A PRESENTATION ABOUT

STUDY OF ILLNESS CONDITION, FAMILY

NURSING CARE PLAN, HEALTH TEACHING
PLAN AND GORDONS FUNCTIONAL
PATTERN
In Talon-Talon Health Center
GROUP 2
LEADER: IBRAHIM, FITRIA RAINACIENCE
Members:
Estoesta, Lhey Mie-Gel
Evangelio, Mark
Gagaracruz, Frauline Claire
Gulane, Eliel
Jaafar, Amina
 TODAY'S AGENDA:
Discuss the following:
Patient's Profile
Study of Illness Condition
Nursing Care Plan
Gordon's Functional Pattern
Health Teaching Plan
PATIENT'S PROFILE
Name: Adzfhar Bensar
Age: 5 months
Sex: Male
Birthday: 04/27/2022

Vital Signs:
Temp: 36 C
RR: 50 bpm
PR: 176 bpm
02 sat: 99%
Weight: 6.9 kg

Chief Complaint: Cough five days now

History: Fever

Medication: Paracetamol
STUDY OF ILLNESS CONDITION
 ASSESSMENT

SUBJECTIVE OBJECTIVE
VITAL SIGNS
CUES: CUES:
- The mother verbalized, - Irritated Temp: 35.6 C
“Nag-uubo kasi siya mga 5 RR: 50 bpm
days na biyaun. Mabuggat in HR: 176 bpm
pag-ubo niya biya di niya O2 sat: 99%
maguwa in plema niya.” Weight: 6.9 kg

ANATOMY PHYSIOLOGY

RESPIRATORY SYSTEM
The lungs and respiratory
system allow us to breathe.
They bring oxygen into our
bodies (called inspiration, or
inhalation) and send carbon
dioxide out (called expiration,
or exhalation). This exchange
of oxygen and carbon dioxide
is called respiration.

PATHOPHYSIOLOGY A cough is your body's way

of responding when
something irritates your
throat or airways. An
irritant stimulates nerves
that send a message to
your brain. The brain then
tells muscles in your chest
and abdomen to push air
out of your lungs to force
out the irritant.
 The mother verbalized,
ANALYSIS “Nag-uubo kasi siya mga 5
days na biyaun. Mabuggat
in pag-ubo niya biya di niya
maguwa in plema niya.”
A cough is a reflex that expels air from our
airways. It’s our body’s way of helping to
clear our airways of irritants like dust,
mucus, and germs. Coughs come in a
variety of forms. For example, you may see
coughs referred to as either productive or
nonproductive. A productive cough is a
cough that brings up mucus or phlegm,
while a nonproductive cough is dry.
PRIORITIZE WORK- Encourage everyone to set
boundaries so they can
LIFE BALANCE spend time with their
families, etc.
ENCOURAGE OPEN Make sure there is good
communication between
CONVERSATIONS management and staff.
 PATHOGENESIS
AND
LIFE - THREATENING PATHWAY
NURSING CARE PLAN
ASSESSMENT

Subjective cues:
- The mother verbalized, “Nag-
uubo kasi siya mga 5 days na
biyaun. Mabuggat in pag-ubo
niya biya di niya maguwa in
plema niya.”
NURSING CARE PLAN ASSESSMENT
Objective cues:

Irritated
Vital Signs:
Temp: 35.6 C
RR: 50 bpm
HR: 176 bpm
O2 sat: 99%
Weight: 6.9 kg

Chief Complaint:
“ Cough five days now with fever, phlegm
can’t expectorate”
NURSING DIAGNOSIS
Ineffective Airway
Clearance related to
copious bronchial
secretions as
evidenced by failure to
expectorate (clear
airway secretions).
OBJECTIVE OF CARE At the end of 8 hours
nursing intervention, the
patient will be able to:

maintain adequate
respiration and clear airway

Have a greater air exchange

Decrease presence of nasal

discharge
 Establish rapport
INTERVENTIONS To develop cooperation and
INDEPENDENT: trust of the client.

Monitor vital signs

To obtain baseline data.

Position the patient upright if tolerated.

Regularly check the patient’s position to
prevent sliding down in bed.
Upright position limits abdominal contents
from pushing upward and inhibiting lung
expansion. This position promotes better
lung expansion and improved air exchange.
INTERVENTIONS Use pulse oximetry to monitor oxygen
saturation; assess arterial blood
INDEPENDENT: gases (ABG’s)
Pulse oximetry is used to detect changes in
oxygenation. Oxygen saturation should be
maintained at 90% or greater. Alteration in
ABGS may result in increased pulmonary
secretions and respiratory fatigue.

If coughing is unsuccessful, perform

nasotracheal suctioning as needed.

Suctioning is necessary when patients

cannot cough out secretions properly due to
weakness, thick mucus plugs, or extensive or
tenacious mucus production.
INTERVENTIONS
INDEPENDENT:

Educate parents in suctioning

techniques. Provide opportunity for
return demonstration. Modify
techniques for home setting.

This promotes safe and effective removal of

secretions from the airway.
 Give medications as prescribed, such
as antibiotics, mucolytic agents,
INTERVENTIONS bronchodilators, expectorants, noting
DEPENDENT: effectiveness and side effects.

A variety of medications are prepared to

manage specific problems. Most promote
clearance of airway secretions and may
reduce airway resistance.

Refer to the pulmonary clinical nurse

specialist, home health nurse, or respiratory
therapist as indicated.

Consultants may be helpful in ensuring that

proper treatments are met.

COLLABORATIVE:
 Established rapport by playing or
singing songs to the pediatric
IMPLEMENTATION client.

Monitored vital signs every 4 hours

to know if there are changes in the
patient’s situation.

Positioned the patient in an upright

position and frequently changes
especially when the patient will slide
down the bed.
Used pulse oximetry to monitor 3
times a day, the same time every
day to assess the ABG.
 Performed nasotracheal suctioning if
needed.
IMPLEMENTATION
Gave Health teaching/Education to
the parents or mother in suctioning
techniques, and gave them the
opportunity to do it after.

Gave prescribed medications as

prescribed and documented the
effectiveness and side effects.

Referred the patient and the mother

to a clinical nurse specialist, home
health nurse, or respiratory therapist
as indicated.
 After the 8 hours of nursing
EVALUATION: interventions, the patient
was able to:
Maintained adequate
respiration and a clear
airway through the mother’s
efforts by following the
interventions advised. (GOAL
WAS MET)
Had a greater air exchange
(GOAL WAS MET)
Decreased presence of nasal
discharge.(GOAL WAS MET)
NURSING CARE PLAN #2 ASSESSMENT
Objective cues:

Irritated
Vital Signs:
Temp: 35.6 C
RR: 50 bpm
HR: 176 bpm
O2 sat: 99%
Weight: 6.9 kg

Chief Complaint:
“ Cough five days now with fever, phlegm
can’t expectorate”
NURSING DIAGNOSIS

Ineffective breathing
pattern related to
respiratory tract
inflammatory process as
evidenced by persistent
cough with phlegm and
increased respiratory
rate
OBJECTIVE OF CARE At the end of 4 hours
nursing intervention, the
patient will be able to:

exhibit an effective
breathing pattern

Maintain respiratory
rate within established
limits
 Assess vital signs as needed.
INTERVENTIONS provide information about changes that
INDEPENDENT: can reveal respiratory compromise early.

Assess the characteristics of sputum.

Secretions can be a contributing factor
to breathing pattern changes.

Place patient with proper body alignment.

A sitting position permits maximum lung
excursion and chest expansion.
 Allow the patient to have enough
INTERVENTIONS relaxation intervals
INDEPENDENT: Continuous sobbing raises oxygen
demands, and respiratory muscle fatigue
can exacerbate airway blockage.

Educate the family on proper feedings

to achieve effective breathing.
This prevents crowding of the
diaphragm.

Educate family on home care

Proper home care is encouraged for fast
recovery as drugstore cold or cough
medicines are not approved by the FDA for
pediatric patients under 6 years of age.
IMPLEMENTATION
Monitored vital signs as needed and noted the respiratory rate, depth,
and breathing effort every 4 hours.

Assessed the amount, color, consistency and odor of the sputum.

Positioned patient in upright position leaning on the parent’s torso for

support to maximize breathing pattern.

Emphasized to the family the value of cuddling to keep the child

comfortable. and relaxed.
IMPLEMENTATION
Educated the family on giving small frequent feedings.

Educated family on home care and cough and colds remedies

appropriate for patient’s age. Instructed the family to offer plenty of
fluids, use of saline drops and proper positioning.
EVALUATION
After 4 hours of nursing
intervention, the patient:

Exhibited an effective
breathing pattern with
relaxed breathing at normal
rate and depth

Maintained respiratory rate of

40 bpm
11 GORDON'S FUNCTIONAL PATTERN
ASSESSMENT
HEALTH PERCEPTION/MANAGEMENT HEALTH PATTERN
CLIENT’S HEALTH HISTORY: THE CLIENT STARTED COUGHING ACCOMPANIED WITH FEVER

FIVE DAYS AGO.

CLIENT’S PRESENT CONDITION: THE CLIENT COUGHS AT LEAST EVERY 5 MINUTES. HE

ALSO CRIES EASILY AND LOOKS QUITE IRRITABLE.

ELIMINATION
MOTHER VERBALIZED, “WAY MAN SIYA PROBLEMA A IHI PATI TAE NIYA MA’AM.”
CHILD'S MOTHER SAID THAT THERE WERE NO PROBLEMS WITH THE CHILD’S ELIMINATION.

ACTIVITY - EXERCISE
- “AWN SIYA UBO 5 DAYS NA. SIPON-SIPON DIN.”
- “MINSAN BIYA WAY SIYA ENERGY YAUN ANAK SAH MAKAPANAYAM PA RIN SIYA SIN

PANAYAMAN NIYA. MAG-UBO UBO LANG."

THE PATIENT’S CHILD HAS BEEN COUGHING WITH MUCUS FOR 5 DAYS ALREADY. THE

CHILD CAN PLAY, HOWEVER, HE IS SOMEWHAT TIRED.

SLEEP-REST
“DI MAKATUG MARAYAW ANAK KO. MINSAN MAKABATI PASAL

MAG-UBO."
PATIENT CANNOT SLEEP PROPERLY DUE TO COUGHING.

ROLE - RELATIONSHIP
- THE CLIENT IS THE FIRST CHILD IN THE HOUSEHOLD CONSISTING

OF HIS MOTHER AND FATHER.

VALUE - BELIEF
- THE CLIENT’S RELIGION IS ISLAM.
ASSESSMENT OF LEARNING NEEDS
 LEARNING NEEDS
Knowledge on cough and colds
prevention
Knowledge on proper treatment of cough
and colds

 READINESS TO LEARN
P (Physical Readiness)
Measure ability: The client’s mother can easily comprehend asked questions
and statements.
Complexity of task: The task can be considered easy with the right
instructions which include a follow through of step by step procedures.
Health Status: The client’s mother is a healthy adult.
Gender: Female (client’s mother)

E (Emotional Readiness)
Anxiety Level: The client’s mother did not show any signs of anxiety upon
interaction, but appropriate worry is shown in her face.
Support System: The client’s mother together with his father served as a
support system.
Motivation: The client’s mother is cooperative and responsive regarding
questions about the client’s condition.
Frame of Mind: The client’s mother intends to obtain appropriate knowledge
about cough and colds prevention and proper treatment for said conditions.
Developmental Stage: Generativity vs Stagnation; Conventional

E (Experimental Readiness)
Level of Aspiration
Short-term: To obtain knowledge regarding cough and colds

prevention
Long-term: To avoid frequent recurrence of cough and colds
Locus of Control: The client’s mother seems to demonstrate

willingness and determination to widen her knowledge.

K (Knowledge Readiness)
Present Knowledge: The client’s mother has little idea regarding

cough and colds and needs further in-depth information.

Cognitive Ability: The client’s mother can read and write, and

understand simple cause and effect. Additionally, she can speak

her mind regarding thoughts on the disease condition.

 LEARNING STYLES
The client’s mother prefers visual and

tactile learning styles.

The client’s mother can engage in a one

on one discussion.

HEALTH TEACHING PLAN

 GOAL
At the end of the 15 minutes nursing health
teaching plan, the client’s mother will be
able to acquire and carry out the
knowledge and techniques obtained from
the discussion to achieve promotion and
maintenance of the client’s airway and
breathing pattern.
 PURPOSE
Provide knowledge for the significant
other (parent) regarding the patient’s
manifestations and current condition
Prevention of the manifested signs and
symptoms of the client to further
progress
Promotion of respiratory wellness
 GOAL
At the end of the 15 minutes nursing health
teaching plan, the client’s mother will be
able to acquire and carry out the
knowledge and techniques obtained from
the discussion to achieve promotion and
maintenance of the client’s airway and
breathing pattern.
OBJECTIVES AND SUBOBJECTIVES
KNOWLEDGE

A. Educate about the current

manifestations of her child: common cold

B. Determine the etiology of common

C. Determine hallmark signs and symptoms

of cough and colds

D. Determine prevention measures of

having common colds
 COURSE OUTLINE 3 mins

Definition of common colds; Illness epidemiology

A common cold is a viral infection of the baby's nose and throat.
The common cold is an infection of the nose and throat (upper
respiratory tract infection). Babies are especially likely to get the
common cold

Illness etiology
Can be caused by one of more than 200 viruses. Rhinoviruses are
the most common. The rhinovirus is spread through the air by
coughing and sneezing, close personal contact, and by touching
contaminated surfaces and objects.
DISCUSSION
 3 mins
Risk Factors
Immature immune systems.
Exposure to other children.
Time of year.

Common cold hallmark signs

First s/sx
congested/runny nose
nasal discharge clear at first but may thicken and turn yellow green

other s/sx
Fever, Sneezing, Coughing, Decreased appetite, Irritability, Difficulty sleeping.

DISCUSSION
 3 mins

Prevention of common colds

Keep the baby away from anyone who's sick: no visits yet, avoid public
places
Wash hands before feeding or touching the baby: wash hand for 20 secs
with soap and water; can use alcohol. teach any older children to handwash
Clean the baby's toys and pacifiers often. Clean frequently touched
surfaces.
Teach everyone in the household to cough or sneeze into a tissue: throw
tissues and wash hands

DISCUSSION
OBJECTIVES AND SUBOBJECTIVES
PHYSICAL

A. Encourage to increase fluid intake

(breast milk/milk formula)

B. Encourage to suctioning of child’s nose

C. Encourage to provide moistened air in

the room

D. Encourage the child to rest often and

limit activities.
 COURSE OUTLINE 10 mins

Increase fluid intake

Fluids help minimize mucosal drying and maximize ciliary action to move

secretions.

How to suction child’s nose and purpose

It is normal for a baby’s nose to get congested (stuffed up) from time to
time. When this happens, mother can use nasal saline to thin their mucus
and then suction it out with a bulb syringe. Suctioning mucus out of the
nose makes it easier for them to breathe, suck, and eat. Do this before
feeding them, but only if they seem congested.
DISCUSSION/ELABORATION
 COURSE OUTLINE 10 mins
How to suction child’s nose and purpose
To use the bulb syringe, squeeze the air out of the bulb. Keep the bulb
squeezed.
Gently place the tip of the squeezed bulb into a nostril.
Let go of the bulb to let the air back into it. This will pull the mucus out of
the nose and into the bulb.
Squeeze the mucus out of the bulb and onto a tissue.
Suction the other nostril the same way.
If mucus is too thick to suction, you can thin it with saline or prescribed
respiratory drops
Gently wipe off the mucus around the baby’s nose with tissues to prevent
irritation.
Limit suctioning to no more than 4 times each day to avoid irritating the
nose. DISCUSSION/ELABORATION
 10 mins

How to provide moistened air in the room and its purpose

Increasing humidity of inspired air will reduce thickness of secretions

and aid their removal.

Run a dehumidifier, use exhaust fans, open a window (if the air

outside is dry), keep doors closed, and take shorter showers to

lower humidity.
Run a humidifier, place a bowl of water close to a heating

system, let your laundry air dry, and get houseplants to increase

the humidity.

DISCUSSION/ELABORATION
 10 mins

Importance of resting and activity limitations.

Fatigue is a contributing factor to ineffective coughing.

Effective coughing requires enough energy and may

consume an extra effort to the patient.

DISCUSSION/ELABORATION
OBJECTIVES AND SUBOBJECTIVES
ATTITUDE

A. Express freely any other concerns and

feelings regarding the information given
from the teaching session.
 COURSE OUTLINE 2 mins

Expression of feelings

Questions or queries

DISCUSSION
RESOURCES
Pamphlet

METHOD OF EVALUATION
Question and Answer
ANY QUESTIONS?
 THANK YOU!
If you need help or are looking for mental health support and
resources, feel free to approach me after this presentation.