RISK FOR INJURY

NURSING CARE PLAN

Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Interventions
Subjective Data: Risk for injury r/t Short term:  Inform the  It is very Goal Met
“Mahilig po sya increased After 2 hours of mother to check important to
maglaro sa harap ng independence nursing check children Short term:
her child time
bahay, pero minsan outside the home. intervention, the when they are After 2 hours of
to time. nursing intervention,
hindi ko po gaanong client will be given not beside us to
nababantayan.”, as instruction be sure if they the client was able to
verbalized by the carefully to be able  Encourage the are safety or not. reduce the risk for
mother. to reduce the risk mother or other injury through
for injury through member of the  At this age, the attaining safe
Objective Data: attaining safe family to assist child must need environment:
 The child is environment: the child an assist or  Stones and
slightly naughty.  Watch door companion, this landing steps
whenever
 Some part of  Stones and is to prevent  Watch door
their surrounding he/she tend to from any
Landing steps  Edges
is rocky, and  Edges play outside of accident.
some of it is their house. Long term:
sandy. Long term:  To maintain the After 2 weeks of
 Scratches on the  After 2 weeks  Tell the mother safety of the nursing intervention,
knees of nursing to remove those child. the client was free
intervention, from injury.
hazardous
the client will
things that may
be free from
injury. lead into
accident (such
as sharp stones,
broken glasses,
wires).
  Encourage the
mother to
discuss safety
rules with the
child (such as
don’t play with
stones, or sharp
objects).

RISK FOR INFECTION

NURSING CARE PLAN
Nursing Nursing
Assessment Planning Rationale Evaluation
Diagnosis Interventions
Subjective Data: Risk for infection Short term:  Establish  To gain trust and After the nursing
“Pag-uwi niya laging r/t presence of After 2 hours of rapport cooperation of interventions, the
may sugat, kakalaro open wounds; nursing the patient. mother and the
sa labas at di naman insufficient intervention, the  Teach patient to patient will be able
niya maiwasan.” as knowledge to mother of the client wash hands  Hand washing to gain knowledge in
verbalized by the avoid exposure to will gain often, reduces the risks infection control as
mother. pathogens. knowledge in especially for infection. evidenced by his
infection control as before toileting, discussion in wound
Objective Data: evidenced by before meals,  To impart to the care. The goal was
 Broken skin discussing the and before and patient when the met as evidenced by:
 Redness in wound care. after wound become  No presence of
wound administering infected and open wound.
 Increased body Long term: self-care. when to sought  Skin is free from
temperature After 2 weeks of medical care. infection.
nursing  Discuss to the
intervention, the mother of the  To know if the
client will be free patient the patient really
from infection. following signs understands the
of infection; principle of
 redness, proper wound
swelling, care.
increased pain,
or purulent
drainage on the
site and fever.

 Demonstrate
and allow
return
demonstration
of wound care.