Assessment S> Hindi pa pumuputok ung ubo ng anak ko medyo dry pa as verbalized by the patients mother O> Received

d px awake, alert, coherent,wheezing sounds noted upon auscultation on right upper lung field,unproductive cough noted V/S:BP: 110/50 T:36.5*C P:97 R:19

Diagnosis Ineffective airway clearance related to retained mucus secretion as evidenced by wheezing sounds on upper right lung field

Planning After 8 hours of nursing intervention the client will be able to demonstrate reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange.

Intervention -Provide safe environment by raising side rails -Encourage increase in water intake -Back pat to loosen secretions -Assist in nebulizing the patient -Encourage deep breathing and coughing exercise -Assist in giving meds -Position in Fowlers position to promote airway

Evaluation After 8 hours of nursing intervention the client was able to demonstrate reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange.

Assessment S> Paputol-putol yung tulog nya dahil may nurse at doctor na lagging nagchecheck sakanya as verbalized by the patients mother O> Received patient

Diagnosis Disturbed sleep pattern related to caregiving responsibilities as evidenced by verbalization of S.O

Planning After 8 hours of nursing intervention the client will be able to report increase sense of well-being and feeling rested

Intervention -Identify factors known that interfere with sleep including present illness -Note environmental factors, such as unfamiliar or uncomfortable room,excessive noise or light,etc

Evaluation After 8 hours of nursing intervention the client was able to report increase sense of well-being and feeling rested

awake,alert,coherent, shows signs of restlessness, mild eye bags noted V/S:BP: 110/50 T:36.5*C P:97 R:19

-Listen to reports of quality of sleep -Provide more pillows for comfort -Adjusted room temp to the patients desired room temp -Provided safe environment by raising side rails Diagnosis Disturbed energy field related to slowing or blocking of energy flows secondary to pathophysiological factors Planning After 8 hours of nursing intervention the client will be able to verbalize feelings of relaxation and well- being Intervention Identify factors known that interfere with sleep including present illness -Note environmental factors, such as unfamiliar or uncomfortable room,excessive noise or light,etc -Listen to reports of quality of sleep -Provide more pillows for comfort -Adjusted room temp to the patients desired room temp -Provided safe environment by raising side rails Evaluation After 8 hours of nursing intervention the client was able to verbalize feelings of relaxation and wellbeing

Assessment S> Dahil sa sakit niya medyu nanghihina siya pero nakakagalaw pa naman siya O> Received px awake, alert, coherent, restlessness, mild eye bags noted, slow movement during assessment V/S:BP: 110/50 T:36.5*C P:97 R:19