I. Personal DataI. Personal Data

Name of the Child: Yoyo Potter

Date of Birth: June 3, 2007Age: 3 years old

Place of Birth: Mariano Marcos Memorial Hospital and Medical Center

Weight: 17 kilogramsHeight:89 cm

Name of Parents: • Father: Papa G, Sr

Age: 35 years old

Occupation: Instructor

• Mother: Mama C

Age: 27 years old Occupation: FILD VIP Services

Status: Married

Religion: Catholic

Monthly Income: 24,000 pesos

Family BackgroundName Age Civil Status Sex Educ. Background Place

Papa G, Sr 35 yrs. Old Married Male BS in Com Sci Brgy. 12, Laoag City

Mama C 27 yrs. Old Married Female BS in Com Sci Brgy. 12, Laoag City

Yeye 5 yrs. Old Single Female Kinder II Brgy. 12, Laoag City

Yoyo 3 yrs. Old Single Male Preparatory Brgy. 12, Laoag City

Pcos, Jr 4 mos. Old Single Male - Brgy. 12, Laoag City

Yoyo Potter, 3 years old, living with his family at Barangay 12 Herbosa Street,Laoag City. They are five in the family and he is the second child of Papa G, Sr and Mama C. His siblings are Yeye, 5 years old a Kinder II pupil of Kids Kollege and Pcos, Jr, 4 months old. His father is presently working at Data Center College of the Philippines as Computer Instructor and his mother is presently working at Fort Ilocandia as FILD VIP Servicer.

• Date of Interview: September 16, 2010

II. Health History

Yoyo Potter sometimes experience fever, cough and cold. According to his father, they always consult their Doctor at Provincial Hospital for immediately treatment in their sickness and to avoid in becoming serious. The Doctor usually prescribed them paracetamol to alleviate the temperature of the child. He and his siblings also take their vitamins everyday which are ascorbic acid, vitazinc and propan to supplement their health needs. He and his siblings also practice proper nutrition and drinks plenty of water to avoid future illness. He also received immunizations upon birth which are BCG, OPT, OPV, Hepa B, Measles and A H1N1.

Immunizations:Vaccine Date Dosage

BCG June 3,2007 1

DPT July 4, August 5, September 6, 2007 3

OPV July 4 , August 5, September 6, 2007 3

Hepa B June 3, July 4, August 5, 2007 3

Measles March 5, 2008 1

A H1N1 August 19, 2010 1

III.Factors Affecting Growth and Development

-Heredity/Genetics:Analysis on Effects of Growth and Development

Renaldo Ruiz56 yrs.

old

Mama C27 yrs.

old

Perlita Ruiz

55 yrs. old

Yeye Potter5 yrs.

old

Yoyo Potter3 yrs.

old

Pcos Potter, Jr4 mos.

old

Papa G, Sr

35 yrs old#

Antonia Potter69 yrs.

old

Cesar Potter

+

Yoyo looks like his father. He always treat the people in the house with respect when he communicate such as adding lolo, lola, mama, papa, tito, tita, manong and manang in his sentence to those who are elder than him. He also has the sense of humor to make his relatives to smile by acting like an old man. Yoyo inherit the talent of his father which is singing. His father teaches Yoyo to sing.

Yoyo’s ancestor doesn’t have any history of diabetes and asthma. His grandfather at father side was already dead and according to his father, Yoyo’s grandfather died when his father was still young and he doesn’t know the reason why. Yoyo’s father has a history of hypertension.

Analysis:

The only noted heredity disorders in our clients is hypertension which is present to his father. Other than that, there is no noted factor related to genetics that could interfere our clients growth and development.

Environment: Place, People and Neighborhood

Potter family is from Brgy. 12, Herbosa Street, Laoag City. They are living in a simple way with semi concrete house. They are nuclear family with 2 maids.

Upon entering gate of the house, we saw how clean it was. The plants were properly arranged, and there were no scattered garbage seen. Near the house, there is deep well with a concrete cover. Inside the house, there is a stair with handle. In their backyard, there are fruit bearing trees like guavas and bananas. There is also a storage room for old materials such as metals, old appliances and carpentry tools. Near the fence, there is a compost pit for biodegradable garbage only and there are sacks near the fence which are intended for recycled materials such as plastic bottles, cans, and containers. They have also poultry and 2 dogs. It is also clean and the animal is also well-fed. The child together with his playmate plays in their basketball court. Near the court is a nipa hut with 2 swings which they use during siesta hours.

There is also a radio for entertainment but the outlet can be reach by the children during playtime.During his dinner, He ate a half cup of rice, 1 piece of fried chicken, dinengdeng, 1 banana and a glass of water. And at night he takes 1 tbsp. in every vitamin which are ascorbic acid, vita zinc and propan which is good for his health.

On the other side, their neighbors are their relatives. Their surroundings are also clean, peaceful and there is no scattered dogs and cats which may harm the child.

Analysis:

They are aware of the environmental effect to their child’s growth and development that’s why they always maintain their place clean and orderly for their safety. Their neighbors also have a good relationship like letting the child play together with his playmates to develop their child's social relationship and adopt himself to environment.

- Health: Present Health StatusYoyo is presently experiencing non

producting cough and colds, but according to his father, he takes his medicine regularly to cure his sickness and vitamins everyday to supplement their health conditions. And when Yoyo have an illness, they immediately consult their Doctor for check-up. He sleeps from 8 pm to 6 am. He sleeps 10 hours everyday. Yoyo always take a bath in the morning and his parents also secure the hygiene of the child before sleeping. He also practices hand washing after playing in the court, before and after eating.

Body Mass Index

BMI= weight in kilogram height in meter²=17Kg .7921 m²=21.46

Analysis:

Proper hand washing and adequate rest and sleep helps the child to grow healthy and physically fit.

Nutrition:1 Day Recall of the Meal

Breakfast 6:40-7:10 ½ cup of rice

Noodle soup

Hotdog

½ hardboiled egg

A glass of milk

Snack 9:30-10:00 Cupcake

Pineapple juice

Lunch 11:45-12:10 ½ cup of rice

Adobo

Pinakbet

1 slice of watermelon

A glass of water

Dinner 7:00-7:30 ½ cup of rice

Fried chicken

Dinengdeng

1 banana

A glass of water

Yoyo’s parents always supervise the food that he is eating every day. He must avoid eating junk foods and drinking soft drinks because it will affect his appetite and it is not good for his health. He is recommended to drink milk and eat fruits and green leafy vegetables, meat, fish and cereals which are rich in vitamins, protein, iron, carbohydrates, calcium and other important nutrients which are helpful in the growth and development of the child. On his breakfast, he take ½ cup of rice, ½ hardboiled egg, hotdog and a glass of milk to gain energy to use for his activity. He drink a glass of pineapple juice and a cu[cake for his snack at the time of 9:30-10:00 and during his lunch, he take a ½ cup of rice, adobo/fried fish with a dish of pinakbet, a glass of water and a slice of watermelon as his dessert.

During his dinner, He ate a half cup of rice, 1 piece of fried chicken, dinengdeng, 1 banana and a glass of water. And at night he takes 1 tbsp. in every vitamin which are ascorbic acid, vita zinc and propan which is good for his health.

Yoyo loves to eat fried chicken, sinigang and string beans. His favorite snack is choco tops and spaghetti. He doesn’t have any allergy.

Analysis:

The child is properly guided to his health and he is not choosy to the foods that are being served.

Socio-economic Status: Income of the Family,

Expenses

Based on the gathered data, the parent of the child divides their monthly income to food, savings, miscellaneous and expenses. 50% goes to food (marketing and grocery every week) which is 12000 pesos. 20% goes to expenses ( for the monthly payment of electricity, water and telephone bill) which is 4800 pesos. 20% goes to miscellaneous (allowances, tuition fees, salary of the maid and for emergency cases) which is 4800 pesos. 10% goes to their savings which is 2400 pesos.

Analysis:

The income of the family is able to satisfy their needs. The family prioritize their health. Therefore the growth and development of the child is continuously developing.

- Family Structure: Ordinal Position, Family Structure

• Yoyo and his family are living at his father’s family house together with their relatives. They live with peace and love to everyone. Yoyo’s parents priorities their education and health. They spend to much time with each other during weekend happily, sometimes they also go to mall to have fun and unwind. Every Sunday, they always go to church to thank, pray and worship the Lord. Yoyo is much closer to his father because his father is always at his side when his mother was still working at Pampanga. They go to Marcos Stadium every afternoon such as jogging, playing basketball together with his cousins. Yoyo mingle himself to everyone inside the house. His parents inculcated them the good values that a child must possess, such as showing respect especially to elder people.

Analysis:

The child is much closer to his father because his father is always at his side when his mother is still working at Pampanga to work there because the child is longing for the love, affection and presence of his mother.

Prenatal Influence: Lifestyle and Behavior of the Mother during

Pregnancy When his mother was pregnant, she

doesn’t experience any illness at all. His mother has her monthly check-up to secure the baby. His mother always took good care of him when he was still in his mother’s womb. She ate nutritious food to make the baby healthy as well as her condition such as food rich in protein, calcium, vitamins, iron and many more nutritious foods. His mother always follow the traditional Filipino beliefs and practices such as taking a bath every morning and sleeping in the afternoon is prohibited because she might be experiencing edema and etc. during his 9th month, his mother delivered him through cesarean section at Mariano Marcos Memorial Hospital and Medical Center. He was born as healthy, completely and well baby.

Analysis:

The mother did not experience any illness during her pregnancy. She was aware and she cares for the child (Yoyo) inside her womb. That’s why she ate nutritious foods and had a prenatal check-up every month. Therefore the child delivered normal and healthy.

Culture and Race

The child grows with love and care from his parents. Being a Catholic, his parents inculcate to his mind about the teachings of God like going to church, praying and respecting elder people. The child parents are both Filipino and he has a brown skin, black hair and with his age, his height and weight is normal. Therefore the child is not prone to skin cancer.

Analysis:

The child’s parent secure that the child will grow good and has a fear of God. Being a Filipino citizen, he is not prone to cancer.

III. Developmental Milestone

Sigmund Freud Theory

During the anal stage, Freud believed that the primary focus of the libido was on controlling bladder and bowel movements. The major conflict at this stage is toilet training. The child has to learn to control his or her bodily needs. Developing this control leads to a sense of an accomplishment and independence.

According to Freud success at this stage is dependent upon the way in which parents approach toilet training. Parents who utilize praise and rewards for using the toilet at the appropriate time encourage positive outcomes and help children feel capable and productive. Freud believed that positive experiences during this stage served as the basis for people to become competent, productive and creative adults.

However, not all parents provide the support and encouragement that children need during this stage. Some parents instead punish, ridicule or shame a child for accidents. According to Freud, inappropriate parental responses can result in negative outcomes.

Task under this stage includes:Toilet training- The child is able to

defecate without any assistance from his parents.

Analysis:• The child is able to achieve the task

which is the toilet training.

Erik Erickson TheoryErickson envisioned life as sequence of levels

or achievement. Each stage signals a task that must be achieved. The resolution of the task can be complete, partial or unsuccessful. Erickson believes that the greater the task achieve, the healthier the personality of a person. Failure to achieve the task influences the person’s ability to achieve the next task.

Erickson emphasizes the people must change and adopt their behavior to maintain control over their lives. In his view, no stage in personality development can be by passed, but people can be fixated at first stage or regress to a previous stage.

Under Erickson and stage of development, client is under “early childhood”. Its central task is “autonomy vs. shame and doubt”. Indication of positive resolution includes child gains control over eliminated functions and motor abilities, they begin to explore their surroundings.

While self-consciousness, over control ad over restriction own activities are the indication of negative resolution, which lead to shame and doubt if achievement is impossible.

A task under this stage includes:Toddlers become capable of

satisfying some of their own needs- The child knows how to feed himself, wash and dress, and use the bathroom.

Under Personal and Social Independence he positively showed:

• Plays interactive games• Buttons up• Uses spoon spilling little• Puts on clothing• Washes and dries hands• Dresses with supervision• Separates from mother easily• Dresses without supervision• Removes garment• Helps in house simple task

Analysis:

The child was able to achieve most tasks of his age, but some of which were not achieved however the child still have the chance to achieve it until he reach 5 years of age.

Jean Piaget TheoryThe pre-operational stage occurs between

ages two and six. Language development is one of the hallmarks of this period. Piaget noted that children in this stage do not yet understand concrete logic, cannot mentally manipulate information, and are unable to take the point of view of other people, which he termed egocentrism.

During this stage, children also become increasingly adept at using symbols as evidenced by the increase in playing and pretending. For example, a child is able to use an object to represent something else, such as pretending a broom is a horse. Role playing also becomes important during the pre-operational stage. Children often play the roles of “mommy”, ”daddy”, ”doctor” and many others.

Task under this stage includes:• Vocabulary and comprehension- The child is able

to recall the previous event or story.

Under Language some were positively achieved such as:

• Points to one named body part• Names 1 picture• Follows direction• Uses plurals• Gives 1st and last name

Analysis:The child was able to pass the

tasks given except the “opposite analogies”. Even though he failed to do the task it doesn’t mean he is delay because the task given is advance at his age.

Lawrence Kohlberg Theory

He focuses on the way children gain knowledge of right and wrong conducts. In stage 1 which is Obedience and Punishment, the earliest stage of moral development is especially common in young children, but adults are also capable of expressing this type of reasoning. At this stage, children see rules as fixed and absolute. Obeying the rules is important because it is a means to avoid punishment. And the second stage is Individualism and Exchange, at thus stage of moral development, children account for individual points of view and judge actions based on how they serve individual needs. In the Heinz dilemma, children argued that the best course of action was the choice that best-served Heinz needs. Reciprocity is possible, but only if it serves one’s own interests.

• Task under this stage includes:• Able to determine right and wrong

actions- The child knows how to differentiate right and wrong conducts.

Example:When the child wants to go with his father, his father always tell to his son that “agbati ka ah ta igatangan kanto ti jollibee’m” and the child answered “wen papa, kiss ko latta ngaruden”.

Analysis:The child was able to achieve

the tasks given and someday he might be a good boy, loyal and obedient person as he knows what is right and what is wrong.

Robert Havighurst TheoryA development task is a task which arises at

or about a certain period in the life of the individual, successful achievement of which leads to his happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks.

According to the theory of developmental tasks the mastery of a developmental task leads to happiness and increases the probability of competence in the following tasks. This theory may be the roof under which theories of life crises, continuity, stress, learned helplessness, and socialization may be specific models to explain satisfaction and/or competence in managing developmental tasks. -- By applying the theory of developmental tasks to the process of aging this process in the negative sense may be seen as a consequence of not mastering developmental tasks.

Task under this age includes:Learn to walk, to take solid foods, control elimination of body wastes, sex difference, sexual modesty, relate emotionally to parents, siblings and others, to distinguish right from wrong, achieve physiological stability from physical to mental stability.

*The child is able to perform those tasks.

Under gross motor:*of the entire test given, he positively responds on:

• Balance in one foot for 1 second.• Throws ball overhead• Catches bounced ball• Kicks ball forward• Jumps in place• Hops on 1 foot• Balance on 1 foot in 10 seconds• Pedals tricycle• Balance on 1 foot for 5 seconds• Broad jump

Analysis: The child’s tasks under this

stage were achieved but some are not such as imitates bridge, and opposite analogies but the child still have the chance to achieve it because he is still 3 years of age

IV. Physical AssessmentDate Performed: September 16, 2010General appearance:

The child appears to be stated in his chronological age, he is very cheerful. The way he dress is appropriate to the weather and his postures is erect, coordinated, smooth and steady gait. His body build is bilateral firm and the muscles were developed.

Anthropometric measurements: Height-89 cmWeight-17 kg

Vital signs: Pulse Rate: 110 beats per minute Respiratory Rate: 24 breaths per minute

Body Temperature: 36.6°C

• Head -normocephalic-Symmetrical-Round in shape-Facial features vary

• Eyes-Eyelid margins moist and pink, with

large lashes, evenly spaced and curved outward and are symmetrical

-Eyebrows are present bilaterally and are symmetrical

-Pupils are round, and of equal in diameter

-Lens is transparent in color-Brown iris-Able to read a letter with a font size of

12 in 1-2 ft. distance -Pupil responses are uniform when on

object moves in toward the nose-Both eyes move in a smooth,

coordinated manner in all directions

• Nose-Located symmetrically in the midline of

the face-Same as face in color and it is smooth-Mucosa is pink and moist with uniform

in color-Able to identify the smell of a chocolate

• Ears-Equal in size and similar in appearance-Skin smooth and color pink -Alignment of pinna with corner of the

eye and within 10° angle of interval position• Mouth

-Lips are symmetrical in net position and with smiling, swelling and drooping and with a color of pink

-With 24 deciduous teeth

• Neck-Muscles are symmetrical with the head

in central position-Able to move the head in a full range of motion (ROM) without any

discomfort • Chest

-Symmetrical chest expansion-Normal breath sound heard-With cardiac rate of 110 beats per

minute-With a respiratory rate of 24 breaths per minute-lungs clear to auscultation on

inspiration and expiration• Back

-Uniform in color and pigmentation

• Abdomen-Symmetrically-Uniform in color and pigmentation-Rises with inspiration and falls with

expiration-Right upper quadrant- non tender and soft-Right lower quadrant-non tender and soft-Left upper quadrant-non tender and soft-Left lower quadrant-non tender and soft

• ExtremitiesUpper

-Bilaterally symmetrical-Proportional to body size-Able to form in desirable range of motion

(ROM)-With a capillary refill of 2 seconds-With short and clean nails

Lower -Bilaterally symmetrical-Proportional to body size-Able to form in desirable range of motion (ROM)-With a capillary refill of 2 seconds-With short and clean toenails

IV. Result MMDST (Analysis and Interpretation)

Child’s AgeDate of interview :2010-09-16

Date of birth :2007-06-03

2003-03-13

(3 years, 3 month, 13 days)

1. Personal Social SectorTask intersecting within the Linea. Play Interactive Games – PASSED

His father said that Yoyo can play interactive games together with his playmates. Less than 90% and more than 75% of the children at his age can perform the task.b. Buttons–up – PASSED

His father verbalized that Yoyo can do buttons up without help. More than 25% and less than 50% of the children at his age can perform the task.c. Puts on clothing - PASSED

His father said that Yoyo can put on his clothes independently without any assistance from others. More than 75% and less than 90% of the children at his age can perform the task.d. Washes and Dries Hands – PASSED

Yoyo’s father reported that he can wash and dries hands without his supervision. 75% and of children of his age can perform the task.e. Dresses with Supervision - PASSED

Yoyo can dress himself as reported by his father with supervision. More than 25% and less than 50% of children of his age can perform the task.f. Separates from Mother Easily – PASSED

His father said that he is now able to separate with him easily because of the influence of his playmates. The child belongs to the more than 50% and less than 25% of children who can perform the task.

Task on the Left of the Linea. Uses Spoon Spilling Little – PASSED

His father said that the child is now using spoon when eating.b. Helps in House Simple Tasks – PASSED

His father said that the child can also help and do house simple task.c. Removes Garment – PASSED

According to his father, he can remove his garment without supervision.Task on the Right of the Linea. Dresses without Supervision – PASSED

Yoyo can dress himself without supervision as reported by his father.

Analysis:On this sector, within the intersecting line, the child was

able to perform all activities. The child responded well to the examiners instruction. All task elicited before and after the age line was performed.

2. Fine Motora. Copies - PASSED

The child was able to copy . More than 25% and less than 50% of children at his age can perform the task.b. Imitates Bridge – FAILED

The child was not able to imitate the bridge that was done by the examiner. More than 50% and less than 75% of children at his age can perform the task.c. Tower of 5 Cubes – PASSED

Examiners asked Yoyo to build a tower of cubes and he was able to do it. More than 75% and less than 90% of children at his age can perform the task.d. Imitates Vertical Line – PASSED

Examiners draw a vertical line on a piece of paper and the client can imitate the vertical line. Less than 90% and more than 75% of children at his age can perform this task.e. Picks a Longer Line – PASSED

The child can pick a longer line as instructed by the examiner. More than 25% and less than 50% of children at his age can perform this task.

Task on the Left of the Linea. Tower of 2 Cubes – PASSED

Examiners asked the child to assemble the tower of cubes and he was able to do it.b.Tower of 4 Cubes – PASSED

Examiners asked the child to assemble the tower of cubes and he was able to do it.Task on the Right of the Linea. Copies - PASSED

Examiners asked the client to copy and he was able to do it. b. Copies + - PASSED

Examiners asked the child to copy + and he was able to do it.

• Analysis:Based on the gathered data, the child was able to

perform some activities with on the intersecting line except for one that he has failed to do. He passed all those at the right side and left side of the line.

3. Language

Task Intersecting the Linea. Comprehends 3 Prepositions – REFUSED

The child was not able to comprehend three prepositions.b. Uses Plurals – PASSED

The child can already differentiate small number to large numbers as reported by his father. More than 50% and less than 75% of children at his age can perform this task.c. Gives First and Last Name – PASSED

His father verbalized that the child can give first and last name. More than 25% and less than 50%of children at his age can all read perform the task.

Task on the Left of the Linea. Name 1 Picture – PASSED

The child can name the picture that was pointed by the examiner.b. Follows Direction – PASSED

Yoyo when as to follow some directions and he was able o do it.c. Points to one Named Body Part – PASSED

The child was able to identify what body part is being pointed by the examiner.Task on the Right of the Linea. Opposite Analogies – FAILED

The child was not able to perform the said task.

• Analysis:He was able to pass some tasks given. He does not

have any delays on the left side of the age line. Even though he failed and to perform the task, it doesn’t mean that he has any delay because the task is given in advance in his age.

4. Gross Motor Task Intersecting the Line a. Balance on 1 Foot – PASSED

He was able to balance on one foot on one second. 75% of children at this age can do this task.b. Pedal Tricycle – PASSED

His father said that he can pedal tricycle by himself and more than 50% and less than 75% of children at his age can do the task.c. Broad Jump – PASSED

The examiner asked the child to jump and he was able to do it. 75% of children at his age can do they said task.d. Balance on 1 Foot – PASSED

He was able to balance in 1 foot in 5 seconds when we told him to balance his body. More than 25% and less than 75% of children at his age can perform the task.e. Hops on 1 Foot – PASSED

The child was able to hop on 1 foot only and 25% and less than 50% of children in his age can perform the task.

Task on the Left of the Linea. Throw Ball Over Hand – PASSED

He can throw the ball over hand and he can pass the ball to others.b. Jump in Place – PASSED

He can jump in place without any supervision. c. Kick ball Forward – PASSED

He was able to kick the ball forward.Task on the Right of the Linea. Balance in 1 Foot – PASSED

He was able to balance on 1 foot in 10 seconds when we told him to balance his body.b. Catches Bounded Ball – PASSED

He was able to catch the bounded ball when the examiner passed it to him.Analysis:

Under this sector, the child was able to perform and passed the entire task given. Therefore he has no delay in his gross motor sector. He was also able to pass all the right side of the age line and this means that he is advance at his age. The result shows that he is physically fit and he has fine reflexes.

VII. Nursing Care Plan

Nursing Diagnosis (1):Risk for falls related to lack of

supervision/unattended child on bed located near windowNursing Inference:

Children age of 3 are very playful and need supervision as they grow . But because of the presence of bed located near the window and lack of supervision there is a high susceptibility of falling that may cause physical harm hence there is a risk for fall.Nursing Goal:

• After 1-2 days of nursing intervention the client will be able to demonstrate behavior to reduce risk factor.

Nursing Responsibility Rationale

1. Note age, and evaluate developmental level and level of cognition.

Young children are at greater risk because of developmental issues and unable to recognized danger.

2. Discuss to parents/ caregiver the need for proper supervision

To supervise the child and prevent possible fall.

3. Ascertain knowledge of safety needs/ injury prevention and motivation to prevent injury.

Client/ caregivers may not be aware of proper precautions to safety issues in all settings

4. Identify needed interventions and safety devices

To promote safe environment and individual safety

5. Determine care giver’s expectations of children, cognitively impaired and/or elderly family member and compare with actual activities.

Reality of client’s ability and needs may be different than perception or desires of caregivers.

6. Promote education geared to increasing individual’s awareness of safety measures and available resources.

To promote wellness

Nursing Evaluation:

After 1-2 days of effective nursing injury the client was able to identify risks and the steps to avoid them.

Nursing Diagnosis (2):Risk for injury related to

disarrangement of environment.Nursing Goal:

After 1-2 days of effective nursing injury the client will identify risks and the steps to avoid them.

Nursing Responsibility Rationale

1. Identify needed interventions and safety services.

To promote safety environment and individual safety.

2. Provide information regarding conditions that may results in increase risk of injury.

To assist the client to reduce or correct individual risk factor.

3. Discuss concern about discipline practices

To reduce individual risk factor

Nursing Evaluation:

After 1-2 days of effective nursing injury the client was able to identify risks and the steps to avoid them.

Nursing Diagnosis (3):Ineffective Airway Clearance

related to retained secretion and presence of mucous as manifested by non-productive cough an verbalization of his father “agpanpanateng isuna ken aguy-uyek ngem han met mairwar”.

Nursing Inference:Due to mucous secretion

there will be obstruction on the airway causing decrease inhalation.Nursing Goal:

After 2-3 hours of rendering appropriate nursing intervention the client will be able to expectorate secretion and maintain airway.

Nursing Intervention:1. Encourage deep breathing and coughing exercise.-to maximize effort of mobilizing secretions2. Increased fluid intake-to help liquify secretion3. Provide supplemental humidification as needed-to mobilized secretion

4. Perform postural drainage, percussion and vibration

-this technique and in mobilizing secretion5. Keep back dry-to prevent complication

Nursing Evaluation:After 2-3 hours of rendering appropriate

nursing intervention the client was able to expectorate secretion and maintain airway.

VIII. AppendicesDocumentation

In SchoolAt 8’oclock in the morning, we saw our client for MMDST. A

three year old child, a very naïve guy who doesn’t want to talk with us and saying “I want to go home”. I, together with my group mates did things to catch up his attention. We encourage him to play basketball with us, we ask questions (with a smile) just to get his trust to begin with our MMDST interview. After we get his attention and trust, we started the procedure to test his skills if he will PASSED or FAILED with the tests we give to him. The first activity that had given to him is to buttons up, and he passed the test. We ask him to draw different lines and shapes. After the activity, we decided to have a break, for him to relax and have much energy for the next activities. After the break we continue the activities to test his capability to throw a ball overhand. Next, is passing the ball, he did a great job and also for kicking the ball. In catching the ball and jumping in a chair, his shyness again appear, but it doesn’t affect his capability to fail the task given. He does well in arranging the cubes but the only problem is that he is easily distracted to other things.

In Their HouseFriday morning, we went the child’s house for

the completion of our MMDST. Were very quite excited to see him again and to see what environment he has.

As we passed on through their gate we saw him playing together with his cousin. It is reciprocal of what kind of attitude he had shown when we were interviewing him at school. He is very shy, easily get tired on the activities we gave, and he doesn’t want to talk to us but all of these get fade away when we were at the house we saw him as a very active, jolly and know how to mingle with us, he also do jokes and make us laugh. After our conversation with him, we start observing their surroundings. During the observation we saw some possibilities that would harm to him like falling from the stairs, trees and swings. We saw outlet that he might easily reach. Their yard is clean and they also have proper place of disposal like compost pit and sacks. They also have poultry and a pet like dog.

After the observation and interview we say goodbye to the child and he answered us “bye with smile while waving his hand.