ASSESSMENT SUBJECTIVE: lagi niyang nakakamot yung mga kati-kati niya, as verbalized by the mother.

DIAGNOSIS Risk for impaired skin integrity related to raking pruritus

PLANNING After 8 hours of nursing intervention the patient will be able to maintain intact skin integrity.

IMPLEMENTATION 1. Keep nails short and clean. 2. Wear gloves or elbow restrain from scratching. 3. Give clothes that are thin, loose, and not irritating. 4. Close area of pain (long sleeves, long pants, underwear layer). 5. Avoid exposure to sunlight or heat.

RATIONALE 1. To minimize the trauma and secondary infection 2. To prevent scratching.

EVALUATION GOAL MET After the nursing implementation the patients mother was able to perform instructions and the patient was able to maintain intact skin.

3. Because excessive heat can increase itching.

OBJECTIVE: Rashes Skin reddness

4. To prevent scratching.

5. exposure to sun rays or heat can cause rashes.

ASSESSMENT SUBJECTIVE: Hindi ko alam na nakakahawa pala ang tigdas eh, as verbalized by the patients mother. OBJECTIVE:

DIAGNOSIS Deficient Knowledge related to new condition

PLANNING After 8 hours of nursing interventions , we will be able to: 1. Assess the patients willingness and capabilities for learning. 2. Formulate strategies for facilitation of better learning.

IMPLEMENTATION 1. Determine who will be the learner: patient, family, significant other, or caregiver.

RATIONALE 1. Many elderly or terminal patients may view themselves as dependent on their caregiver, and therefore not want to be part of the educational process.

EVALUATION GOAL MET After the nursing implementations, we were able to assess the patients capabilities and needs for learning, and was able to formulate strategies for better learning as evidenced by: Clients cooperation during questioning Verbalization of desired to learn

2. Assess motivation and 2. Adults must see a need willingness of patient or purpose for learning. and caregivers to learn. 3. Assess ability to learn or perform desired health-related care. 3. Cognitive impairments need to be identified so an appropriate teaching plan can be designed. 4. Adults learn material that is important to them.

4. Identify priority of learning needs within the overall plan of care. 5. Question patient regarding previous experience and health teaching.

5. Adults bring many life experiences to each learning session. Adults learn best when teaching builds on previous knowledge or experience.

6. Identify any existing misconceptions regarding material to be taught. 7. Determine patient's learning style, especially if patient has learned and retained new information in the past. 8. Determine patient or caregiver's self-efficacy to learn and apply new knowledge.

6. This provides an important starting point in education.

7. Matching the learner's preferred style with the educational method will facilitate success in mastery of knowledge. 8. A first step in teaching may be to foster increased self-efficacy in the learner's ability to learn the desired information or skills.

ASSESSMENT SUBJECTIVE: Ano ba ang pwede kong gawin?, as verbalized by the mother. OBJECTIVE: The client manifested: Cooperation Follows instructions Active asking about the disease.

DIAGNOSIS Readiness for enhanced knowledge: disease information

PLANNING After 8 hours of nursing intervention the patient will be able to verbalize better understanding of the disease

IMPLEMENTATION 1. Provide physical comfort for the learner.

RATIONALE 1. This allows patient to concentrate on what is being discussed or demonstrated. 2. This allows patient to concentrate more completely. 3. This is especially important when providing education to patients with different values and beliefs about health and illness. 4. This allows learner to know what will be discussed and expected during the session. 5. For easy understanding.

EVALUATION GOAL MET After the nursing implementations the patient verbalized better understanding relating to the disease of her child.

2. Provide a quiet atmosphere without interruption. 3. Provide an atmosphere of respect, openness, trust, and collaboration.

4. Establish objectives and goals for learning at the beginning of the session. 5. Give clear, thorough explanations and demonstrations. 6. Provide information using various mediums, usually what the client prefers.

6. Match the learning style with the educational approach.

7. Ensure that required supplies or equipment are available so that the environment is conducive to learning. 8. When presenting material, move from familiar, simple, and concrete information to less familiar, complex, or more abstract concepts. 9. Focus teaching sessions on a single concept or idea. 10. Encourage questions.

7. This is especially important when teaching in the home setting.

8. This provides patient with the opportunity to understand new material in relation to familiar material.

11. Encourage repetition of information or new skill. 12. Provide positive, constructive reinforcement of learning.

9. This allows the learner to concentrate more completely on material being discussed. 10. Learners often feel shy or embarrassed about asking questions and often want permission to ask them. 11. To assist in remembering. 12. A positive approach allows learner to feel good about learning accomplishments, gain confidence, and maintain self-esteem while correcting mistakes.

LEARNING OBJECTIVES General Objective: This study aims to impart knowledge on measles and means to restore and maintain the patients health status by utilizing a holistic approach of promoting nursing management. It also aims to enhance students capability of using critical thinking skills and analysis by accomplishing this case study.

Specific Objectives: To determine the content on the nursing assessment, diagnosis planning, implementation & evaluation for measles.

To know the underlying causes & health history on the clients medical diagnosis upon admission.

To search the medical management as being ordered based upon the clients diagnosis & laboratory result.

To asses the anatomy and physiology of the system that is related to the patients condition.

To evaluate effectiveness of the intervention & detect any progress of the clients condition.

To create a patho-physiology of measles based on the patient condition.