UNIVERSITY OF TECHNOLOGY, JAMAICA

CARIBBEAN SCHOOL OF NURSING

NURSING CARE PLAN

Students name: Jerilee Watts

_ ID #: 1201465 Date: June 19, 2014 Needs: (1) Rest, Comfort& Activity (2) Psychosocial

Pt.s initials:T.H Age:13 yrs Diagnosis: 3rd Degree Burns

ASSESSMENT
Subjective Data

NURSING
DIAGNOSIS
Impaired physical

PATIENT OUTCOME
After 8 hours of nursing

mobility related to loss of interventions patient will

muscle function as
evidenced by patients
inability to walk.
Objective Data
Burn Scars observed
to upper and lower
extremities patient
demonstrates
difficulty with
mobility and activity

exhibit signs of mobility

within his scope.

(3) Nutrition
INTERVENTION

RATIONALE

1. Assist with range of motion

5. Maintaining and improving joint

exercises.
2. Change positions every 2 hours.
3. Provide safe environment. E.g.

functioning and muscle strength.

6. Eliminates pressure on the tissue

raise bed rails and use the wheel

chair
4. Place important objects within
reach

EVALUATION OF
CARE
After 8 hours of nursing
interventions patient was

able to exhibit signs of

and increases circulation.
mobility within his
7. Avoid injuries due to accidents and
scope.
falls
8. To maximize patients
independence

ASSESSMENT

NURSING
DIAGNOSIS
Ineffective coping related

PATIENT OUTCOME
After 8 hours of nursing

1. Build rapport with patient

to hospitalization as

interventions patient

2. Help patient to identify personal

Patient voiced I want

evidenced by patients

should be able to

to go home.

verbalization I want to

demonstrate the ability to

go home.

cope with stressors by

Subjective Data

utilizing two new stress

Objective Data

reducing skills.

Patient demonstrates

INTERVENTION

strengths
of regular exercise
4.

Instruct patient to participate in

deep breathing exercises
hospitalization

directed behaviour in

with patient

interventions patient was

8. To create a base for overcoming

able to demonstrate the

challenges

ability to cope with

9. To help the patient to get their

stressors by utilizing

mind off the stressor

two new stress reducing

10. To help patient to relax

skills.

11. To help the patient to understand

why they need they be in the

6. Encourage family members to visit

problem solving

EVALUATION OF
CARE
After 8 hours of nursing

7. To develop a trusting relationship

3. Educate patient about the benefits

5. Explain to patient the reason for

the like of goal

RATIONALE

hospital
12. To help the patient to not feel left

(Finding something to

out and forgotten

do when bored)

ASSESSMENT

NURSING DIAGNOSIS

PATIENT OUTCOME

INTERVENTIONS

RATIONALE

EVALUATION

Subjective Data

Objective Data

Risk for Imbalanced

After 8 hours of collaborative

1. Request a consultation with a

Nutrition less than body

and nursing interventions the

dietician to assess nutritional

appropriateness of the

collaborative and nursing

requirements related to

patient will be able to achieve

status of patient to develop

patient's diet to meet those

interventions the patient

increased metabolic needs

optimal nutritional status as

nutritional goals and a

needs

was able to achieve

following burn injury.

evidenced by wound healing

nutritional plan.

and weight stability.

2. Encourage the patient to eat a

balance diet.
3. Provide oral care prior to
eating
4. Assist patient to eat

6. To determine the

7. To replenish the nutrients

lost due to the burn injury
8. To encourage patient to eat

After 8 hours of

optimal nutritional status

as evidenced by wound
healing and weight
stability.

and enjoy the meal.

9. To ensure optimal
consumption of diet.

5. Monitor fluid input and

output

10. To monitor and evaluate

patients fluid and
electrolyte balance.