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ASSESSMENT Subjective: “Hindi siya masyadong makahinga dahil sa sipon niya.” As verbalized by the client’s mother.

Objective: - Sneezing - Stuffy nose - Use of accessory muscles when breathing - Nasal flaring - Mouth breathing - RR: ?cpm

NURSING DIAGNOSIS Ineffective Airway Clearance related to Excessive Secretions as evidence by Stuffy Nose, Nasal Flaring and Use of Accessory Muscle.

SCIENTIFIC EXPLANATION Irritant (Inhalation) Inflammatory Response Increase Production of Secretions Airway Constriction Colds (Common Colds)

PLANNING Long Term Outcome: After 1 week of nursing interventions, the client will be able to demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange. Short Term Outcome: After 8 hours of nursing interventions, the client’s mother will be able to verbalize understanding of cause and therapeutic management regimen.

INTERVENTIONS - Encourage deep breathing exercise. - Position head midline with flexion appropriate for age or condition. - Provide information about the necessity of raising and expectorating secretions versus swallowing them. Collaborative: - Administer prescribed medications.

RATIONALE - This will promote proper lung expansion. - To open or maintain open airway in at-rest or compromised individual. - To examine and report changes in color and amount.

EVALUATION Long Term Outcome: GOAL ACHIEVED, The client was able to demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange. Short Term Outcome: GOAL ACHIEVED, The client’s mother was able to verbalize understanding of cause and therapeutic management regimen.

Reference: Foundations of Nursing By: Lois White

- Prescribed medications such as bronchodilators helps in aiding effective airway clearance. - Nebulization helps in liquefying secretions for better and faster expectorating the secretions.

- Provide supplemental humidification via use of nebulizer.

Assessment Subjective: “Lagi po ako naglalaro sa labas” as verbalized by the client. Objective: -always playing outside the house -dirty playground -poor sanitary hygiene -sweaty hair -sweaty skin -dirty house

Nursing Diagnosis Risk for infection related to increase in environmental exposure to pathogens

Scientific Explanation bacteria poor sanitary hygiene entrance of bacteria distruction of 1st line of defense spreading of the microorganisms

Planning Long Term Objective: After 1 week of nursing interventions, the client will be able to be free from pathogens. Short-Term Objective: After 8 hours of nursing interventions, the client will be able to: -gain knowledge and could give 3 out of 5 ways to prevent infection -demonstrate good sanitary hygiene such as taking a bath everyday and brushing of teeth after meals

Intervention -Instruct in daily mouth care

Rationale -At high risk for nosocomial / health care associated infections -To reduce bacterial colonization -For mobilization of respiratory secretions -It is the first line defense against infection -Skin is the first line defense for microorganism

Evaluation Long Term Objective: Goal achieved. The client was able to be free from pathogens Short Term Outcome: The client was able to: -gain knowledge and could give 3 out of 5 ways to prevent infection -demonstrate good sanitary hygiene such as taking a bath everyday and brushing of teeth after meals

-Recommend routine body showers -Encourage deep breathing -Stress proper hand washing -Instruct client in techniques to protect integrity of skin care for lesions

infection occur Reference: Fundamentals of Nursing By: Kozier

ASSESSMENT Subjective: “Hindi niya matukoy / masabi ang ibang kulay na tinatanong ninyo.” As verbalized by the client’s mother. Objective: - No response - “I don't know” response - Age: 5 yrs. old

NURSING DIAGNOSIS Risk for Delayed Development related to Learning Disabilty

SCIENTIFIC EXPLANATION Poor attendance in educational program. Mother doesn’t teach at home. Risk for Delayed Development.

PLANNING Long Term Outcome: After 1 week of nursing interventions, the client will be able to perform motor, social, selfregulatory behavior, cognitive and language skills appropriate for age within scope of present capabilities. Short Term Outcome: After 8 hours of nursing interventions, the client’s mother will be able to verbalize understanding of age-appropriate development / expectations.

INTERVENTIONS - Note chronological age.

RATIONALE - To help determine developmental expectations. - Small incremental steps are often easier to deal with.

EVALUATION Long Term Outcome: GOAL ACHIEVED, The client was able to perform motor, social, selfregulatory behavior, cognitive and language skills appropriate for age within scope of present capabilities. Short Term Outcome: GOAL ACHIEVED, The client’s mother was able to verbalize understanding of age-appropriate development / expectations.

- Encourage setting of shortterm realistic goals for achieving developmental potential. - Provide information regarding normal development, as appropriate, including pertinent reference materials. Collaborative: - Review expected skills / activities using authoritative test or assessment tool (MMDST). - Identify available community resources as appropriate.

Reference: Foundations of Maternal and Child Nursing By: Lois White

- To enhance the client or the mother’s client knowledge.

- Provides guide for comparative measurement as child / individual progresses. - Provides additional assistance to support family efforts in treatment program.