MANILA DOCTORS COLLEGE

Pres. Diosdado Macapagal Blvd., Metropolitan park, Pasay City

NURSING PROCESS

I. ASSESSMENT
A. General data:
Name: YIB Informant: Mother NB
Address: Malate, Manila Date of admission: Feb. 16, 2010
Place of birth: Manila Order of admission: carried by relative
Date of birth: July 15, 2005 No. of days in the hospital:
Age: 4Y7M Date of history taking: February 18, 2010
Gender: female

B. Chief Complaint:
High grade fever for two days, accompanied by dry cough and maculopapular rash
along the ears and neck.
C. History of present illness:
One week prior to confinement, patient was having colds and cough. Patient was not
given any medications, patient was encouraged to increase fluid intake.
Four days prior to confinement, patient had a fever of 39C, with accompanying
symptoms of dry cough. Given paracetamol (once) that gave a temporary relief.
Three days prior to confinement, patient sought consultation on a pediatrician.
Cefuroxime and clarithromycin was given. Patient was advised to be confined for further medical
management.
On the day of admission, patient was brought to the ER of the MDH for further medical
management. Patient was seen with maculopapular rashes along the ears down the neck. Patient was
also assessed with cervical lymphadenopathy and fever of 40C and accompanying symptoms of dry
cough, hypertrophic tonsils and hyperemic buccal mucosa.

D. Past History:
Birth history: born full term, normal spontaneous delivery, with no known maternal complications
Childhood illness/es: none
Immunizations: patient completed vaccinations in the year 2006.
Previous hospitalization: the patient was not hospitalized during the last six months.
Operations: none
Injuries: none
Allergies: no known drug or food allergies.
Medications taken prior to confinement: Paracetamol
Cefuroxime
Clarithromycin
E. Systems review
Gordon’s eleven functional patterns
HEALTH PERCEPTION PATTERN
According to the patient’s mother, her daughter seldom gets sick and would rate her daughter’s health
to be 8/10 with 10 being the highest. The patient did not have any absences from school. Patient had
cough and colds a month ago but no therapeutic regimen was done, patient’s water intake was just
increased. During the past few days, patient had a 39C fever with accompanying symptoms of dry
cough and according to the mother, “itchy rashes all over the face”. Patient was given (Paracetamol)
Tempra, once and gave a temporary relief. When patient was brought to the pediatrician, patient was
given Cefuroxime and Clarithromycin. According to NB, they were advised to bring patient to the ER for
further management of the patient’s disease.

During admission, according to the mother, at first she had no idea where her daughter caught the
disease but YB’s teacher told her yesterday (Feb 17 2009) that one of YB’s classmates from her
nursery class also had measles about a week ago. According to her (mother NB) when her daughter
was admitted, she was sometimes inactive and irritable. Patient was also irritable because the rashes
in her face are itchy. Patient is energetic whenever toys are brought in the hospital.

NUTRITIONAL-METABOLIC
According to the mother, her daughter has always been picky when it comes to her meals. She rarely
eats rice and would prefer bottle-feeding with powdered milk. Also, her daughter prefers foods with
soup and hotdog and “chicken joy”. Patient drinks about 4 glasses of water every day.

During confinement, the mother was advised to increase the patient’s fluid intake. Patient’s diet was
specifically for her age. Patient still preferred bottle-feeding and NB added that the patient “hates the
hospital food” so they often buy fastf ood outside just so patient YB would eat.

ELIMINATION
Before admission, patient would defecate once everyday sometimes twice, without any difficulties.
Stool is usually semi-formed and with a light brown-brown color. When it comes to urinating, patient
would usually urinate 3-4 times a day, but mother complains that her daughter would wet the bed at
night especially when, “patient played too much.” Patient is toilet trained.

During admission, patient’s elimination pattern did not change. She would consume about two diapers
a day, and would be carried to the comfort room to defecate due to limited movements because of the
IV line.

ACTIVITY-EXERCISE
Before admission, NB says her daughter is very active and very playful. She would play around with
her older sister. Patient is usually supervised by her babysitter or her mother when it comes to eating,
bathing, toileting and grooming.

During admission and upon observation, patient was very active when she plays with her toys.
According to her mother, it seems that YB has lesser energy to do activities.

SLEEP-REST
According to the mother, patient usually goes to bed at 8 or 9:00 PM and wakes up at around 7:00 AM.
Patient usually take naps in the afternoon and this serves as her rest.

During admission, mother NB said that there are usual awakenings at night because the patient would
complain that she misses her bed. Patient would also sleep during the day and still sleeps more than 9
hours.

ROLES-RELATIONSHIP
Patient is the second child and according to mother, she does not give everything her daughter wants
especially the material things. According to her, patient YB is closer to his father, AB. The parents live
with their daughters and said that whenever their daughters were sick, they immediately turn their
attention to them and her relatives would be concerned.

The informant said that she and her husband would exchange places when taking care of their child.
Also, YB’s babysitter would take turns in taking care of YB. According to the patient, she already
misses her older sister and according to her, the patient already wants to go home. Also the
hospitalization made their family closer especially when her relatives would visit the patient.

VALUES-BELIEF
According to the informant, the patient does not always get what she wants because they do not want
to spoil her. Their religion is Muslim. According to the mother, they are already teaching their kids
about their religion, and how to pray.

The hospitalization made the family closer to God and said that nothing has changed with their
relationship with Him.

D. Family assessment:
Name Age Sex Occupation Educational Relation to
attainment patient

AB 36 Male Businessman College Father

graduate

NB 35 Female Businesswom College Mother

an graduate

JB 8 Female n/a Elementary sibling

level

E. Heredo- Familial Illness

Paternal- hypertension, cancer of the colon
Maternal- diabetes, hypertension

F. Developmental history

Theorist Age Task Client based

Freud’s 5 stages of 4 Concentrates on the
development (phallic stage) preschooler’s
gratification involving the
genitals. At this stage,
children gratify their sex
instinct by fondling their
genitals and developing
an incestuous desire of
the opposite sex parent.
As verbalized by the
mother, “mas madalas
mas malapit sya sa
daddy nya. At minsan sa
daddy nya lang sya
sumusunod.”

Kohlberg’s stages of
Moral Development
According to Freud, a
four-year-old girl
develops an intense
sexual longing for her
father. At the same time,
she becomes jealous. If
she could not have her
way, she would destroy
his rival for her paternal
affection – her mother.
Jung later called this the
Electra Complex.
4 Fear of punishment, not As verbalized by NB,
(Toddler to 7 years) respect for authority, is “sumusunod lang yan
(Punishment and the reason for decisions, sakin dahil alam nila na
obedient orientation) behavior and conformity may palo sila sa akin pag
hindi sya sumunod”

Erikson’s psychosocial 4 During this stage, the As verbalized by NB,

(Initiative vs. Guilt) repertoire of motor and “hinahayaan naming sya
mental abilities that are makipag laro sa kapatid
open to children greatly nya. Pag wala naman
expands. Parents who yung ate nya, sa mga
give their children pinsan nya.
freedom running, sliding,
bike riding, and skating
are allowing them to
develop initiative.
Parents who curtail this
freedom are giving
children a sense of
themselves as nuisance
and inept intruders in an
adult world. Rather than
actively and confidently
become passive
recipient of whatever the
environment brings.
Fowler’s stages of 4 Young children, during As verbalized by NB, “sa
spiritual development (intuitive-projective) the first stage of faith pagdadasal lagi naming
(intuitive-projective), sila kasama pumunta ng
follow the beliefs of their Mosque. At tinuturuan na
parents. They tend to din naming sila paano
imagine or fantasize ang paraan ng
angels or other religious pagdadasal namin.”
figures in stories as
characters in fairy tales
Piaget’s phases of 4 During preoperational As verbalized by NB
cognitive development (Preoperational) stage increases the “madalas bulol pa din
ability to store words and sya pero naiintindihan
language structures. naman yung gusto nyang
There is the capacity to sabihin kasi nga bata
understand and make pa.” NB also indicated
use of the words. This is that the patient does not
the age adults have any imaginary
communicate with the friends because she has
children. It is significant her older sister whom
in language development she can play with.
when adults talk, teach,
read, and even sing to Patient is able to count
the children. Language from 1-10
develops when there is Able to sing ABCs
more verbal Able to write her own
communication. name
Children are more eager
in imitating and trying
various sounds and
words than their correct
usage. They are able to
fantasize, dream,
imagine and freely
associate with others.
Concerned with
themselves, they talk to
toys, tell wild stories, and
have an imaginary friend
 which is call collective
monologue.

H. Physical examination
Physical Assessment
Date of history taking: Jan 22 & 23, 2010

A. Physical Examination
Height: 39.4 in (3.2 ft)

Weight: 39 lbs

BMI: 19

Vital Signs

Temperature: 37.4

PR: 120 bpm

RR: 23 bpm

BP: unable to acquire

Regional Examination:

A. General Appearance

The client is comfortable, seen patient lying on the bed, with coordinated movement.
Patient was distracted with the T.V. Patient had no odor problems but is seen with a low
energy level and did not answer all of the examiner’s questions.

B. HEAD AND FACE

I: Normocephalic with frontal, parietal and occipital prominences

Upright and still

Slightly asymmetrical facial features

Hair is black in color, thin and has some presence of flakes

Even distribution of hair

Presence of maculopapular rashes along the ear and face

C. EYES

I: Anicteric sclera

Pinkish conjunctiva

Eyebrows are symmetrically aligned

Eyelashes are equally distributed and curled slightly onward

Eyelids are intact, no discharges, no discoloration, close symmetrically

D. NECK

I: Able to move with slight difficulty

Presence of maculopapular rashes along the neck and back of the neck.
 Pa: Slightly supple neck

E. MOUTH AND PHARYNX

I: Lips are pale pink, symmetrical; lip margin is well defined, smooth but quite dry.

Able to purse lips

No ulcers

Moist and pinkish gums

No bleeding, swelling and inflammation of gums

Uvula positioned midline of soft palate

Tongue midline without deviation, moves freely

Slightly red, hypertrophic tonsils

Hyperemic buccal mucosa

No presence of exudates

Presence of dental caries.

F. THORAX AND LUNGS

I: Chest contour is symmetrical.

Spontaneous and non-labored breathing

Presence of maculopapular rashes over the chest

PA: No deformities, masses and lumps found

No tenderness in the areas palpated.

A: With presence of fine crackles in the upper zone of the anterior chest during expiration

G. ABDOMEN

I: Flat contour

Presence of maculopapular rashes over the abdomen

A: Audible bowel sounds

H. EXTREMITIES

I: Ongoing IV fluid on right arm

Poor muscle tone

P: Smooth and moist skin. Warm to touch.

II. Personal/Social history

Habits: watching T.V., playing.

Vices: none

Lifestyle: active

Social Affiliation: none

Client’s usual day like: wakes up at 7 a.m. watches T.V., eats her breakfast, at 10:00 AM, patient
goes to her school and goes back home at 12:00 PM. 12:15 patient eats lunch or drinks bottled
milk. 2:00 PM patient takes a nap. 4:00 PM patient plays with her sister until around 6 PM. 7PM
patient eats dinner/drinks bottled milk. 9PM patient goes to sleep.
 Rank/Order in the Family: second child

Travel: none

Educational Attainment: N/A

III. Environmental history:

According to the mother, they live in a condominium unit along Vito Cruz in Manila. The unit has two
rooms, each of the room with one window. Patient YB is sharing a room with her older sister. Overall
the unit has four windows. The building is near a shopping mall, and near a wet market. Their source of
electricity is Meralco and source of water is Maynilad. Patient goes to a nursery school near the
condominium. According to the mother, there are about 10 students.

PEDIATRIC HISTORY

• Maternal and birth history

Birth date: July 15, 2005

Birth weight: 2,800g

Type of delivery: Normal spontaneous delivery

Condition after birth: No complications

IV. Pathophysiology: Theoretical based

Modifiable risk Etiologic agent: Non-modifiable risk

factors: factors:
Paramyxovirus
Nutrition: Age: 6-moths- 3
malnourished people, years
particularly Vit A
deficiency Sex: females
Transmitted via
Immunization: people respiratory droplets Season: outbreaks in
who have not the summer season
received the proper (Philippines)
vaccination series
6-19 days of Overcrowding
intubation period

The respiratory
epithelium becomes
infected

Prodromal (pre- s/sx: fever, cough, coryza (runny

eruptive) period of 2- nose), conjunctivitis, photophobia
4 days

Replication in the viremia

regional lymph nodes

Infection of the Enanthem

endothelial cells (Koplik’s
spots)

Eruptive phase (4th- Cutaneous eruption of measles

7th day) (maculopapular rashes)

Infection of the
epithelial cells
 Complications:

Diarrhea

Pneumonia

Otitis media

Reactivation of latent
TB

Pyogenic infections
and PEM

Subacute, scelorotic
PAN-encephalitis

Febrile convulsions

Vitamin A deficiency

Client based:

Modifiable risk Etiologic agent: Non-modifiable risk

factors: factors:
Paramyxovirus
Nutrition: Sex: females
malnourished people,
particularly Vit A Season: outbreaks in
Transmitted via the summer season
respiratory droplets (Philippines)

6-19 days of
intubation period

Prodromal (pre- s/sx: fever,

eruptive) period of 2- cough
4 days

Replication in the regional

lymph nodes (cervical lymph
nodes)

Infection of the Enanthem

endothelial cells (Koplik’s
spots)

Eruptive phase (4th-

Infection of the Cutaneous eruption of measles

epithelial cells (maculopapular rashes)

V. Laboratory values:
Date ordered: 2-15-10

Normal values Result Indications

Hemoglobin (2-6 years old) 110-160 123 Measures the amount of oxygen-carrying
protein in the blood.
Hematocrit (2-6years old) 0.31-0.43 0.35 measures the percentage of red blood
cells in a given volume of whole blood.
RBC(2-6years old) 3.9-5.3 4.70 is a count of the actual number of red
blood cells per volume of blood. Both
increases and decreases can point to
abnormal conditions.
WBC 5-10x10 9/L 2.0 Decreased

s a count of the actual number of white

blood cells per volume of blood. Both
increases and decreases can be
significant.
Lymphocytes 0.25-0.33 0.40 Increased

Lymphocytes are involved in protection of

the body from viral infections such as
measles. Elevated levels may indicate an
active viral infection and a depressed
level may indicate an exhausted immune
system or if the neutrophils are elevated
an active infection.
Date ordered: 2-16-10

Normal values Result Indications

Hemoglobin (2-6 years old) 110-160 119 Measures the amount of
oxygen-carrying protein in
the blood.
Hematocrit (2-6years old) 0.31-0.43 0.35 measures the percentage
of red blood cells in a given
volume of whole blood.
RBC(2-6years old) 3.9-5.3 4.63 is a count of the actual
number of red blood cells
per volume of blood. Both
increases and decreases
can point to abnormal
conditions.
Platelet (1 day-1 week) 84-478x10^9/L 221 They are vital to
coagulation of the blood to
prevent excessive bleeding.
Elevated levels suggest
dehydration or stimulation
of the bone marrow where
the cells are produced and
decreased levels may
indicate an immune system
failure, drug reactions, B12
or folic acid deficiency.
Stab 0.03-0.05 0.01 The presence of these
immature cells is called a
"shift to the left" and can be
the earliest sign of a WBC
response, even before the
WBC becomes elevated.
Lymphocytes 0.25-0.33 0.28 Lymphocytes are involved
in protection of the body
from viral infections such as
measles. Elevated levels
may indicate an active viral
infection and a depressed
level may indicate an
exhausted immune system
or if the neutrophils are
elevated an active infection.
Monocytes 0.03-0.05 0.06 Increased

Elevated levels are seen in

tissue breakdown or
chronic infections,
carcinomas, leukemia
(monocytic) or lymphomas.
Low levels are indicative of
a state of health.
WBC 5-10x10 9/L 1.87 Decreased

White blood cells’ main

function is to fight infection,
defend the body by
phagocytosis against
invasion by foreign
organisms, and to produce,
or at least transport and
distribute, antibodies in the
immune response.

CXR:

Feb. 17 2010

>There are reticular infiltrates seen in the inner lung zones

>the rest of the lungs are clear

>heart is unenlarged

>the diaphragm, sulci, and bony thorax are intact.

IMPRESSION:

Interstitial pneumonitis
 VI. Drug Study

Drug Indication Action Side effects/adverse effects Nursing considerations Patient teaching

Date ordered:2-16- Upper & lower resp Synthetic, broad- At site of injection: pain and - Assess patient for infection (vital signs, wound appearance, sputum, urine, stool, and WBCs) at Report any adverse
10 tract infections, UTI spectrum antibiotic thrombophlebitis beginning and throughout therapy. effects including skin
& pyelonephritis; suitable for gram- - Obtain a history before initiating therapy to determine previous use of and reactions to penicillins or rash; if accompanied by
Brand name: skin & soft tissue & negative bacteria. GI: diarrhea, N&V, flatulence, cephalosporins. Persons with a negative history of penicillin sensitivity may still have an allergic response. fatigue, sore throat and
gonococcal Acid resistant, abdominal distention, glossitis - Obtain specimens for culture and sensitivity before therapy. First dose may be given before receiving enlarged spleen and
Unasyn
infections. destroyed by results. lymph nodes
penicillinase CNS: Fatigue, malaise, headache - Observe patients for signs and symptoms of anaphylaxis (rash, pruritus, laryngeal edema, wheezing).
Generic Name:
Ampicillin Sodium Discontinue the drug and notify the physician immediately if these occur. Keep epinephrine, an
GU: dysuria, urinary retention antihistamine, and resuscitation equipment close by in the event of an anaphylactic reaction.
Classification: - Caution patient to notify physician if fever and diarrhea occur, especially if stool contains blood, pus, or
antibiotic, penicillin Misc: itching, chest pain, edema, mucus. Advise patient not to treat diarrhea without consulting health care professional. May occur up to
swelling, erythema, chills, tightness several weeks after discontinuation of medication.
Dosage: 750 ml IV in throat, epistaxis, substernal pain, -Instruct patient to notify physician if symptoms do not improve.
mucosal bleeding.

Drug Indication Action Side effects/adverse Nursing considerations Patient teaching

effects

Date ordered: 2-16- Mild pain or Produces analgesia by blocking Hemolytic anemia, *Use cautiously in patients with history of chronic *Advise patient that drug is only for short-term use and to consult prescriber
10 fever generation of pain impulses, neutropenia, leukopenia, alcohol use because hepatotoxicity has occurred after if giving to children for longer than 5 days or adults for longer than 10 days.
probably by inhibiting pancytopenia, liver therapeutic effects.
Brand name: prostaglandin synthesis in the damage, jaundice,
CNS or action of other
substances that sensitize pain hypoglycemia, rash,
Tempra Forte *Acetaminophen may produce false-positive *Tell patient not to use for marked fever (higher than 103.1oF or 39.5oC),
receptors to mechanical or urticaria. decreases in glucose levels. fever persisting longer than 3 days, or recurrent fever unless directed by
Generic Name: chemical stimulation. Is thought prescriber.
Paracetamol to relieve fever by central action
in the hypothalamic heat-
Classification: anti- regulating center. *Assess for allergic reaction during treatment: rash,
pyretic and analgesic urticaria. *Alert: Warn patient that high doses or unsupervised long-term use can
cause hepatic damage. Excessive ingestion of alcohol may increase the
Dosage: 5ml every 4 risk of hepatoxicity.
hours if temperature
is >38C
Drug Indication Action Side effects/adverse effects Nursing considerations Patient teaching

Date ordered: 2-16- For the relief of symptoms Potent H1-receptor Most common: Somnolence, - Assess symptoms and record baseline before and during treatment. - Ensure patients are aware that this medication may
10 associated with seasonal antagonist. Mild dry mouth, fatigue, make them drowsy. If affected they should not drive
allergic rhinitis, perennial bronchodilator that pharyngitis, dizziness or operate machinery.
- Assess respiratory status, such as wheeze or tightness of the chest.
Brand name: protects against
allergic rhinitis and the
Benadryl histamine-induced
treatment of the - Patients who have missed a dose should take it as
bronchospasm; low to - Cetirizine is good at reducing rhinorrhoea and sneezing, but less
uncomplicated skin soon as they remember. If it is almost time for the
Generic name: negligible anti effective at reducing nasal congestion.
manifestations of chronic next dose, patients should skip the missed dose.
cholinergic and
Double doses should not be taken.
Cetirizine idiopathic urticaria. sedative activity. No
- Other products such as eyedrops and inhalers may be required to
hydrocholoride antiemetic activity
control severe hay fever.
- Health education advice should be given regarding
Classification: limiting exposure to allergens.
antihistamine, - Evaluate therapeutic response.
second generation,
piperazine - If allergy-testing is planned, medication should be stopped 48 hours
before testing.
Dosage: 5ml PO BID

Drug Indication Action Side effects/adverse effects Nursing considerations Patient teaching

Date ordered: 2-16-10
Brand name: Ventolin
nebules
Generic name: Salbutamol
Classification:
sympathomimetic
To prevent or treat bronchospasm in
patients with reversible obstructive
airway disease. Dosage depends on
form. Drug of choice for acute
bronchospasm. Inhaled route has
faster onset and is more effective than
tablet or syrup.
Relaxes Tremor, nervousness, headache, Use cautiously in patients with Avoid excessive use. Sensitivity to
bronchial and hyperactivity, tachycardia, palpitations, cardiovascular disorders. sympathomimetics. Discontinue if paradoxical
vascular smooth nausea, vomiting, bronchospasm, bronchospasm or cardiovascular effects occur.
muscle by hypersensitivity reactions. Cardiovascular disease (eg, coronary insufficiency,
Warn the patient about the risk of
stimulating beta2 paradoxical bronchospasm and if it arrhythmias, hypertension). Diabetes.
occurs, stop drug immediately.
receptors. Hyperthyroidism. Seizure disorders. Reevaluate
periodically. Elderly. Labor & delivery. Pregnancy
(Cat.C). Nursing mothers: not recommended.

Dosage: 1.24 ml, q8

Drug Indication Action Side effects/adverse effects Nursing considerations Patient teaching

Drug
Date ordered: 2-16- Indication of URIs caused by Streptococcus
Treatment Action Inhibits protein Side effects/adverse
CNS: effects
Dizziness, headache, Nursing
-Culture considerations
infection before Patient teaching
-Take drug with food if GI effects occur. Take the full course of
10 pyogenes, S. pneumoniae, LRIs, skin and skin- synthesis in susceptible vertigo, somnolence, fatigue therapy. therapy. Do not drink grapefruit juice while taking this drug.
Date ordered: 2-16- Needed
structurefor normal bone
infections causedand The role of vitamin A
by Staphylococcus in epithelial
bacteria, causing cell tiredness -have a full nutritional -comply with dietary recommendations.
10
Brand name: (not tooth development,
aureus, S. pyogenes, visual dark differentiation,
disseminated mycobacterial as well as in other assessment done by a
death. GI: Diarrhea, abdominal pain, -Doregistered
not cut ordietician.
crush, and -Shake suspension before use; do not refrigerate; do not cut, crush,
named) adaption,
infections skin
due disease,
to Myobacterium avium and M. processes, involves the
physiological nausea,
nausea,vomiting, or decreased
dyspepsia, flatulence, ensure that patient does not -take withER
or chew food for best
tablets; absorption.
swallow them whole.
Brand name: (not mucosa tissue
intracellular, repair;
active duodenal ulcerbinding
associated with
of retinol to two families of appetite
vomiting, melena, chew ER tablets.
named)
Generic name: stimulates
Helicobacter production/activity
pylori in combination with proton
nuclear retinoid receptors (retinoic acid pseudomembranous colitis -assess metabolic panel and
Clarithromycin of WBCs.
pump inhibitor, acute otitis media, acute maxillary -avoid self-medicating
-You may experience with
thesevitamin supplements
side effects: Stomachthatcramping,
exceed the
receptors, RARs; and retinoid-X vitamin levels as indicated
Generic name: sinusitis due to H. influenzae, M. cararrhalis, S. irritability -Monitor patient for anticipated RDAs.
discomfort, diarrhea; fatigue, headache (medication may be
Vitamin A pneumonia, mild to moderate community-receptors, RXRs). Other: Superinfections, response. ordered); additional infections in the mouth or vagina (consult with
Classification:
antiinfectives, 2nd gen acquired pneumonia in adults increased PT, decreased WBC -list agents prescribed to care provider for treatment).
headache -store away from heat in tight, light resistant containers.
Classification:
cephalosporins ensure none interact or
-Administer without
impact vitamin regard to
absorption.
Vitamins/supplement meals; administer with food if GI -Report severe or watery diarrhea, severe nausea or vomiting, rash
sDosage: 5ml PO BID dryness or cracking of the lips or skin;
effects occur. or itching, mouth sores, vaginal sores.
or
-with replacement, monitor
Dosage: 200,000 IU levels to ensure
hair loss requirements are met and
levels are as desired.

VII. List of priority of problems:

1. Hyperthermia related to measles

2. impaired skin integrity related to mechanical factor such as shearing forces.

3. risk for infection transmission

4. Deficient knowledge about the disease process

Cues/Needs Nursing Rationale Goals and Interventions Rationale Evaluation

 Diagnosis Objectives

Hyperthermi Body temperature After 2 hours of Independent 1. To decrease After 2 hours of

a related to elevated above nursing temperature by nursing
Subjective: measles normal range interventions, the 1. Promote surface means through interventions, goal
patient core cooling by means of evaporation and was met as
”Bumabalik yung lagnat Tepid Sponge Bath.
temperature will conduction. evidenced by the
nya as verbalized by the
decrease or decrease of the
mother.
maintain within patient core
normal range. 2. Maintain bed rest temperature from
(36.5-37.5 C) (37.8C- 37.3C)
Objective: 2. To reduce
metabolic demands
and oxygen
>Flushed skin, warm to Collaborative consumption.
touch
3. Administer
antipyretics orally
as prescribed by
V/S taken as follows: the physician. 3. To facilitate fast
T: 38.8C recovery.

P: 115 bpm

R: 28 cpm

Cues/Needs Nursing Goals and Objectives Nursing Interventions Rationale Evaluation

Diagnosis
Subjective: Impaired skin After an hour of nursing After an hour of nursing
integrity related intervention the client intervention goal was met
“makati yung rashes to mechanical /family will be able to: as evidence patient’s
nya kaya madalas factor such as mother participated and
nya nakakamot, kaya >participate in 1. Identify underlying 1. assess causative/
shearing forces. prevention measures contributing factors verbalized prevention
yung iba nagsugat condition/pathology
and treatment program measures and treatment
na.” involve.
2. assist client with program.
2. instruct patient’s correcting/minimizing
Objective: condition and promote
mother to inspect skin
optima; healing.
(+) rashes on daily basis,
describing lesions and
(+) wounds changes observed.
3. to provide a positive
3. advise patient’s nitrogen balance to aid in
mother to provide healing and to maintain
optimum nutrition and general good health.
increase protein intake

4. emphasize to 4.to reduce presence of

patient’s mother of the sensations
importance of proper fit
of clothing.
5. enhance commitment
5. Assist the patient’s
plan, optimizing
mother in
outcomes.
understanding and
following medical 6. to divert attention from
regimen scratching itchy sensation
and avoid wounds.
6. instruct mother to
use toys when patient is
feeling itchy.

Collaborative:
 Cues/Needs Nursing Goals and Objectives Nursing Rationale Evaluation
Diagnosis Interventions

Subjective: Risk for infection After 30 minutes of The short term goal was
transmission nursing intervention the met because the family
A risk diagnosis is client /family will be 1. teach the family 1. hand hygiene is members and the health
not evidenced by able to: about the importance of important in reducing
care provider were able
signs and symptoms, hand hygiene. Teach transient flora on outer
as the problem has >know the ways of epidermal layers of skin. to know the ways of
the family to perform preventing the
not occurred and preventing the
nursing interventions transmission of hand hygiene, and 2. Gloves provide transmission of infectious
are directed at infectious agents. health care providers effective barrier protection. agents.
prevention. should perform hand
hygiene consistently 3. Organisms that are
and thoroughly, before spread through an airborne
Objective: and after each patient route are very contagious. It
contact, and after serves as an isolation
Kopliks spots strategy and reduces the
procedures that offer
likelihood of spreading the
Airborne precaution contamination risk. disease from patient to
control patient.
2. Teach family
members to wear
gloves when handling
body fluid from patient.

3. Maintain the
“airborne precaution”
sign outside the
patient’s room.
 Cues/Needs Nursing Goals and Reference: Brunner &
Nursing Interventions Rationale Evaluation
Diagnosis Objectives Suddarth’s Textbook
for Medical-Surgical
Subjective: Deficient After 30 1. Listen carefullyNursing
to what 1. Listening facilitates The short term goal
knowledge minutes of the patients say about detection of was met because The
“Sana pwede na about the nursing illness and previous misunderstanding mother was able to
kaming umuwi. intervention
disease treatment. and misinformation correct the
Kasi nawawala the client
naman na yung process, /family will and provides misinterpreted
related to 2. Explain that Measles are opportunity for information and also
rashes nya” be able to:
misinterpretati highly contagious. education. the mother was able
“Akala ko kapag on of >have an to gain an accurate
may bakuna na ng acquisition of 3. Explain the importance of 2.Measles are highly
information, as follow through of the
measles din a knowledge isolating the patient contagious four days
evidenced by disease process.
magkakaroon.” about the from another family before the rash
verbalization
infectious member who are most appears and four days
As verbalized by inaccurate process. likely to have measles. after the rash
the mother. perception of
health status. disappear.
4. Teach the family about
acquiring another 3.Measles is spread
Objective:
measles immunization, when someone comes
Inaccurate follow- if recommended. in direct contact with
through of infected droplets or
5. Explain the importance of when someone with
instruction
a follow up check up
measles sneezes or
coughs and spreads
virus droplets through
Reference: Brunner & the air.
Suddarth’s Textbook for
Medical-Surgical Nursing 4.The immunization
develops an immunity
that, in 95 percent of
children, lasts for a
lifetime.

5.A follow up check up

prevents the
occurrence of
complications of
Measles.
 Cues/Needs Nursing Goals and Nursing Interventions Rationale Evaluation
Diagnosis Objectives

Subjective: Risk for After 2 hours 1. Determine client’s 1. All factors that can The short term goal
imbalanced of nursing ability to chew, affect ingestion and/or was not met because
A risk diagnosis is nutrition: less intervention swallow, and taste digestion of nutrients the patient was not
not evidenced by the client
than body food. able to ingest the
signs and /family will 2. Dietary influences
symptoms, as the requirements be able to: nutritionally adequate
2. Determine cultural can affect nutritional diet for age.the
problem has not
occurred and >ingest or religious intake. mother also
nursing nutritionally influences on verbalized that the
interventions are adequate dietary choices. 3. Provides information
patient was still a
directed at diet for age. about digestion/bowel
picky eater and
prevention. 3. Auscultate bowel function and may affect
patient was still
sounds. Note choice/timing of
interested in the
characteristics of feeding.
Objective: same meal.
stool
4. To identify what child
-Reports lack of 4. Teach parent to eats in a typical day.
interest in eating discuss with patient Provides opportunity to
what types of identifying teaching
-reports of being a
candy, other needs and providing
picky eater
sweets, snacks and healthy snacks.
-verbalization of sodas child
drinks/eats. 5. To enhance intake
interest in the
same type of food
5. Promote pleasant,
relaxing
environment
ONGOING APPRAISAL

February 16, 2010

A 4 year old female was brought to the E.R of Manila Doctors Hospital for further medical
management. Patient was seen with Maculo Papular rashes along the ears down to her neck. Patient
was also seen with cervical lymphadenopathy. Fever with accompanying signs and symptoms of dry
cough, hypertrophic and hyperemic bucal mucosa.

CBC was done to.

IV is inserted at right metacarpal vein with IVF #1 D5 .03 NaCl 1L x 8 hours. Patient was given the
following medications:

1. Paracetamol 5ml PO q4 >38c

2. Benadryl 5ml PO BID
3. Unasyn 750ml IV
4. Salbutamol Nebules 1.24 ml q8
5. Vit. A 200,000 iu
6. Clarithromycin 5ml PO BID

Airborne precaution was observed.

Patient was diagnosed with fever to consider as measles.

February 17, 2010

Patient was diagnosed with measles. Physician ordered Diet for Age.

Vit. A was discontinued. Patient was still on Airborne Precaution.

Patient had undergone Chest X-ray.

February 18, 2010

Same management was done to the patient. Physician ordered to increase oral fluid intake.

Patient was observed for Maculopapulo rashes over the chest and abdomen.

Discharge Plan
Medications

- Have a measles vaccine.

- If the patient have had measles before, they can have a shot of immune globulin G (IG)

Exercise

- Continue with activities of daily living.

Treatment

- Get plenty of rest.

- When having fever, drink lots of fluid or do tepid sponge bath.
- Drink prescribed anti-pyretic drugs to patients with fever.

Health Teachings

- Do not mingle in crowded area to avoid the spread of the virus

- Teach the affected patient to cover his/her mouth and nose when coughing and sneezing as this
will greatly spread the virus.

OPD check up

- Return to Physician for follow up check-up after 2 weeks.

Diet

- Eat diets that are rich in vitamin C.

- Increase oral fluid intake

Signs and symptoms

- symptoms include bad cold, high fever, runny nose, sneezing, sore throat and a hacking cough
- Followed by rashes all over the body when the above symptoms starts go away.