Impaired tissue integrity ASSESSMENT Subjective: May sugat ako dyan sa cast ko dyan., as verbalized by the patient.

Objective: Wound on the long leg circular cast with window. NURSING DIAGNOSIS Impaired skin integrity related to musculoskeletal trauma secondary to multiple injuries as evidenced by wound on the right leg. RATIONALE Hematoma and wound formation were due to intensive tissue damage due to the multiple physical injuries. PLANNING At the end of the shift, the patient willl be able to have understanding about proper wound care and management. INTERVENTION/S 1. Assessed the patients condition. 2. Vital signs taken and recorded. RATIONALE -To proveide baseline data about patients condition. -To note any progress or changes in patients condition. -To evaluate actual/potential impairment of circulation to the area. -Signs of infection in the area. -Prevention of infection. -For woun healing and to net needs of patient. EVALUATION Goal met. The patient was able to have understanding about proper wound care and management.

3. Assessed blood supply to the impaired area. 4.Inspected for any changes in color, size, texture and turgor. 5.Kept the area clena and dry . 6.Applied appropriate dressing to the tissue.

Ineffective airway clearance related to productive cough secondary to retained mucus secretion in the respiratory tract: ASSESSMENT Subjective: May ubo pa nga din siya ngayon, as verbalized by the mother of the patient. Objective: -wheezes noted when auscultated. -productive cough -intial RR of 35cpm -___ NURSING DIAGNOSIS Ineffective airway clearance related to productive cough secondary to retained mucus secretions in the respiratory tract. RATIONALE Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. PLANNING At the end of the shift, the patient will be able to : expectorate or clear secretions readily. demonstrate absence or reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange. and the patients mother will understand and demonstrate behaviors to improve or maintain clear airway. INTERVENTION/S 1. Established rapport with the patient and significant others. 2. Assessed the patients condition especially respiratory pattern. 3. monitored VS q4 hours. RATIONALE -To provide baseline data about patients condition. -To obtain baseline data and to monitor for respiratory distress. -To note any progress or changes in patients condition. -To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage of or ventilation to different lung segments. EVALUATION After all the nursing interventions, the patient was still having a productive cough but the patients mother understand and known the ways to manage

4. Assisted patient in the proper positioning in the bed (side lying or elevated head) 5. instructed mother to increase the OFI of the patient.

6. Instructed mother to keep clothes especially in the back area to keep clean and dry. 7. Assisted patient and mother in

-To clear/maintain

respiratory ddevices in oxygenation specifically nebulizing. 8. Performed backtapping after each nebulization of Salbutamol. 9. Provided information about the necessity of raising and expectorating secretions than swallowing them. 10. Instructed and encouraged to undergo chest x-ray.

adequate airway and improve respiratory function and gas exchange. -

11. Observed and WOF any signs of respiratory distress.

-To increase compliance in the physicians order and to note for changes in the patients condition. -For early treatment and to prevent damage.

Risk for activity intolerance related to decrease oxygenation in the body secondary to obstructed respiratory tract due to retained mucus: ASSESSMENT Risk factors: Age (infant) Deconditioned status (measles with pna) Presence of respiratory condition problem. NURSING DIAGNOSIS Risk for activity intolerance related to decrease oxygenation in the body secondary to obstructed respiratory tract due to retained mucus. RATIONALE At risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities. PLANNING At the end of the shift, the patient will be able to: participate in conditioning program or activities to enhance ability to perform. perform or maintain desired activity level. INTERVENTIONS 1. Assessed the patients condition. 2. Vital signs taken and recorded q4 hours. RATIONALE -To provide baseline data about patients condition. -To note any progress or changes in patients condition. - To identify potential problems of patients energy and ability to perform needed/desired activities. -Provides baseline for comparison and opportunity to track changes. -To maintain activity performance and to prevent/limit deterioration. -To conserve energy and promote safety. EVALUATION After nursing interventions, the patient was able to actively participate in activities to enhance ability to perform. The patient also maintain desired activity level throughout the shift. Goal met.

3. Ask client/SO about usual level of energy.

4. Determine current activity level and physical condition through observation or use of functional level classification system (Gordons). 5. Promoted appropriate conditioning activities and support such as play and comfort. 6. Instructed and encouraged to increase rest and sleep.