III.

Presenting Problem: During our community visit, we received the patient sitting on the chair with his mother. Conscious. Upon assessment, we have noticed that the patient has flat face with upward slant to the eye, short & wide nec , small, low!set ears, flat nasal bridge . "hen we tal to the patient, we observed that he has a slurred speech but minimal. #oreover, the patient has also presented cough which might be due to poor muscle tone present to people with the so called disease $Down%s &yndrome'.

I(. )ac ground Information* +istory ,ccording to the mother of the patient, the said condition of the patient was due to peripheral blood relativity which means the mother and father of the child are close relatives, cousins perhaps. -he patient has the family history of hypertension and asthma. .n their family, he is the only one who has down%s syndrome. /urthermore, the patient%s current medication for his cough is carbocisteine 0 solmu12 syrup 3 spoon 41 a day. (. ,ssessment: (ital &igns: - 5 46.67C 8 P95 3:; bpm 995 43 cpm8 )P5 3::*6: mm+< General Appearance: Patient received is sitting on the chair, conscious and coherent, conversant and on room air. Patient%s body built is s inny. Patient was accompanied by one of his fellow neighbor. Skin: Patient , has brown s in color with normal s in turgor which might be due to old age. Patient does not have any lesions, pressure sores, open wounds or edema noted.

Hair: Upon inspection, patient has blac ish grey, thin, and coarsed hair that is evenly distributed. =o infestations were noted. =o evidences of alopecia were noted. Head: Upon Inspection, patient , has normocephalic. Closed fontanelles. =o signs of lesions noted. Patient has flat face with upward slant to the eye, short & wide nec , small, low!set ears, flat nasal bridge. Ears: . -he patient%s auricle is properly aligned with the outer canthus of the eye while his pinna recoils after it is folded. -here are no lesions, nor masses noted8 but with cerumen in the ear canal.
The ears are small with an overfolded helix

Eyes: Upon inspection, patient has symmetrically aligned eyebrows, eyelashes and eye lids. Con>ucntiva is normal. &clera is anicteric. Cornea and lens are smooth, without lesions and discharges. Pupil si?e is e@ual with measurement of Amm to the right and left eye. 9eactions to light in both eyes are bris and uniform constriction. Nose: Upon inspection, the patient%s nose has flat nose bridge but with uniform in color with the face. -here were no nasal flaring and lesions noted. )oth nares are patent. =o discharges or any obstructions were seen and assessed. Mouth: Upon inspection, patient%s lip is pin ish in color, no pallor and dryness evident in the outer lip. Patient , has dentures. <ums are pin ish in color. )uccal mucosa is pin ish. &peech is intact. =o mouth pains, bleeding gums, neither difficulty swallowing, lesions were noted. Neck: =ec muscles and head movement were intact. =o nodules were evident and non palpable.
The neck is broad and short, with excess skin on the back

Breast: Upon palpation, no masses and tenderness were present.

Abdomen: Upon inspection, abdomen was uniform in color, no lesions, masses, or scars present. &ymmetrical abdominal movements caused by respirations were noted. =o tenderness and no guarding refle1 upon light palpation. Patient stated that he has no recent bowel changes and abdominal pain. Extremities: Patient refused to be assessed because of the reason he wants to rest and sleep and not to be disturbed anymore, but patient stated that he has no bac problems, has wea ness because of his conditions. =o >oint problems were stated as said by the patient. External Genitalia: -he patient has micropenis or small genitalia. Neurological: Patient was conscious and coherent because and able to state his full name, and where he was and what time of the day. =o numbness or tingling or burning sensation reported.

(I: Intervention Plan:

=eed Problem: Cough

.b>ective with -imeframe: ,fter an hour of nursing intervention the patient will verbali?e relief from cough

Intervention: 3. <et the patient%s vital signs to have a baseline data about patient%s condition. ;. Instruct her not to suddenly stand up when e1periencing di??iness to prevent her from falls which may aggravate her condition. 4. Bncourage watcher* relative to see patient during sleep to prevent fall. C. Consult a Physician which drug can be used to treat her di??iness such as cinnari?ine which is an antivertigo.

9emar s: <oal met. ,fter an hour of nursing interventions, the patient verbali?es relief from di??iness and was able to do her basic tas s such as coo ing rice and cleaning her bed.

(II: 9ecommendations: 3. &ince the patient has financial constraints where undergoing surgery is the only possible solution, I strongly recommend the patient to as assistance to )arangay +ealth "or ers to help her finances. ;. Bncourage the )rgy. +ealth "or ers to visit remote places regularly to enhance the delivery of primary health care.