from pain
 Irritable its toxins is consumed. The management of pain. as evidenced by
 Sweating bacteria then injured the Wong Baker Face
tissues in the abdomen 3. Encourage presence 3. To comfort child. pain scale of 0/10.
causing inflammatory of parent during
response. During the course procedures.
of inflammation, the body’s
immune response, causing 4. Use puppets to 4. For child to enhance
the release of cytokine and demonstrate understanding and
prostaglandin causing an procedure. reduce level of
increase in vascular anxiety and fear.
permeability and causes
pain, which felt by the patient 5. Administer 5. To comfort and
in the abdomen. analgesics, as relieve client’s pain.
indicated.

6. Provide adequate 6. To reduce pain and

rest. promote
relief/comfort.
 7. Discuss with family 7. To promote wellness.
REFERENCES: ways in which they
Doenges, M., Moorhouse, M. can assist client with
F., & Murr, A. (2019). Nurse’s pain management.
Pocket Guide diagnoses,
Prioritized Interventions and 8. Monitor skin color and 8. These are usually
Rationales. Philadelphia, vital signs. altered in acute pain.
Pennsylvania: F. A Davis
Company 9. Monitor effectiveness 9. To promote timely
of pain medication intervention/ revision
of plan of care
Edelyn Santoyo
Name of Student
DRUG STUDY
 Medication Mode of Action Dosage Indication(s) Contraindication(s) Side Effects Adverse Effects Nurses Responsibilities
Generic Name: Inhibits 10mg q 6hrs Short term -Hypersensitivity to any CNS:  CNS:  Check the patient's
ketorolac prostaglandin PO management of of the components Dizziness Drowsiness, medical record for an
synthesis, pain -Renal failure euphoria, allergy or
Brand Name: producing -History of GI bleeding headache contraindication to the
Toradol peripherally -Cardiovascular disease prescribed
mediated GI:  medication.
Classification: analgesia Nausea  Educate patients
RESP:
Nonsteroidal Anti- Asthma, about their
inflammatory Drugs dyspnea medications.
Encourage them to
CV: speak up if something
Edema, pallor, seems amiss.
vasodilation  Assess pain and
other variables (range
GI: of motion, muscle
altered taste, strength) to document
diarrhea, dry whether this drug is
mouth successful in helping
manage the patient's
GU: pain and decreasing
Oliguria, renal impairments.
toxicity  Assess dizziness and
drowsiness that might
affect gait, balance,
and other functional
activities.
 Monitor blood
pressure upon
administration.
 Monitor signs of GI
bleeding, including
abdominal pain,
vomiting blood, blood
in stools, or black,
tarry stools. Report
these signs to the
physician
immediately.
 Monitor pain.
 Instruct patient to
report any signs of
itching, swelling of
ankles, sore throat,
REFERENCES:

Kizior, R., & Hodgson, K. (2019). Saunders Nursing Drug Handbook. Elsevier

Robinson, J. (May 9, 2016). Medication safety: Go beyond the basics. https://www.nursingcenter.com/ncblog/may-2016/medication-safety-go-beyond-the-basics

FDAR:

F Abdominal pain

D Facial grimace, Wong Baker Face pain scale of 6/10, irritable,

sweating

A Administered Paracetamol 150mg/5ml 120mg PO, as indicated; Kept

patient comfortable and safe; Monitored vital signs and skin color.

R After 3 hours

Patient pain was relieved. Wong Baker face pain scale 0/10, no facial
grimace, irritability, and sweating noted.

CUS:

Collaboration:

C I am concerned that the patient is 6-month-old and was rushed

because he fell from the table.

U I am uncomfortable since it happened to the infant and the parents is

not much aware of fall as second major cause of infant injuries.

S It is a safety concern. Can you come and educate the parents about
fall prevention?

Ethico-Moral-Legal Consideration:

Nursing Action  Educate the student nurse about her attitude

towards the patient.

 Instruct the student nurse to apologize and

ensure that it will never happen again.

 Encourage the student nurse to study more

about gender and development of infant.

 Educate the student nurse in regard with

infant’s emotional development, tell her that at
the patient’s age the fear of strangers at its
peak.
Ethical Principle
Upheld