Nursing Care Plan Assessment Subjective: Nakakahinga na siya ng maayos (She can now place herself in a supine position)

As verbalized by the mother of the patient Objective: Received client sitting on a chair and exhibits satisfaction. Relax normal respiratory rate calm good expression normal skin V/S taken: T=36.8 P= 69 R= 16 Diagnosis Readiness for enhanced comfort Inference A pattern of ease, relief, and transcendence In physical, psychospiritual, Environment, and/or social social dimensions that can be strengthened Planning Short term: After six hours of nursing intervention, the patient will demonstrate behaviors of optimal level of ease Intervention Independent: Verify that client is managing pain and pain components effectively Check peripheral pulses and skin color and temperature Interact with client in therapeutic manner Rationale Evaluation Short term: After six hours of nursing intervention, The patient was able to demonstrate behaviors of optimal level of ease

To maintain sense of comfort and contentment

To monitor circulation all over the body

Long Term: After two or more days of nursing intervention, the client will participate in desirable and realistic health seeking behavior

To achieve connectedne ss or harmony with self To enhance sense of comfort

Provide quiet environment, calm activities

Long term: After two or more days of nursing intervention, the client was able to participate in desirable and realistic health seeking behavior

Promote overall health measures

To monitor wellness among the client

Dependent: Assist client to use and modify medication

To make best use of pharmacolog ical management To facilitate clients need without the supervision of health team

Collaborative: Suggest parent be present during procedures to comfort child

Nursing Care Plan Assessment Subjective: Mahirap magsalita as verbalized by the mother of the client Objective: Received client sitting on a chair and exhibits irritable and ashamed Wheezing lungs sound Excessive sputum Abnormal respiratory rate Restlessness Difficulty vocalizing Diagnosis Ineffective airway clearance retained mucous secretions Inference Inability to clear secretions from the respiratory tract to maintain a clear airway Planning Short term: After six hours of nursing intervention, the patient will demonstrate reduction of congestion Intervention Independent: Monitor respiration and breath sounds Rationale Evaluation Short term: After six hours of nursing intervention, the patient was able to demonstrate reduction of congestion Long term: After six hours of nursing intervention, the patient was able to maintain airway patency

To indicate respiratory distress

Long term: After six hours of nursing intervention, the patient will maintain airway patency

Monitor for infant feeding intolerance, abdominal distention and emotional stressors

To compromise airway

Dependent: Assist client to use and modify medication

To make best use of pharmacolo gical management

Collaborative: Keep environment allergen free

To facilitate curative measures

Nursing Care Plan Assessment Subjective: Mahirap pakainin ang aking mga anak as verbalized by the mother of the client Objective: Received client sitting on chair and expresses irritable and ashamed Poor judgement Warm skin Restlessness Incomplete teeth Diagnosis Imbalanced nutrition: less than body requirements Inference Intake of nutrients insufficient to meet metabolic needs Planning Short term: After six hours of nursing intervention, the patient will display free of signs of malnutrition Long term: After six hours of nursing intervention, the patient will demonstrate progressive weight gain toward goal Intervention Independent: Assess teeth and gums for poor oral health Note age, body build and rest level Dependent: Assist client to use and modify medicatio n Collaborative: Assist in treating underlyin g factors such as fad diets Rationale Evaluation Short term: After six hours of nursing intervention, the patient was able to display free of signs of malnutrition

To indicate factors affecting digestion To determine nutritional needs

Long term: After six hours of To make nursing best use of pharmacolo intervention, the patient gical management was able to demonstrate progressive weight gain To enhance toward goal food satisfaction

Submitted by: Eloisa Medrano and Cherry Ann Marges