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B.Sc.

NURSING DEGREE PROGRAM


COLLEGE OF NURSING
NISHTAR MEDICAL COLLEGE & HOSPITAL MULTAN

Student Name: Palwasha khan


Date: 08-11-2016

Faculty Name: Madam Kishwar Anees

Ward No: 04
Week Focus: Nursing care plan & Physical Examination
Initials: Sana khan
Room/Bed No: 24
Religion: Islam

Age: 07 years

Sex: Female

D.O.A: 7-11-2016

Developmental Stage: Childhood


Unmarried

Occupation: Nil

Medical Diagnosis:

Surgical Procedure: Nil

Burn Injury

Patient

Marital Status:

Clinical Profile:
Chief Complain/Concern:
Client has come in hospital with major thermal burn and respiratory
distress.

1. HEALTH PERCEPTION AND HELATH MANAGEMENT PATTERN


A. Clients Perception of Health:
Client states that:
A person who is free to play without pain and disease is healthy

B. Review of Health Status:


(Any childhood/adult illness, hospitalization, accidents and operations)
Patient has remained admit for tetanus one year ago. No other history of
illness is found.
= Female
= Male
C. Family Medical History (Genogram):

Genogram Key

= Decreased.

A $ W = Alive and well


30 years

35 years

( ) = Cause of death
= Adoption
(Vertical)

2 years

7 years

5 years

College of Nursing Nishtar Medical College & Hospital Multan

D. Medication Currently Taken:


(Mention name, dosage frequency, and reason for taking and since when)

Injection Claforan (250mg)


Syrup Cefpan (125mg)
Syrup Brufen
Cream Flamazin

1 BD
1 BD
1 TDS

E. Any Known allergies/drug sensitivities (If present, mention


reaction).
No allergy reported from any drug

F. Any developmental concern:


Client is looking weak according to her developmental concern.

G. Immunization Status: (Polio. DT, Hep B, TT other).


BCG scar is present. Hepatitis B and TT immunization has done.

H. Review of Systems:
Patient has complained of weakness and fever.
I. Any Lab or diagnostic tests:
Complete Blood Count (CBC) test results:
Neutrophils
42.7%
Eiosinophils 5.9%
Basophils
1%
Lymphocytes 31.0%
Monocytes
19.3%
J. Identified Nursing Diagnosis:

Elevated body temperature related to increase metabolic rate as


evidenced by flushed skin and increase respiratory rate (Pocket
Guide for Nurses Alice.C.Murr page No 299)

College of Nursing Nishtar Medical College and Hospital Multan

2.

NUTRITION AND METABOLIC PATTERN


A. History Data & System in Review:
(Skin, Hair and nails changes, Soreness, Nausea/Vomiting, indigestion, Reflex,
bleeding, jaundice, heat, cold, intolerance, voice changes, carries, gum
disease, blood type, any bruises, anaemia)
Patient has complain of vomiting, loss of appetite and abdominal fullness.

B. Any Diagnostic / Lab investigation:


No Diagnostic or lab tests are conducted

C. Identified Nursing Diagnosis /Client Problem


Imbalanced Nutrition: Less than body requirement related to loss of
appetite as evidenced by weakness and weight 20% or under ideal
(Pocket Guide for Nurses Alice.C.Murr page No 370)

3.

ELIMINATION PATTERN
D. History Data & System in Review:
(Diarrhoea, constipation, bleeding, haemorrhoids, changes in bowel habit,
urinary retention, incontinence, dysuria, hematuria, flank pain, urgency,
frequency and hesitation)
Patient has complain of decrease urine output.
E. Any Diagnostic / Lab investigation:
No diagnostic or Lab test is conducted.

F. Identified Nursing Diagnosis /Client Problem


Decreased urinary elimination related to excessive loss of fluid from
alternative route as evidenced by urine output less than 0.5ml/kg/hour in
that child.

College of Nursing Nishtar Medical College and Hospital Multan

4.

ACTIVITY & EXERCISE PATTERN


RESPIRATORY STATUS:

History Data & System Review: (Cough, SOB, Wheezing, pain, hemoptysis)
Respiratory rate: 40 breaths/ mint
Patient has increased respiration rate that is difficulty in breathing and
shortness of breath.
CIRCULATORY STATUS:
History Data & System Review: (Palpitation, Angina, orthopnea,
thrombophelbitis, leg cramps)
Patient is observed with hypotension and decreased myocardial
contractility.

MUSCULOSKELETAL STATUS:
A. History Data & System Review:
(Joint stiffness, cramps, heat, redness, deformity, weakness, edema)
Patient has complain of joint stiffness and edema

B. Any Diagnostic/ Lab Investigations.

No diagnostic or lab tests are conducted.

C. Identified Nursing Diagnosis/Client Problem:

Impaired physical mobility related to generalized tissue edema as


evidenced by limited range of motion and impaired joint flexibility
(Delmers Pediatric Nursing)

5.

COGNITIVE PERCEPTUAL PATTERN


A. History Data & System Review:

(Vision, diplopia, discharge, redness, deafness, vertigo, use of any aids,


coordination, gait, sensation, weakness, headache, syncope, tremor, numbness,
tingling, memory)
Patient has numbness and complain of impaired memory

College of Nursing, Nishtar Medical College and Hospital Multan

B. Any Diagnostic/ Lab investigation.


No diagnostic or Lab tests are conducted
C. Identified Nursing diagnosis/ Client problem.
Impaired memory related to fluid and electrolyte imbalance as evidenced
by inability to recall recent or past events.

6.

SLEEP & REST PATTERN


A. History Data & System in Review:
Parents reports that client has difficulty falling asleep.

B. Any Diagnostic / Lab investigation:


No diagnostic or Lab tests are conducted

C. Identified Nursing Diagnosis /Client Problem

Disturbed Sleep pattern related to shortness of breath and feeling of


discomfort as evidenced by agitation and fatigue on awakening (Nanda
page No: 446)

7.

SEXUALITY REPRODUCTIVE
PATTERN
A. History Data & System Review:

(Female: menarche, pap smear, pregnancies, contraception, abortion, premature


births, vaginal discharge, uterine prolapsed, dysmenorrhoea, Nipple discharge,
Pain, lumps.
Male: sterility, impotence, circumcision, discharge, bleeding, STE)

Patient has normal reproductive structure, no other abnormality is found.

College of Nursing, Nishtar Medical College and Hospital Multan

B. Any diagnosis/Lab investigation.


No diagnostic or lab tests are conducted.
C. Identified Nursing diagnoses/ Client problem.
Nil

8.

ROLE RELATIONSHIP PATTERN


A. History Data/ System Review:
Parents reports that child has good interaction among family members.

B. Draw an ECOMAP:
ECOMAP KEY
Siblings

Parents

Very strong:
Strong:
Normal:

Patient

Weak:
Interrupted:

----

No relationship:

Religion

College of Nursing, Nishtar Medical College and Hospital Multan

C. Identified Nursing Diagnosis/Client Problem:


Readiness for enhanced Family process as evidenced by relationship are
generally positive and interdependent

9.

COPING STRESS AND TOLRANCE


PATTERN

A. History Data & System Review: (Mood, anxiety, depression, memory)

Parents reports that child feels anxious and low mood while talking about
her burn injury

B. Identified Nursing Diagnosis/Client Problem:

Ineffective coping related to poor impulse control as evidenced by


verbalization of inability to cope and ask for help. (Nanda page No 124)

10. VALUE BELIEF PATTERN


A. History Data & System Review:
Parents reports that child questions about the presence of God.

B. Identified Nursing Diagnosis/Client Problem:

Impaired religiosity related to sickness as evidenced by patient questions


religious belief pattern, customs and about existence of God (Pocket
Guide for Nurses Alice.C.Murr page No 438)

College of Nursing Nishtar Medical College and Hospital Multan

11.

SELF PERCEPTION AND SELF CONCEP


PATTERN

A. History Data & System Review:


Parents reports of child irritable mood and decrease sense of competency

B. Identified Nursing Diagnosis/Client Problem:

Situational low self esteem related to disturbed body image as evidenced


by negative feeling about self and non assertive behaviour (Pocket Guide
for Nurses Alice.C.Murr page No 436)

Comments:
Signature of Instructor

College of Nursing Nishtar Medical College and Hospital Multan