ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

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

OBJECTIVE: Rashes Skin reddness

Risk for impaired skin integrity related to raking pruritus

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

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.

1. To minimize the trauma and secondary infection

2. To prevent scratching.

3. Because excessive heat can increase itching.

4. To prevent scratching.

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

GOAL METAfter the nursing implementation the patient’s mother was able to perform instructions and the patient was able to maintain intact skin.

ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE:“Hindi ko alam na nakakahawa pala ang tigdas eh”, as verbalized by the patient’s mother.

OBJECTIVE:

Deficient Knowledge related to new condition

After 8 hours of nursing interventions , we will be able to:

1. Assess the patient’s willingness and capabilities for learning.

2. Formulate strategies for facilitation of better learning.

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

2. Assess motivation and willingness of patient and caregivers to learn.

3. Assess ability to learn or perform desired health-related care.

4. Identify priority of learning needs within the overall plan of care.

5. Question patient regarding previous experience and health teaching.

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.

2. Adults must see a need or purpose for learning.

3. Cognitive impairments need to be identified so an appropriate teaching plan can be designed.

4. Adults learn material that is important to them.

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

GOAL MET

After the nursing implementations, we were able to assess the patient’s capabilities and needs for learning, and was able to formulate strategies for better learning as evidenced by:

Client’s cooperation during questioning

Verbalization of desired to learn

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 DIAGNOSIS PLANNING IMPLEMENTATION RATIONALE EVALUATION

SUBJECTIVE:“Ano ba ang pwede kong gawin?”, as verbalized by the mother.

OBJECTIVE: The client

manifested: Cooperation Follows

instructions Active asking

about the disease.

Readiness for enhanced knowledge: disease information

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

1. Provide physical comfort for the learner.

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.

7. Ensure that required supplies or equipment

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.

6. Match the learning style with the educational approach.

7. This is especially important when teaching in

GOAL MET

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

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.

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

the home setting.

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

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 patient’s health status by utilizing a holistic approach of promoting nursing management. It also aims to enhance student’s 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 client’s medical diagnosis upon admission.

To search the medical management as being ordered based upon the client’s diagnosis & laboratory result.

To asses the anatomy and physiology of the system that is related to the patient’s condition.

To evaluate effectiveness of the intervention & detect any progress of the client’s condition.

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