Patient’s Name: Baby L.

A
Age: 1 year old
Diagnosis: Measles with Pneumonia
Assessment Nursing Planning Implementation Rationale for Evaluation
Diagnosis Goal and Nursing
Objective Intervention

Objective : Acute pain related After 30 min. of Independent: After 30 min of

T- 36.9 to presence of nursing nursing
P- 150 bpm skin rash as intervention the • Monitor V/S - to provide intervention the
R- 55cpm evidenced by patient will be including I and baseline data goal was met as
BP- distraction free from O evidenced by
90/60mmHg behaviour. discomfort • Provide - to calm and patient’s pain
caused by pain comfort soothe the patient scale was
- guarding and clients pain measures such from pain decrease from
bahavior scale will as deep 4/10 to 1/10
- restlessness decrease from breathing
- crying 4/10 to 1/10 exercise
P- warm • Encourage - to divert patients
Q- burning diversional attention
R- anywhere activities ( play
S – 5/10 with the
T - intermittent patient)
• Provide - to promote non
comfort pharmacological
measure management of
( touch, use of pain
hot/cold
compress)
- to prevent fatigue
• Encourage
adequate rest
periods

Dependent:
administer drug
as ordered: - inhibits bacterial
Gentamycin synthesis.
40mg OD

- promotes good
Vitamin A eye sight

-for viewing of the

Collaborative: lungs
CXR
Patient’s Name: Baby L.A
Age: 1 year old
Diagnosis: Measles with Pneumonia
Assessment Nursing Planning Implementation Rationale for Evaluation
Diagnosis Goal and Nursing
Objective Intervention

Objective : Risk for infection After 30 min. of Independent: After 30 min of

T- 36.9 related to nursing nursing
P- 150 bpm inadequate intervention the • Monitor V/S - to provide intervention the
R- 55cpm primary defense patient’s parent including I and baseline data goal was met as
BP- as evidenced by will be able to O evidenced by the
90/60mmHg traumatized identify ways to • Assess and - to asses causative patients parent
tissue. reduce the risk document skin factors was able to
- presence of for infection. condition identify ways to
rashes • Stress proper - to reduce risk for reduce the risk for
- desquamation hand hygiene infection infection.
- traumatized • Provide - reduced risk of
tissue isolation as cross contamination
- crying indicated
• Instruct daily - to reduce bacterial
mouth care colonization
- to provide
• Increase fluid
adequate hydration
intake
• Emphasize -premature
necessity of discontinuation of
 taking treatment when
antibiotics/anti client begins to feel
viral as ordered well may result in
return of infection.

- to promote
• Promote wellness
childhood
immunization
program

Dependent:
administer drug
as ordered: - inhibits bacterial
Gentamycin synthesis.
40mg OD
- promotes good
Vitamin A eye sight

Collaborative: -for viewing of the

CXR lungs
 HEALTH TEACHING PLAN
Objective Content Methodology Evaluation
General Objectives:
After 1 day of
varied learning
activities, the
significant others or
family will be able
to acquire
knowledge, attitude
and skills on
preventing
complications of
the condition of
their Baby.

Specific Objectives:
After 45 minutes
of teaching, the
patients significant
other or family will
be able to:

1. explain the goals

of frequent position Positioning (Goals) Informal -the patients relative
changes. * prevent thrombophiebitis discussion was able to explain the
and pulmonary embolism. goal of frequent
* promote lung expansion position changes and
and prevent complications was motivated to
from pneumonia perform the different
* changing position from positions to become at
lying to sitting several times ease from pain or any
a day can help prevent discomfort felt
changes in the CVS known
as deconditioning.
*the recommendation is to
change body position at least
every 2 hours, and preferably
more frequently in patients
who have no spontaneous
movement.

2. discuss the Therapeutic Exercises

different 1. Deep breathing exercise. Informal -the patient’s parent
therapeutic 2. Diversional activities discussion was able to discuss the
exercises and different therapeutic
demonstration exercises and was able
to demonstrate them
with assistance

3. Importance of
hand washing and
proper hygiene

4. Importance of
Immunization
Program

M edication
E xercise
T reatment
H ealth
O PD
D iet
S afety

Medication:
• Teach significant others about prescribed medication including action,
dosage, frequency of administration and side effects.
• Administer pharmaceutical agents, as indicated (pain relievers/
analgesics, nonsteroidal anti-inflammatory drug and antibiotic.)
• Review list of side effects and potential interactions with other OTC
drugs.
• Emphasize necessity of taking antivirals/antibiotics as directed
premature discontinuation of treatment when client begins to feel well
may result in return of infection and potentiate drug resistant strain.

Exercise:
Teach parents of Patient; mild exercises ( walking)

Treatment:
Procedure or Time Frequency Duration
Treatment
Proper wound care
technique. After taking a No standard Until the rashes
performing hand bath and before frequency for how healed and skin is
hygiene sleeping. often intact.
thoroughly in
adhering to
standard
precaution.
Monitor rashes
incision for S/S
of infection.

Health:
• Provide significant others with information regarding clients condition.
• Teach family members the importance of good hygiene and grooming.
• Review etiology and possible coping behavior.
• Review environmental factors that may require avoidance/modification
of lifestyle or environment to limit impact on the healing process.
• Importance of immunization program adheres on the standards.
• Taking of Nutritious and healthy foods to increase resistance.

OPD:
Instruct significant others to return to hospital for follow up checkups and if there
is any adverse effect after released from the hospital.
Diet:
Teach family members about the importance of drinking large amount of water.
Inform family members that eating a well balances meal each day will make the
body healthy, provide growth of tissue, boost the immune system, and make
the body stronger and healthier.
Safety:
Instruct client and family members about relaxation techniques and to keep
patient away from any dangerous surrounding.
Always secure for the safety of the client and understand her condition.
V. Evaluation

Prognosis of the patient

After 1 day of intervention, the student nurse observed certain changes from the
patient. The patient articulated decreased pain. The patient also exhibits unlabored
respirations; appear weak and tired, afebrile, v/s stable; urine output adequate. The patient
also performs active ROM correctly. The patients has no marked of respiratory distress.