ST. PAUL UNIVERSITY MANILA (St.

Paul University System) 680 Pedro Gil Malate, Manila College of Nursing and Allied Medical Sciences NURSING CASE STUDY (Application of Nursing Process) Submitted: Date: I. ASSESSMENT A. General Information Clients Initials: R.P.J Rm/Wd: Bed 1, Pav. 2 Date Admitted: 05-12-05 Age: 4y/o Sex: M CS: Single Nat.: Filipino Religion: Roman Catholic Educational Attainment: Nursery Occupation: N/A Admission Complaints: fever and rashes Admission Diagnosis: T/C Kawasaki Admitting VS: T: 38.5 P: 110 beats/min R: 25 breaths/min BP: 90/60 Wt.: 13.3 kg Ht.: Arrived on Unit By: Ambulatory assisted by mother Allergies: None Medications: Ceelin (Vitamin C),Penicillin G, Izoniazid, AM-ambroxol, Pyrazinamide, Diephenhydramine, Rifampicin, Paracetamol B. Nursing History (Based on the Functional Health Pattern by Gordon) 1. HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN 1.1 Clients description of his/her health: Before Admission: Patients mother verbalized: Pabalik-balik lagnat ng anak ko tapos bigla siyang nagkaroon ng rashes sa mukha e wala naman siyang allergies. At Present: Patients mother verbalized: Ok na siya ngayon medyo masigla na ulit. 1.2 Health Management: Self Mother stated that the patient had complete immunizations, observes proper hygiene and eats nutritious foods. Family The mother verbalized that she is a good homemaker and plans their meals which consists of foods such as vegetables, meat and fish which are healthy and that all of them observes proper hygiene. 1.3 History of Present Illness: 2 days prior to admission, patient was noted to have moderate to high grade fever accompanied by appearance of erythematous rashes which started from the head and progressed to the trunk down through the peripheral and upper and lower extremities. The patient was highly febrile. And no medications were given except parentheral. The patient was also noted to have a strawberry tongue. 1.4 Past Illnesses: The patients past illnesses were usually fever, cough and colds.

1.5

History of Hospitalization (when, where, and why) Patient was born in Jose Reyes Medical Center dated May 12, 2001. Patient has never been hospitalized again until now. History of Illness In the Family: The father of the patient has Diabetes Mellitus and asthma. But they live in a congested area where space is limited more them to move. Expectations of Hospitalization: Patients mother verbalized: Sana gumaling na ng tuluyan anak ko. Patient verbalized: Gusto ko na po umuwi. Sana gumaling na ako.

1.6

1.7

1.8

Anticipation of Problem of caring upon oneself upon discharge: Patients mother verbalized: Wala naman problema sa pag-aalaga namin sa kanya pero sana di masyado madami yung gamot para di masyadong mahal. Knowledge of Treatment or Practices prescribed: Patients mother verbalized understanding regarding the treatment and practices prescribed. They were explained properly and her questions were answered by the doctor and nurses. Reaction to above prescriptions: Patients mother feels relieved that the prescribed medications will help him recover.

1.9

1.10

2. NUTRITION AND METABOLIC PATTERN 2.1 Usual food Intake (before admission) Breakfast: For breakfast the patient eats hotdog, oatmeal, bread and rice Lunch: For lunch, his meal includes rice, vegetables or any viand served. Supper: For supper, his meal also includes rice, vegetables, fish or any viand served. Snacks: The patient eats sandwiches and fruit juices. Preferences: The patient prefers to eat sweets and spaghetti. 2.2 Usual fluid intake (type/ amounts): The patient drinks 6-8 glasses of water a day and fruit juices during snacks. Preferences: The patient prefers to drink water and juices. 2.3 Any food restrictions: The patient does not have any food restrictions. 2.4 Any problems with ability to eat: The patient has no problems with the ability to eat.

2.5 Any supplements (vitamins/feedings) Vitamin C PO 1 tsp. per day everyday. 3. ELIMINATION PATTERN 3.1 Bladder Usual Frequency per day: Patient usually urinates 10 times a day approximately 400-600 cc. Color: Urine is red orange due to medications-rifampicin. Complaints of usual pattern of urination: Patient has no complaints when urinating. 3.2 Bowel Usual pattern/day (time, frequency, color, consistency): Patient moves his bowel one to two times daily, usually 9 am and with no particular time in the evening. It is light brown in color and appears to be mushy. Complaints of usual pattern of bowel movement: Patient has no complaints when moving his bowels. Home Remedies: Since patient has no complaints on bowel movement, there are no home remedies given for treatment. 3.3 Any assertive Device: There are no assertive devices used by the patient. 3.4 Skin (Condition): The patient has a good skin turgor and eliminates sweat without foul smell. 4. ACTIVITY EXERCISE PATTERN 4.1 Exercise/Leisure: The patient usually enjoys biking every afternoon for 4 times a week. This is also his hobby. 4.2 Any Limitation of Physical Activity: Patient has no limitation on physical activity. 4.3 History of Dyspnea or fatigue: Patient experienced dyspnea for one week. 5. SLEEP REST PATTERN 5.1 Usual sleep pattern: Bedtime: Patient has a usual bedtime of 8 pm and wakes up at 9 am. Hours slept: Patient sleeps for around 10-12 hours. Number of Pillows: Patient is comfortable and contented in sleeping with one pillow.

Sleep Routine: The patient plays for a while until he feels sleepy or watches TV until he falls asleep. 5.2 Any problems regarding sleep: Patient experiences interruption of sleep due to a bad dream then he tends to cry. Usual Remedies: The mother of the patient sleeps beside him at times when he cries.

5.3

6. COGNITIVE - PERCEPTUAL 6.1 Any deficits in sensory perception (hearing, sight and touch): The client doesnt have any deficit in sensory perception. 6.2 Ability to read and write. Any difficulty in learning? The client cant read and write but can count from 120 and can state the alphabet. He was also able to identify pictures that were shown to him. 6.3 Any complaints (e.g. pain) The client feels pain every time CBC is done. On the scale of 1-10, 10 is rated subjectively. 7. SELF PERCEPTION PATTERN 7.1 What the client is most concerned? The client is concerned about getting out of the hospital, for him to be able to go to school and play with his friends. 7.2 Present health goals: The watcher verbalized Sinasabi niya lagi na gusto na niyang gumaling at umalis na dito sa ospital. 7.3 Effects of present illness to self He wasnt able to go to school to learn how to read and write because of his illness. He was required to stay in the hospital long enough until he recovers. 7.4 How does the client see/feel about self? The client is confident that he will recover and will not get the disease again. 8. ROLE-RELATIONSHIP PATTERN 8.1 Language spoken The client speaks Filipino/Tagalog. 8.2 Manner of Speaking The client doesnt speak much; he only uses gestures instead of speaking. The client is soft-spoken and speaks in a respectful tone. He uses po and opo as a sign of respect to older people. 8.3 Significant person to client The mother stands as a significant person right now because she is the one who takes care of him and accompanies him. Since his father is not around, he is more attached to his mother.

8.4 Complaints regarding family The client has no complaints about his family. 8.5 Living with (members of family) The client lives with his father, mother and his two siblings. 9. SEXUALITY SEXUAL FUNCTION PATTERN 9.1 Anticipated change in sexual relations because of illness: It is not applicable to the clients age. 9.2 Knowledge of sexual functioning: The client is able to distinguish the difference between a boy and a girl. 10. COPING STRESS MANGAEMENT PATTERN 10.1 Decision making ability The client is able to decide for himself when it comes to small things like what he wants to eat or what to wear. His parents decide for him when it comes to bigger decisions like going to school. 10.2 Any significant stress in the past The client experiences stress whenever his parents scold him. As of now, his hospitalization brings stress to him. 10.3 Management of stress The client will cry and then will keep quiet after being scolded by his parents. 10.4 Expectation from nurses to provide comfort and security during hospitalization. The client has no expectations from the nurses. 11. VALUE BELIEF SYSTEM 11.1Source of strength and meaning The clients source of strength or meaning is his family and God. 11.2 Importance of God to client Client believes there is God but he doesnt pay much attention to His presence. 11.3 Religious practices (type and frequency) The client goes to mass every Sunday with his family. 11.4 Request for religious person/practice The client has no request for any religious person or practice. 12. DEVELOPMENTAL TASKS (Assess for achievement of developmental tasks) The patient is included in the preschool period, age 3-5. FREUDS STAGE OF CHILDHOOD: Phallic Stage - Childs pleasure zone shifts from the anal to the genital area. He learns sexual identity through awareness of the genital area. Childs sexual interest

could lead to fondling his own genitals as a normal area of exploration. According to the mother, the client was able to distinguish a boy from a girl. He was able to determine the work of a man from a woman like a woman cooks food while a man drives a car and does carpentry. He can also determine the sex of his playmates if he or she is a boy or a girl. DEVELOPMENTAL TASK OF ERIKSON: Initiative vs. Guilt - Learning initiative is learning how to do things. The child initiates motor activities of various sorts on their own and no longer merely responds or imitates the actions of parents or other children. The client was able to do things on his own as stated by his mother and relative. As told by the mother, the client was given more freedom in playing physical activities like running and bike riding. The mother also allows the child to play with toys that would develop his skills like coloring books and molding clays. Also, the mother noted that the client enjoys playing outside their house with his playmates. PIAGETS THEORY OF COGNITIVE DEVELOPMENT: Preoperational Thought (Intuitive Thought) - Thought becomes symbolic. The child tends to look at an object and see only one of its characteristics. He knows the different parts of the body, able to count from one to twenty, and was able to differentiate shapes of certain object being shown to him. Also, when asked what is the use of a key, the client thinks that it is only a metal and it doesnt have a purpose. KOHLBERGS THEORY OF MORAL DEVELOPMENT: Preconventional - They tend to do good out of self-interest rather than out of true intent to do good or because of a strong spiritual motivation. They imitate what they see and have great difficulty knowing what rules apply to new situations. When asked the reason why he has to eat the vegetables, the client answered that it is what his mother and father instructed him to do. He doesnt know that eating vegetables would be for his own good. He imitates his siblings when they kiss the hands of the elders because he knows if he did that, he would make his parents proud.

C. PHYSICAL ASSESSEMENT AREA

1. Head to Toe Examination 1.1. General Survey

Date performed: July 5, 2005 MODE OF ASSESSMEN T NORMAL FINDINGS ABNORMA L FINDINGS

Inspection Inspection Inspection Inspection inspection inspection inspection

inspection

inspection inspection inspection 1.2 Vital Signs Inspection Palpation Inspection Palpation Palpation & inspection Palpation & inspection Inspection Palpation

> awake, alert & responsive to people & environment >good body posture > walks easily, with comfort and good balance. > skin uniform in color > body symmetrical > (-) body deformities > personal hygiene & grooming appropriate to age & socioeconomic group >hair dark brown in color, moderate in quantity, equal in distribution and smooth in texture. > Height appropriate with age and gender. > (-) body and breath odor. > (+ nonproductive cough T= 36.9 C PR= 122 bpm RR= 45 bpm > (-) tenderness > round, smooth skull contour > (-) lumps > (-) deformities > size proportional to body > temporal arteries are palpable

1.3 Head & Face a. Cranium

b. Temporal arteries c. Face

Inspection

Inspection Inspection Inspection & palpation Inspection & palpation d. Cranial Nerve V & VII Inspection

> symmetrical facial movement & features > (-) involuntary movements > (-) edema > (-) masses > good contraction of the temporal and masseter muscles on both sides when client was asked to clench

Inspection Inspection Inspection e. Nose & Cranial Nerve I Inspection Inspection Palpation Inspection Inspection Inspection Inspection 1.4 Eyes & Vision a. External Eye Structure

his teeth > good facial sensation > (+) corneal reflex > (-) facial weakness > symmetrical > (-) discharge > (-) tenderness > perceives odor on each side and identifies it > (-) nasal obstruction > (-) nasal flaring > (-) deformities

Inspection Inspection Inspection & Palpation Inspection & Palpation Inspection Inspection Inspection Inspection

> dark brown eyes symmetrical & aligned > eyebrows normal in quantity & distribution > (-) edema > (-) nodules > white sclera & pink conjunctiva > pupils 3mm in size, round in shape & symmetrical > (-) erythema > (-) swelling of lacrimal gland & lacrimal sac > can recognize picture within reasonable distance > symmetrical corneal reflections > normal conjugate movement of eyes in each direction > good convergence > (-) ptosis > PERRLA

b. Visual Acuity

Inspection

c. Extra Ocular Muscle Function (cranial nerve III, IV, VI)

Inspection Inspection Inspection Inspection

d. Pupillary reflex e. Internal Eye Structure with Opthalmoscope 1.5 Ears & Hearing a. External Ear

Inspection Not done (no opthalmoscope)

Inspection Inspection Inspection & Palpation Inspection Inspection Inspection Inspection

> (-) deformities > (-) discharge > (-) lumps > (-) lesions > (-) ear pain > (+) pinna recoil > can hear on both ears within

b. Hearing

reasonable distance & volume c. Ear Canal & Tympanic Membrane with Otoscope Not done (no otoscope)

1.6 Neck a. Musculoskeletal structure Inspection > muscle equal in size > head centered > (-) masses > (-) scars > not palpable > central placement in midline of neck > spaces are equal on both sides > ascends during swallowing but is not visible > smooth coordinated movement with no discomfort > head flexes 45 degrees > head hyperextends 60 degrees > head laterally flexes 40 degrees > with equal strength > able to shrug his shoulders against resistance > palpable > full equal pulsation > arms equal in size on both sides of the body > (-) contractures/tremor s > normally firm > no gross deformities, tenderness, swelling > no edema on arms > nails are pinkish in color, smooth and convex in size & hard to touch >no signs of cyanosis

Palpation b. Lymph Nodes c. Thyroid Gland Palpation Inspection Inspection Palpation

d. musculoskeleta l function & cranial Nerve XI

Inspection

Inspection Inspection Inspection Inspection Inspection

Palpation e. Carotid Arteries 1.7 Upper Extremities a. musculoskeletal structures, skin, nails

Inspection Inspection Palpation Inspection & Palpation Inspection Inspection

>skin is pink with slight rashes present

b. Musculoskeletal function

Inspection Inspection

Inspection

>smooth coordinated movement >able to flex, extend, rotate, abduct, and adduct upper extremities > palpable with equal pulsations

c. Brachial and Radial arteries

Palpation

1.8 Anterior Chest a. Breast and Axillae

Inspection Inspection Palpation

>same color with other parts of the body >(-) lesions >(-) tenderness, swelling, mass > symmetrical chest expansion >(-) mass, tenderness and swelling >(+ rales ) >no lesions > no signs of inflammation > (-) tenderness and swelling >(-) murmurs > no lesions, tenderness > no signs of inflammation > full & symmetric chest expansion >Chest wall intact >Skin intact > no presence of any limps & bulges

b. Thorax

Inspection Palpation Auscultation Inspection Inspection Palpation Auscultation

c. Pericardium

1.9 Back a. Musculoskeletal Structures

Inspection & Palpation Inspection Inspection Inspection Inspection Inspection & Palpation

b. Fist percussion over spine and kidney

c. Posterior Thorax

Inspection Palpation Inspection

> (-) lesion >(-) lumps > with full & symmetrical chest Expansion >(-) jugular venous distention > not palpable > symmetric

1.10 Neck Veins 1.11 Abdomen a. Four abdominal

Inspection Palpation Inspection

Quadrants

Inspection Palpation Palpation

>protruding abdomen >(-) tenderness > (-) mass

b. Specific Organs Liver Spleen Kidneys 1.12 Lower Extremities a. Musculoskeletal structures, skin and toe nails

Palpation Palpation Palpation Inspection Inspection Palpation Inspection & Palpation Inspection Inspection and Palpation Inspection

> not palpable > not palpable > no palpable > Legs equal in size > (-) contractures / tremors > normally firm > no gross deformities, tenderness or swelling > no edema on legs > toenails re pinkish in color smooth, convex I shape, & hard to touch > no signs of cyanosis >Smooth coordinated movement > able to flex, extend, abduct & adduct lower extremities >Palpable with equal pulsation

b. Musculoskeletal function

Inspection Inspection

c. Popliteal, Posterior, Tibial & pedal arteries

Palpation

Summary of Abnormal Findings Based from the above physical assessment done, the presence of nonproductive cough, (+) rales and presence of rashes on the skin were noted.
C. REVIEW OF RECORDS:

1. Medical Plan of Care: IV therapy Medications- Pen G IV 200,000 U q 6 hrs; IZN 200 mg 15 mL 4 cc OD; Ambroxole 1 tsp. BID PO; PZN 7.5cc OD PO; Diphenhydramine 15 mg IV q 8 hrs; Rifampicin 4 cc OD PO; Paracetamol 3 mL q 4 hrs. PO

DATE PERFORME D June 13,2005

DIAGNOSTIC TEST Urinalysis F. Physical 1.specific gravity

RESULTS

NORMAL VALUES

SIGNIFICANCE Urinalysis is a test used to assess the status of the kidney function, nutrition, and certain metabolic and systemic disease.

IMPLICATION OF ABNORMAL RESULT

NURSING RESPONSIBILITIES

1.005

1.0151.030

The client has Before: decreased specific 1. Explain that this test requires urine specimen-aids gravity of urine diagnosis of renal or urinary tract diseases and indicating that there is helps evaluate over all body function dehydration due to the 2. Check patients history for recent use of fever manifested by medications that may affect results the client. 3. teach patient that the first voided morning specimen is the ideal urine specimen for analysis because of its concentration and characteristic audity After: 1. If culture and sensitivity is needed a clean catch or midstream method is used and the perineal area or penis should be applied with and Iodine preparation to reduce contamination. 2. Tell the patient that the specimen are collected over a time that may range from 2-24 hours Before: The clients WBC is 1. Explain the procedure to the patient before the increased indicating procedure proper. that there is infection 2. Inform the patient that the test requires blood in the body system. sample and he need not fast before the test, but that he should avoid eating heavy meal before the test. 3. Advise the patient to avoid strenuous exercise for 24 hours before the test.

June 15,2005

Hematology test A.WBC

17.2

5.0-10.0 10^g/ul

WBC is used to determined infection in the body system. It is also used to determine the need for WBC differential bone

B. RBC

3.79

4.0-6.0 10^12/ul

C. Hemoglobin

96

120140g/dl

D. Hematocit

0.28

0.380.45%

E. Neutrophils

0.72

0.630.65%

marrow biopsy. RBC is used to support other hematologic tests in diagnosis of anemia and polycytopenia. Hemoglobin through the red blood cells transports O2 and removes CO2 from the body. It is used to measure the severity of anemia or polycythemia. Hematocrit is significant as the percentage of RBC in the total volume. Changes in RBC size will make a difference in the test values. Neurtrophils are the most numerous of the circulating leukocytes.

The clients RBC is decreased indicating there is inflammation and granulation in the lungs. The hemoglobin of the client is decreased due to inadequate food intake which leads to malnutrition.

4. If patient is being treated for an infection, tell him that this test will be repeated to monitor his progress. 5. Check patients history for drugs that may alter results. After 1. Monitor Vital Signs closely, if temperature increases do TSB and refer to POD. 2. If a hematoma develops at the venipuncture site, apply warm soaks to ease discomfort. 3. Instruct patient to resume to normal activities restricted before the test.

The hematocrit of the client is decreased due to inadequate food intake which leads to malnutrition.

The clients neutrophils is increased indicating that the bone marrow is releasing cells that are not developed and

June 15, 2005

Chest X- ray AP/LAT Roentological & UTZ findings

Primary Kocks infection

none

Phagocytosis is the major mode of action. It is the bodys primary line of defense against infection because they are the first to arrive in the inflammatory site. X-ray films of the chest are used to identify various abnormalities of the lungs and structures in the thorax; the size of the heart, abnormalities in the ribs or diaphragm can also be determined.

that the stimulation for production and release of leukocytes is not enough.

The client had an Before: anterior posterior (AP) 1. Explain the procedure to the patient before the lateral (LAT) view of xactual test/ examination. ray. It was seen that 2. Remove clothing of patient down to the waist then the client is (+) primary drape maintaining and respecting patients kochs infection; an privacy. extensive pathologic 3. Remove all jewelry or any metal objects. process in the lungs in 4. Position patient noting for its safety (cover testes, the absence of may lead to impotence) symptoms is detected. 5. Instruct patient correctly and clearly. (deep breath and hold) After: 1. Isolate patient from other patient; same as isolation of the patients articles. 2. Standard safety precautions should be observed. 3. Do hand washing and meticulous hygiene. 4. Adequate nutrition should be given to the patient. 5. Monitor VS with U & B monitoring; refer accordingly. 6. Note for bleeding/ blood on secretions and stool. 7. Monitor patients condition; give meds on time as

ordered by the doctor. June 16, 2005 Chemistry Report form Specimen: Serum Alanine Aminotrasferase (PE/ALT) 47 5-45 u/L AlanineAminotransferase (ALT) is a necessary enzyme in the Krebs cycle. It is essential for tissue energy production. It is an indicator of hepatocellular damage. The clients ALT is Before: increased indicating 1. Explain to the patient that this test help assess that there is liver functions, that he need not restrict foods or disseminated fluids before the test and that the test requires a Tuberculosis which blood sample. often have associated 2. Falsely elevated ALT levels may follow use of liver involvement. barbiturates, chlorpromazines, isoniazid, Damaged liver cell methyldopa, oprate analgesics, pararelease increased aminosalicylic acid, phenothiazines, henytoin, amount of ALT. salicylates, tetracycline and other drugs that affect liver. If meds must be continued, make a note on the laboratory slip. 3. Ingestion of lead or exposure to other tetrachloride injures hepatic cells and elevates ALT sharply. After: If a hematoma develops, at the venipuncture site, apply warm soaks to ease discomfort.

June 19,2005

Urinalysis F. Physical 1.specific gravity

1.015

1.0151.030

Urinalysis is a The clients specific Just continue nursing care. test used to gravity of urine is assess the status within normal values. of the kidney function, nutrition, and certain metabolic and systematic disease.

June 19, 2005

Chemistry Report form Specimen: Serum 44 Creatinine 53-133 umd/L Creatinine is a non protein end product in the breakdown of creatinine phosphate in the skeletal muscle. Decrease in Serum Total Protein reflects decrease in Albumin Globulin Albumin is the smallest protein molecule and makes up the largest portion of total serum protein. It is synthesized in the liver Although the Before decreased in 1. Explain to the patient that this test evaluates creatinine is too little to kidney function. indicate actual muscle 2. Instruct him to resist foods and fluids for about 8 wasting, it also hours before the test. suggest incoming 3. Tell the patient that the test requires a blood problem with regards sample. to total muscle mass. 4. Check the patients history for any drugs that may interfere the test results. For instance, ascorbic, The client has barbiturates, diuretics might increase creatinine decreased total protein levels. due liver function 5. Check the patients record diet history for foods disease, since liver is that may interfere with the test results. Example, greatly involved in a diet high in roasted meat increase creatinine Tuberculosis. level. After The client has 1. If a hematoma develops at the venipuncture site, decreased albumin apply warms soaks to ease discomfort. indicating loss of appetite during the Before disease process. 1. Explain to the patient that this test determines the protein content of blood. Tell him that he need not restrict foods or fluids before the test. Mention that the test requires a blood sample. 2. Check the patients medication history for drugs that may influence Serum Protein levels, such as

56 Total Protein

60-80 q/L

30 Albumin A

40 - 60 q/L

1.115 A/G Ratio

1.5 - 2.2

Albumin/Globulin ration (A/G ratio) shows the proportion of albumin to globulin. Though once considered useful, it is now rarely used as the ratio may influence many diseases.

The client has cytotoxic agents. If they must be continued, note decreased A/G ratio on the laboratory slip. indicating that there is 3. Avoid pretest administration of a contrast agent decreased which falsely elevates test results. sedimentation rate After occurring within the 1. If a hematoma develops at the venipuncture site, large cells. Viscosity of apply warm soaks to ease discomfort. the blood of decreased plasma protein also slows the 1. Observe for frothy urine--- it may indicate protein sedimentation rate. excretion. 2. Observe the patient for signs of edema. 3. Instruct the patient & the family to save all urine & notify nursing staff of each void.

June 18,2005

HEMATOLOGY TEST WBC

12.5

5.0-10.0

Before: 1. Explain to the patient that this test helps diagnose liver and other disorders by measuring certain protein levels in the blood. Answer any question he may have. 2. Instruct that a blood sample will be taken and he need not restrict foods or fluids before the test. 3. Check patient medication history and report any current drug therapy. Certain drugs interfere with total protein level. After: If a hematoma develops at the venipuncture sites, apply warm soaks to ease discomfort. Before: 6. Explain the procedure to the patient before the White blood cells The clients WBC is procedure proper.

10^g/ul

are used to determine infection in the body system. It is also used to determine the heed for WBC Differential or bone marrow biopsy.

RBC

3.83

4.0-6.0 10^12/ul

7. Inform the patient that the test requires blood sample and he need not fast before the test, but that he should avoid eating heavy meal before the test. 8. Advise the patient to avoid strenuous exercise for 24 hours before the test. 9. If patient is being treated for an infection, tell him that this test will be repeated to monitor his progress. 10. Check patients history for drugs that may alter results. Red blood cells The clients RBC is After are used to decreased indicating 4. Monitor Vital Signs closely, if temperature support other there is inflammation increases do TSB and refer to POD. hematologic tests and granulation in the 5. If a hematoma develops at the venipuncture site, in diagnosis of lungs. apply warm soaks to ease discomfort. different 6. Instruct patient to resume to normal activities diseases. restricted before the test. Hemoglobin through the red blood cells transports O2 and removes CO2 from the body. It is used to measure the severity of anemia or polycythemia. The hemoglobin of the client is decreased due to inadequate food intake which leads to malnutrition.

still increased indicating that there is infection in the body system.

Hemoglobin

95

120140g/dl

Hematocrit

0.29

0.380.45%

Hematocrit is significant as the percentage of RBC in the total volume. Changes in RBC size will make a difference in the test values. Neutrophils are the most numerous of the circulating leukocytes. Phagocytosis is the major mode of action. It is the bodys primary line of defense against infection because they are the first to arrive in the inflammatory site. Echocardiograms are used to measure the diameter of the cardiac chambers and evaluate other structural

The hematocrit of the client is decreased due to inadequate food intake which leads to malnutrition.

Neutrophils

0.61

0.630.65%

The clients neutrophils is now decreased may be referred to as a degenerative shift when the body cannot respond sufficiently to mature leukocytes, indicating overwhelming bacterial infections.

June 21, 2005

Echocardiograph y/ color flow/ Doppler

Situs solitus; AV:VA Before: concordance; normal 1. Explain to the patient everything about the test. systemis and 2. Warn him of he might feel slight discomfort during pulmovenous the test. connection; IVS intact; 3. Tell patient that he will be instructed to breath in IAS intact; good LV and out slowly to hold his breath or to inhale a function; normal gas with slightly sweet odor.

abnormalities the heart.

June 24, 2005

Hematology test WBC 15.8 5.0-10.0 10^g/ul

Hemoglobin

112

120140g/dl

of cardiac chambers; with 4. Instruct patient to remain still during the test. mild mitral After: regurgitation; slightly 1. Monitor VS closely. dilated LMCA of 2.75 2. Check for any abnormalities on heart sounds/ mm; normal RMCA irregular heart sounds; breathing. and (-)pericardial 3. Monitor condition of patient at all times. effusion; with ejection 4. Give meds on time as ordered by the doctor. fraction of 81 %. 5. Refer to the POD accordingly for any abnormal development on the patient. Before: 11. Explain the procedure to the patient before the White blood cells The clients WBC is procedure proper. are used to still increased 12. Inform the patient that the test requires blood determine indicating that there is sample and he need not fast before the test, but infection in the infection in the body that he should avoid eating heavy meal before the body system. It is system. test. also used to 13. Advise the patient to avoid strenuous exercise for determine the 24 hours before the test. heed for WBC 14. If patient is being treated for an infection, tell him Differential or that this test will be repeated to monitor his bone marrow progress. biopsy. 15. Check patients history for drugs that may alter results. Hemoglobin The hemoglobin of the After through the red client is decreased 7. Monitor Vital Signs closely, if temperature blood cells due to inadequate food increases do TSB and refer to POD. transports O2 and intake which leads to 8. If a hematoma develops at the venipuncture site, removes CO2 malnutrition. apply warm soaks to ease discomfort. from the body. It 9. Instruct patient to resume to normal activities is used to restricted before the test. measure the

severity anemia polycythemia. Hematocrit 0.33 0.380.45%

of or The hematocrit of the client is decreased due to inadequate food intake which leads to malnutrition.

Hematocrit is significant as the percentage of RBC in the total volume. Changes in RBC size will make a difference in the test values. Lymphocytes have a major activity in the immunology and immune reactivity Neutrophils are the most numerous of the circulating leukocytes. Phagocytosis is the major mode of action. It is the bodys primary line of defense against infection because they are the first to arrive

Lymphocytes

0.22

0.250.35%

Neutrophils

0.78

0.630.65%

The client has slight decreased lymphocyes though it is still consider to be in the normal values. The clients neutrophils is now decreased may be referred to as a degenerative shift when the body cannot respond sufficiently to mature leukocytes, indicating overwhelming bacterial infections.

in the inflammatory site. June 26, 2005 Hemoglobin 93 120140g/dl Before: 16. Explain the procedure to the patient before the procedure proper. 17. Inform the patient that the test requires blood sample and he need not fast before the test, but that he should avoid eating heavy meal before the test. 18. Advise the patient to avoid strenuous exercise for 24 hours before the test. 19. If patient is being treated for an infection, tell him that this test will be repeated to monitor his progress. Platelets are The client has 20. Check patients history for drugs that may alter produced in the increase platelet due results. bone marrow as to myeloproliferation of After fragments of megakryocytes. 10. Monitor Vital Signs closely, if temperature megakaryocytes. increases do TSB and refer to POD. It is significant to 11. If a hematoma develops at the venipuncture site, evaluate platelet apply warm soaks to ease discomfort. production. 12. Instruct patient to resume to normal activities restricted before the test. Hemoglobin through the RBC transports O2 and removes CO2 from the body. It is used to measure the severity of anemia or polycythemia. The hemoglobin of the client is decreased due to inadequate food intake which leads to malnutrition.

Platelet

830

140-400 10^g/ul

II. PLANNING NURSING CARE PLAN

CUES Subjective: Grandmother verbalized, inuubo siya Objective: (+) rales restlessness nonproductive cough NURSING DIAGNOSIS Ineffective airway clearance r/t presence of secretion in the lung fields. PLANNING Within the shift, the patient will be able to readily expectorate secretions and maintain airway patency. INTERVENTION Auscultate lung fields. RATIONALE To know the extent and location of secretions for possible postural drainage. To avoid the compression of the diaphragm and promotes maximal inspiration. To clear out secretions. Facilitates in breathing and aids in oxygenation. To loosen secretions clogged in the lungs and easily expectorated. Facilitates drainage of secretions. It relaxes bronchial vessels and makes expectoration easier. EVALUATION The patient was able to expectorate secretion and maintained airway patency.

Elevate head of bed 45-90

Suction respiratory tract as ordered. Administer oxygen as indicated. Do CPT as ordered.

Do Postural Drainage. Give expectorants/ bronchodilators as ordered.

 Give health teachings: > Encourage intake of warm water. >Give tea with honey Tepid Sponge Bath if fever exists; Sponge Bath if temperature is within normal range. Monitor temperature qH if fever exists. Provide a cool environment. Administer antipyretics and antibiotics as ordered. Give Health teachings: Increase Oral Fluid Intake. Imbalanced Nutrition: Less than Body Requirements r/t low food intake secondary to loss of appetite. At the end of the 6hour shift, the patient will be able to consume adequate nourishment as manifested by good appetite. Teach watcher proper TSB. Know weight, strength, activity/rest level. Discuss patients eating habits including food, preferences and state of oral cavity, drug interaction, side effects and allergy. Consider six small nutrient dense meals than 3 larger meals.

Warm water loosens secretions trapped in airways. To lessen the irritation of larynx. Heat loss through evaporation. Patient was able to maintain body temperature within normal range as evidenced by T=36.9C

Subjective: Pabalik-balik ang lagnat niya as verbalized by the relative. Objective: T=38.5 C Skin warm to touch Flushed skin WBC=13.2x10 4 g/L Discomfort Subjective: Relative verbalized, Wala siyang gana kumain. Hindi siya gaanong makanguya. Objective:

Altered body temperature r/t presence of systemic infection.

At the end of the shift, patient will maintain body temperature within normal range (36.5-37.5 C)

To know the effectiveness of intervention given. Heat loss through convection. Antipyretics lower body temperature; Antibiotics kills and inhibits growth of bacteria To replace fluid loss and prevent dehydration. If the nurse is not available, the mother can do it. To provide baseline for future comparison. To determine if these factors affect patient appetite, food intake, and absorption. 6 feedings reduce feeling of fullness and satiety and decreases possibility of

The patient was able to consume adequate nourishment as manifested by good appetite.

Loss of appetite Dry lips Body weakness Wt. 13 kg

Provide good oral care before and after meals. Provide a pleasant environment and prevent or minimize unpleasant odor or sight. Health Teaching: Do handwashing before eating. Encourage more oral fluid intake but limit fluid intake at least one hour before meals. Mild anxiety r/t hospital procedures. Within the shift, patient will appear relax and anxiety will be reduced as manifested by: Active interaction with the nurse/doctor . Absence of irritability. Establish a therapeutic relationship and conveying empathy. Provide accurate information about the situation. Be truthful with patient, avoid bribing. Provide comfort measures. Modify procedures as possible.

vomiting. May enhance appetite. Unpleasant environment may have negative effect on appetite. To reduce presence of microorganism in the hand. Water relieves dry mouth and may enhance appetite. Limiting fluid intake before meals decreases possibility of early satiety. For patient to be at ease on hospital staff. Helps patient to identify what is reality based. To sooth fears and provide assurance. To acquire resting period or relaxing moments. To avoid overwhelming of patient.

Subjective: Relative verbalized, Natatakot siya lagi kapag may dumadating nakaputi. Objectives: Slightly scared Restlessness Irritability Poor eye contact Teary eyes upon the

The patient appeared relax and anxiety reduced as manifested by active interaction with the nurse/ doctor and absence of irritability.

arrival of nurse/doctors Subjective: Grandmother verbalized, Naiinip na siya dito sa hospital kasi wala siyang makalaro. Objective: Shy Untalkative Withdrawn attitude Irritability Looks bored Seeking for someone to play with Appears lonely

Impaired social interaction r/t prolonged hospitalization.

Within the shift, patient will be involved in achieving positive changes in social behaviors and interpersonal relationships manifested by being responsive and eliciting positive interaction with staff.

Note changes in social behavior or patterns relating with others. Establish therapeutic relationship with patient. Encourage patient verbalization of problem. Provide positive reinforcement by involving family members with patients care. Provide positive feedback when interacting with patient. Plan activity for the patient (e.g. playing with others). Instruct watcher to interact with patient always.

To determine underlying problem regarding behavior. Establishes rapport and facilitates interaction with patient. To determine feeling of discomfort and problems about social situation. For the improvement in social behaviors and interactions. To develop positive social skills. To establish harmonious relationship with patient. Facilitate interaction between family members.

Patient elicited positive social behavior as manifested by his responsiveness and good interaction with staff.

E. Data from the Textbook: Definition of diagnosis: Kawasaki Disease- is an acute febrile illness with inflammation of small and medium size blood vessels throughout the body in particular, the coronary arteries (blood vessels around the heart). It is also known as Mucocutaneous Lymph Node Syndrome. It is most likely caused by a very common infectious microorganism that only causes problems in a small number of in predisposed individuals. - infectious disease caused by bacteria or bacterial super antigens (particularly Streptococcus pyogenes) and/or virus: because Kawasaki disease is rarely seen in adults, this suggests that adults may have developed immunity with the causative agent. The disease is usually self-limiting and resolves spontaneously without treatment within 4-8 weeks. S/S FROM THE BOOK 1. FEVER (ABOVE 39 DEGREES CELSIUS) S/S MANIFESTE D BY CLIENT RATIONALE When infectious bugs stimulate white blood cells in a specific way, they release a substance called endogenous pyrogenes which signals the brains hypothalamus to raise the bodys thermostat setting. In turn, the body heats up by increasing its metabolic rate, shivering or seeking warm environment. Kawasaki Disease is also known as the Mucocutaneous Lymph Node Syndrome. The microorganism responsible for the occurrence of this disease will attack and invade some of the mucous membranes in the body including conjunctiva. As microorganism attacks, the inflammatory response of the body will be activated particularly causing the conjunctiva to be inflamed. Because microorganism attacks the body, immune response will be activated. Basophils will dilate the passageway including the capillaries to have more amount of blood to be perfused so as rashes may be visible. Dilation of passageway is necessary to attract more monocytes / macrophages against microorganisms. Kawasaki Disease is also known as the Mucocutaneous Lymph Node Syndrome. The microorganism responsible for the occurrence of this disease will attack and invade some of the mucous membranes in the body including oral mucous membrane. As microorganism attacks, the inflammatory response of the body will be activated particularly causing the oral mucous membrane to be red and be dried. Caused by tissue erythema and prominent papillae.

2. CONJUNCTIVITIS

3.CHANGES IN EXTREMITIES SUCH AS PERIPHERAL EDEMA, PERIPHERAL ERYTHEMA AND DESQUMATION OF PALMS ANS SOLESPARTICULARLY PERIUNGUAL PEELING 4. DRY, RED, CRACK LIPS WITH BLEEDING

5.OROPHARYNGEAL REDDENING

6. ANEURYSMS

8.VOMITING

Kawasaki Disease involves inflammation of the blood vessels. And because of the inflammation, it make the blood vessel weak and might break. Then the calcium from the bones will fill up that break as a process of calcification. As a result there will be a smaller passage of the blood and much pressure will cause the aneurysm. Due to the entry of the microorganisms responsible for the occurrence of this disease in the human body, making the individual immunosuppressed thus there will be loss of appetite. Loss of appetite may result to accumulation of gastric acids in the stomach making individual to vomit.

PTB (Primary Complex) - is chronic recurrent infections. Disease that usually affects the lungs, although any organ can be affected. It is transmitted by droplet nuclei airborne droplets produced when an infected person sneeze, coughs, speaks or sings. Infection may occur when a susceptible host breathes in air containing droplet nuclei and the contaminated particle to reach the alveoli. S/S FROM THE TEXTBOOK 1. FATIGUE S/S MANIFESTED BY PATIENT RATIONALE Because of fever, an individual would experience discomfort. The body would decrease the glycogen reserve that leads to hypoxia or muscle wasting. Therefore, there would be not enough oxygen that would circulate in the body. Due to discomfort, anorexia and weight loss may occur. The bacteria causes infiltration and granuloma which releases chemicals that results to loss of appetite. Cough may indicate serious pulmonary disease. It result from irritation of the mucus membranes anywhere in the respiratory tract. Due to presence of secretions, the client would stimulate to release these secretions. Purulent discharge is due to infection while bloodtinged sputum appears because of the irritation of the mucous

2. ANOREXIA AND WEIGHT LOSS

3. COUGH: initially dry, later productive of purulent and /or bloodtinged sputum

membranes. 5. LOW GRADE AFTERNOON FEVER AND NIGHT SWEATS Inhalation of mycobacterium invades the alveoli that activates the t-cells. An inflammatory response would occur that stimulates WBC to release pyrogens that signals the hypothalamus to increase heat and raise the metabolic rate.
F. PROBLEM LIST Nursing Diagnosis Ineffective airway clearance r/t presence of secretion in the lung fields High Risk for Altered Body Temperature r/t presence of systemic infection Imbalanced Nutrition: Less than Body Requirements r/t low food intake secondary to loss of appetite. Mild Anxiety r/t hospital procedures Impaired Socialization r/t prolonged hospitalization Prioritization Day Day 1 2

F. PROBLEM LIST
Date Identification Day 3

DRUG STUDY Name of Drug Penicillin (Penicillin G Potassium Penicillin G Sodium Penicillin V) Dose, Frequency and Route 200,000 U q 6 ID Classification/Action /Indication > anti-infectives > binds to bacterial cell wall resulting in cell death Pharmacokinetics: Absorption: Contraindication/adverse Reactions > Previous hypersensitivity to penicillins (cross sensitivity may exist with cephalosphorins) Nursing Responsibilities > Assess patient for infection at beginning and throughout course of therapy.

Variably absorbed from the GI tract. Procaine and henzathine penicillin IM absorptish is delayed and prolonged and results in sustained AR: therapeutic blood levels. > CNS: seizures Distribution: GI: N/V, diarrhea, gastric - Widely distributed, distress, pseudomembranous although CNS penetration is poor in the colitis presence of uninflammed GU: interstitial nephritis meninges. Cross the Derm: rashes, urticaria placenta and enter breast milk. Hemat: eosinophilia, CHON binding: 60% hemolytic anemia, leukopenia Metabolism and Excretion: Minimally metabolized by Local: phlebitis at IV site, pain at IM site

> Observe patient for signs Hypersensitivity to and symptoms of draphylaxis procaine/benzathine (rash, pruritus, laryngeal (only) edema, wheezing). Some products that > Instruct patient to take med. contain tartrazine and RTC and to finish drug should be avoided in completely even if feeling patients with known better. Advise patient that hypersensitivity. sharing med. May be dangerous. > Advise patient to report signs of superinfection (block, furry overgrowth on tongue, loose/foul-smelling stools and allergy).

the liver, excreted mainly Misc: superinfection, allergic unchanged by the reaction including Anophylaxis kidneys. and serum sickness life: 30-60 mins. Isoniazid (INH, Isotamine) 200/5ml 4 cc OD > anti-tubercular > Inhibits mycobacterial cell wall synthesis and interferes with metabolism. Pharmacokinetics: Absorption: > Hypersensitivity > Advise patient to notify physician/other health care - Acute liver disease - Previous hepatitis from provider promptly if signs and symptoms of hepatitis/yellow Isoniazid eyes and skin, N/V, anorexia, AR: dark urine, unusual >CNS: peripheral neuropathy, tiredness/weakness or seizures, psychosis peripheral neuritis (numbness, EENT: visual disturbances tingling paresthesia) occurs. > Advise patient to take med. exactly as directed. > Caution patient to avoid the use of alcohol during this therapy, as this may increase the risk of hepatotoxicity. > Emphasize the importance of regular follow-up physical and ophthalmogic exam. to monitor progress and to check for side effects.

Well absorbed following GI: N/V, hepatitis oral and IM admin. Derm: rashes Distribution: - Widely distributed to Endo: gynecomastia many body tissues and Hemat: blood dyscracias fluids. Readily crosses Misc: fever the blood-brain barrier. Crosses the placenta and enters breast milk in concentrations equal to plasma. > Used as first-line antitubercular in combination with other agents in the tx of active disease. Prevention of tuberculosis in patient

exposed to active disease. AM-Ambroxol (Ambroxol HCl) Children 6-12 y/o: 1 tsp bid-tid orally .Cough and cold remedy, treatment of respiratory disorders associated with viscous mucus. Special precautions to pregnancy and lactation > Advise client to increase oral fluid intake to loosen up the phlegm. > Explain to the patient the drugs mechanism of action. > Give the medication to the right patient, at the right time. > Document administration of medication. > Teach patient the proper breathing and coughing exercises. Pyrazinamide 250/5 ml 7.5 cc OD oral Action: decreased bone marrow reserve Indication: used in combination with other agents in the treatment of active tuberculosis Hypersensitivity. AR: Frequent arthralgia, mayalgia (usually mild and self limiting), urticaria, pruritus, photosensitivity Baseline Assessment Question with hypersensitivity to pyrazynamide, isoniazid, ethionamide, niacin. Ensure collection of specimen with culture, sensitivity. Evaluate results of initial CBC, hepatic function test, uric acid levels. Intervention monitor hepatic resultsbe alert with hepatic reactions: jaundice

 malaise, fever, liver tenderness, anorexial/N&V, (stop drug and notify physician promptly check serum uric acid levels assess with hot painful joints esp. big toe, ankle, knee (gout) evaluate blood sugar levels, diabetic status carefully (pryrazinamide makes management difficult) assess with rash, skin eruptions Monitor CBG for thrombocytopenia, anemia. Diphenhydramine 15 mg, IV, q8h > Antihistamine > Blocks histamine, thereby decreasing allergic response, affects respiratory system, blood vessels, GI system. > Acute asthmatic attack, severe liver disease, lower respiratory disease, neonate > Side Effects: fatigue, drowsiness, dizziness, nausea, vomiting, urinary retention, blurred vision, dry > Advise patient to take with food/fluid stomach. > Use with caution to patient with asthma. > To relieve dry mouth, give ice chip, hard candy or

mouth, constipation

sugarless gum. > Do not give without doctors order. > Report any adverse effect or untoward effect.

Rifampicin 200/5 ml

4 cc OD oral

Action: Inhibits RNA synthesis by blocking RNA transcription in susceptible organism. Indication: Active tuberculosis (with other agents). Elimination of meningococcal carriers.

> hypersensitivity to concurrent indenairs, nesfinavir, pyrazinamide, or squinavir. AR: CNS: headache, fatigue, drowsiness, dizziness, mental confussion, generalized numbness CV: shock EENT: visual disturbance, exudative conjunctivitis GI: epigastric distress, anorexia, nausea and vomiting, abdominal pain, diarrhea, flatulence, sore mouth and tongue GU: hemoglobinuria, hematuria HEMATOLOGIC: eosiniphilia, thrombocytopenia, hemagtic

> Perform mycobacterial studies and susceptibility test prior to and periodically during therapy to detect possible resistance. > Assess lung sounds and character and amount of sputum periodically during therapy. > Evaluate renal function, CBC, and urinalysis periodically and during therapy. > Monitor hepatic function at least monthly. May increase BUN, AST, HLT, and serum alkaline phosphatose, bilirubin and uric acid considerations.

anemia MUSCULOSKELETAL: osteomalacia RESPI: shortness of breath, wheezing SKIN: pruritus, urticuria, rash

Paracetamol 250/5 ml

3 ml q4h oral

Action: Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Has no significant antiinflammatory properties or GI toxicity. Indications: mild pain, fever.

> previous hypersensitivity > products containing AR: HEMATOLOGIC: hemolytic anemia, neutropenia, leucopenia, pancytopenia HEPATIC: liver damage, jaundice METABOLIC: hypoglycemia SKIN: rash, urticaria

> use liquid form for children and patients who have difficulty in swallowing > in children, dont exceed 5 doses in 24 hours > advise patient that drug is only for short term use and to consult prescriber if giving to children for longer than 5 days > warn patient that

II IMPLEMENTATION (for charting) NURSING DIAGNOSIS IMPLEMENTED NURSING INTERVENTION Ineffective airway Auscultated lung clearance r/t presence of fields. secretion in the lung Elevated head of fields. bed 45-90. Backclapping done. Chest physiotherapy and postural drainage done. Administered medications as ordered. Increased oral fluid intake. Provided adequate rest and limited activities. High risk for altered body Monitored temperature r/t presence temperature. of systemic infection. Sponge bath done daily. Increased oral fluid intake. Administered antipyretics and antibiotics as ordered. Provided a cool environment. Imbalanced Nutrition: Considered six Less than Body small nutrient Requirements r/t low dense meals than food intake secondary to 3 larger meals. loss of appetite. Provided good oral care before and after meals. Provided a pleasant environment and prevent or minimize unpleasant odor or sight. Did handwashing before eating. Encouraged more oral fluid intake but limit fluid intake at least one hour before meals. Mild anxiety r/t hospital procedures. Established a therapeutic

EVALUATION The patient was able to expectorate secretion and maintained airway patency.

Patient was able to maintain body temperature within normal range as evidenced by T=36.9C

The patient was able to consume adequate nourishment as manifested by good appetite.

The patient appeared relax and anxiety reduced as manifested

 Impaired social interaction r/t prolonged hospitalization.

relationship and conveying empathy. Provided accurate information about the situation. Avoid bribing. Provided comfort measures. Modified procedures as possible. Noted changes in social behavior or patterns relating with others. Established therapeutic relationship with patient. Encouraged patient verbalization of problem. Provided positive reinforcement by involving family members with patients care. Provided positive feedback when interacting with patient. Planned activity for the patient (e.g. playing with others). Instructed watcher to interact with patient always.

by active interaction with the nurse/ doctor and absence of irritability.

Patient elicited positive social behavior as manifested by his responsiveness and good interaction with staff.

DISCHARGE PLANS Date of possible discharge: A week after treatment 1. Medication to be taken at home:Rifampicin, Isoniazid,Pyrazinamide and Ferrous Sulfate 2. Diet: Eat foods that are nutritious and healthy. 3. Activities restricted: Avoid extraneous activities. Advise not to skip meals. 4.Special Health Teachings Proper Diet 5. Check-up Schedule:

FOLLOW-UP EVALUATION (Home Visit)

HEALTH TEACHING GUIDE Topics: PROPER DIET Time Allotment: 15 minutes OBJECTIVES Nutrition& Activity To promote the nutritional status and activity of the patient. CONTENT TEACHING STRATEGY Oral explanation and cite some examples of food that the patient can eat. EVALUATION

Advise the patient to drink the take home medications. Also tell the patient to increase his intake of nutritious foods and drinks. Instruct mother of the patient to increase fluid intake preferably clean distilled/sterilized water.

The mother of the patient will be able to verbalize understanding on the proper diet.

Breathing Exercise Pattern To achieve Reference: more efficient Promotes muscle and controlled relaxation ventilation and Relieves anxiety to decrease the Eliminates ineffective, work of uncoordinated pattern of breathing of the respiratory muscle activity patient. Slows the respiratory rate Decreases the effort for breathing Demonstration or instruction to patient to patient: Inhale through the nose like youre smelling the scent of a certain flower Exhale through the mouth like youre blowing candles Handwashing To eliminate the presence of microorganisms and thus prevent the cause of infection. Prevents the patient from transferring infection to other people.

Discussion with actual demonstration from nurse then a return demonstration from the patients.

Patient has prolonged exhalation. Patient demonstrated good breathing exercise through performing procedure closely as how nurse did the exercise.

Effective handwashing requires at least 15 seconds of vigorous scrubbing with special attention to the area around the nail beds and in between fingers, where there is a high burden. Hands should be thoroughly rinsed after this washing then dry their hands with clean towel. Do this especially before and after meals.

Discussion with actual demonstration of the nurse to the patient.; then ask the patient to do it with the nurse daily same procedure. Lastly, ask patient to demonstrate it alone to the nurse. Same demonstrations and return

Patient demonstrated the procedure very well just as how the nurse had done it.

demonstrations will be done by the relatives of patient present in the discussion.