OUTCOME PRESENT STATE TEST

Name: Russel Jr C. Navea Date Admitted: October 13, 2022

Age: 3 years old Chief Complaints: Cough and Runny nose
Sex: Male Admitting Diagnosis: None
Civil Status: Child Attending Physician: None
Address: Booy District, Tagbilaran City Ward/Area: House
CLIENT IN CONTEXT ASSESSMENT INTERVENTIONS RATIONALE EVALUATION

Chief Complaint/Reason for Independent: Goal Met. At the end of the

Consultation:
Cough and Runny Nose
History of Present Illness:
Five days PTA, the patient
experiences a runny nose and
seems irritable.
History of Past Illness:
N/A
Socio-economic Status:
N/A
Subjective Cues: “Ang ubo sa
akong anak kay naay plema
ug gisip.on sad siya.” as
stated by the mother.
Objective Cues:
Runny nose noted
Productive cough noted
Wheezing noted upon
auscultation
Vital signs:
Temperature: 36.9 degree
celsius
Heart rate: 80 bpm
Respiration rate: 20 bpm
Height: 128 cm
- Assess the patient’s vital
signs and characteristics of
respirations at least every 4
hours.
- Assess the respiratory rate,
depth, and rhythm.
- Assess breath sounds and
adventitious sounds such as
wheezes.
- Teach the patient the
proper ways of coughing and
breathing.
span of care, the child
manifests better lung
- To assist in creating an ventilation and normal
accurate diagnosis and production of mucus in the
monitor effectiveness of airway. Child no longer
breathes through the mouth.
medical treatment.
He also sleeps 6-8 hours a
day. The parents also know
and understand about the
disease and treatment.
- To distinguish between
normal and abnormal
respiratory sounds and
establish the proper
diagnosis.
- The most convenient way to
remove most secretions is
coughing. So it is necessary
to assist the patient during
this activity. Deep breathing,
on the other hand, promotes
oxygenation before
controlled coughing.

Weight: 14.50 kg
Organ Involved:
Each cough occurs through
the stimulation of a complex
reflex arc. This is initiated by
the irritation of cough
receptors which are found in
the trachea, main carina,
branching points of large
airways, and more distal
smaller airways; also, they
are present in the pharynx.
An infection in the respiratory
tract can lead to
inflammation in the nasal
passage and a runny nose.
Nursing Diagnosis:
Ineffective Breathing Pattern
related to respiratory tract
infection as evidenced by - Let the patient drink plenty - To ensure that mucus in
persistent cough with phlegm of water. sinuses thins out to a runny
and irregular breathing consistency and is easy to
sound. expel.
Ineffective airway clearance
related to obstruction or
presence of thickened
secretions as evidenced by
runny nose.