Assessment Diagnosis Planning Intervention Rationale

Evaluation
Subjective:
“Dalawang araw nang inuubo at sinisipon ‘yung bata,” as verbalized by the mother
.
“Hindi ko pa ‘yan napakokonsulta sa Pedia”, as verbalized by the mother
Objective:

>presence of white nasal drainage

>production of white sputum
>coughing
>rhonchi can be heard upon auscultation
>RR: 32 cpm
>HR: 110 bpm
>Temp: 36.9°C
Ineffective airway clearance related to excessive production of nasal secretions
and irritation of mucous membranes of the respiratory tract as manifested by:
• White nasal drainage
• White Sputum
• Coughing
• Ronchi
• RR:32cpm

At the completion of home care instruction, the client will be able to maintain
airway patency and the caregiver will be able to apply learning to her daughter
After 30 minutes of nursing intervention, the mother will be able to:
Define common colds accurately.
Verbalize gained knowledge about the nature of common colds and the impo
rtance of its proper management.
Enumerate at least three ways on how to properly control the secretions
and facilitate drainage
Identify non-pharmacologic therapeutic measure
Verbalize importance of conferring with the pediatrician and consult abo
ut the problem
Verbalize encouragement in the application of learning to her daughter.

The nurse will:

• Establish rapport.
• Assess the caregiver’s level of knowledge in understanding the condition
.
• Discuss with the caregiver the definition of common colds and its charac
teristics, comprehensively.
• Enumerate to the caregiver ways on how to control the secretions and fac
ilitate drainage including:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.

• Encourage the caregiver to seek health assistance from the hospital or h

ealth center.
To foster good nurse-patient relationship.
To deliver information in understandable manner.
To provide brief information about the client’s condition.

To lessen secretions and facilitate expectoration.

• To identify and monitor health status of the infant.

Goal met. The caregiver defined common cold accurately.
Goal met. The caregiver verbalized understanding about the nature of common cold
s and the importance of its proper management.
Goal met. The caregiver verbalized four ways on how to properly control the secr
etions and facilitate drainage specifically the following:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.
Goal met. The client was encouraged to consult the paediatrician immediately pri
or to the infant’s condition.

Assessment Diagnosis Planning Intervention Rationale

Evaluation
Subjective:
“Dalawang araw nang inuubo at sinisipon ‘yung bata,” as verbalized by the mother
.
“Hindi ko pa ‘yan napakokonsulta sa Pedia”, as verbalized by the mother
Objective:

>presence of white nasal drainage

>production of white sputum
>coughing
>rhonchi can be heard upon auscultation
>RR: 32 cpm
>HR: 110 bpm
>Temp: 36.9°C
Ineffective airway clearance related to excessive production of nasal secretions
and irritation of mucous membranes of the respiratory tract as manifested by:
• White nasal drainage
• White Sputum
• Coughing
• Ronchi
• RR:32cpm

At the completion of home care instruction, the client will be able to maintain
airway patency and the caregiver will be able to apply learning to her daughter
After 30 minutes of nursing intervention, the mother will be able to:
Define common colds accurately.
Verbalize gained knowledge about the nature of common colds and the impo
rtance of its proper management.
Enumerate at least three ways on how to properly control the secretions
and facilitate drainage
Identify non-pharmacologic therapeutic measure
Verbalize importance of conferring with the pediatrician and consult abo
ut the problem
Verbalize encouragement in the application of learning to her daughter.

The nurse will:

• Establish rapport.

• Assess the caregiver’s level of knowledge in understanding the condition

.
• Discuss with the caregiver the definition of common colds and its charac
teristics, comprehensively.
• Enumerate to the caregiver ways on how to control the secretions and fac
ilitate drainage including:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.

• Encourage the caregiver to seek health assistance from the hospital or h

ealth center.
To foster good nurse-patient relationship.
To deliver information in understandable manner.
To provide brief information about the client’s condition.

To lessen secretions and facilitate expectoration.

• To identify and monitor health status of the infant.

Goal met. The caregiver defined common cold accurately.
Goal met. The caregiver verbalized understanding about the nature of common cold
s and the importance of its proper management.
Goal met. The caregiver verbalized four ways on how to properly control the secr
etions and facilitate drainage specifically the following:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.
Goal met. The client was encouraged to consult the paediatrician immediately pri
or to the infant’s condition.

Assessment Diagnosis Planning Intervention Rationale

Evaluation
Subjective:
“Dalawang araw nang inuubo at sinisipon ‘yung bata,” as verbalized by the mother
.
“Hindi ko pa ‘yan napakokonsulta sa Pedia”, as verbalized by the mother
Objective:

>presence of white nasal drainage

>production of white sputum
>coughing
>rhonchi can be heard upon auscultation
>RR: 32 cpm
>HR: 110 bpm
>Temp: 36.9°C
Ineffective airway clearance related to excessive production of nasal secretions
and irritation of mucous membranes of the respiratory tract as manifested by:
• White nasal drainage
• White Sputum
• Coughing
• Ronchi
• RR:32cpm

At the completion of home care instruction, the client will be able to maintain
airway patency and the caregiver will be able to apply learning to her daughter
After 30 minutes of nursing intervention, the mother will be able to:
Define common colds accurately.
Verbalize gained knowledge about the nature of common colds and the impo
rtance of its proper management.
Enumerate at least three ways on how to properly control the secretions
and facilitate drainage
Identify non-pharmacologic therapeutic measure
Verbalize importance of conferring with the pediatrician and consult abo
ut the problem
Verbalize encouragement in the application of learning to her daughter.

The nurse will:

• Establish rapport.

• Assess the caregiver’s level of knowledge in understanding the condition

.
• Discuss with the caregiver the definition of common colds and its charac
teristics, comprehensively.
• Enumerate to the caregiver ways on how to control the secretions and fac
ilitate drainage including:
proper positioning
 increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.

• Encourage the caregiver to seek health assistance from the hospital or h

ealth center.
To foster good nurse-patient relationship.
To deliver information in understandable manner.
To provide brief information about the client’s condition.

To lessen secretions and facilitate expectoration.

• To identify and monitor health status of the infant.

Goal met. The caregiver defined common cold accurately.
Goal met. The caregiver verbalized understanding about the nature of common cold
s and the importance of its proper management.
Goal met. The caregiver verbalized four ways on how to properly control the secr
etions and facilitate drainage specifically the following:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.
Goal met. The client was encouraged to consult the paediatrician immediately pri
or to the infant’s condition.

Assessment Diagnosis Planning Intervention Rationale

Evaluation
Subjective:
“Dalawang araw nang inuubo at sinisipon ‘yung bata,” as verbalized by the mother
.
“Hindi ko pa ‘yan napakokonsulta sa Pedia”, as verbalized by the mother
Objective:
>presence of white nasal drainage
>production of white sputum
>coughing
>rhonchi can be heard upon auscultation
>RR: 32 cpm
>HR: 110 bpm
>Temp: 36.9°C
Ineffective airway clearance related to excessive production of nasal secretions
and irritation of mucous membranes of the respiratory tract as manifested by:
• White nasal drainage
• White Sputum
• Coughing
• Ronchi
• RR:32cpm

At the completion of home care instruction, the client will be able to maintain
airway patency and the caregiver will be able to apply learning to her daughter
After 30 minutes of nursing intervention, the mother will be able to:
Define common colds accurately.
Verbalize gained knowledge about the nature of common colds and the impo
rtance of its proper management.
Enumerate at least three ways on how to properly control the secretions
and facilitate drainage
Identify non-pharmacologic therapeutic measure
Verbalize importance of conferring with the pediatrician and consult abo
ut the problem
Verbalize encouragement in the application of learning to her daughter.

The nurse will:

• Establish rapport.

• Assess the caregiver’s level of knowledge in understanding the condition

.
• Discuss with the caregiver the definition of common colds and its charac
teristics, comprehensively.
• Enumerate to the caregiver ways on how to control the secretions and fac
ilitate drainage including:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.
• Encourage the caregiver to seek health assistance from the hospital or h
ealth center.
To foster good nurse-patient relationship.
To deliver information in understandable manner.
To provide brief information about the client’s condition.

To lessen secretions and facilitate expectoration.

• To identify and monitor health status of the infant.

Goal met. The caregiver defined common cold accurately.
Goal met. The caregiver verbalized understanding about the nature of common cold
s and the importance of its proper management.
Goal met. The caregiver verbalized four ways on how to properly control the secr
etions and facilitate drainage specifically the following:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.
Goal met. The client was encouraged to consult the paediatrician immediately pri
or to the infant’s condition.

Assessment Diagnosis Planning Intervention Rationale

Evaluation
Subjective:
“Dalawang araw nang inuubo at sinisipon ‘yung bata,” as verbalized by the mother
.
“Hindi ko pa ‘yan napakokonsulta sa Pedia”, as verbalized by the mother
Objective:

>presence of white nasal drainage

>production of white sputum
>coughing
>rhonchi can be heard upon auscultation
>RR: 32 cpm
>HR: 110 bpm
>Temp: 36.9°C
Ineffective airway clearance related to excessive production of nasal secretions
and irritation of mucous membranes of the respiratory tract as manifested by:
• White nasal drainage
• White Sputum
• Coughing
• Ronchi
• RR:32cpm

At the completion of home care instruction, the client will be able to maintain
airway patency and the caregiver will be able to apply learning to her daughter
After 30 minutes of nursing intervention, the mother will be able to:
Define common colds accurately.
Verbalize gained knowledge about the nature of common colds and the impo
rtance of its proper management.
Enumerate at least three ways on how to properly control the secretions
and facilitate drainage
Identify non-pharmacologic therapeutic measure
Verbalize importance of conferring with the pediatrician and consult abo
ut the problem
Verbalize encouragement in the application of learning to her daughter.

The nurse will:

• Establish rapport.

• Assess the caregiver’s level of knowledge in understanding the condition

.
• Discuss with the caregiver the definition of common colds and its charac
teristics, comprehensively.
• Enumerate to the caregiver ways on how to control the secretions and fac
ilitate drainage including:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.

• Encourage the caregiver to seek health assistance from the hospital or h

ealth center.
To foster good nurse-patient relationship.
To deliver information in understandable manner.
To provide brief information about the client’s condition.

To lessen secretions and facilitate expectoration.

• To identify and monitor health status of the infant.

Goal met. The caregiver defined common cold accurately.
Goal met. The caregiver verbalized understanding about the nature of common cold
s and the importance of its proper management.
Goal met. The caregiver verbalized four ways on how to properly control the secr
etions and facilitate drainage specifically the following:
proper positioning
increasing warm fluid intake
facilitating warm water bath
Demonstrate proper back tapping.
Goal met. The client was encouraged to consult the paediatrician immediately pri
or to the infant’s condition.