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Nursing Health History and Care Plan

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  The client was breastfed purely during the first three months and on the fourth month, vegetable and fruit juices are slowly introduced with no known adverse reactions or allergies noted. The client, G, is a six month and 27 days old male with a height of 71.5 weight 8.5 and a physical development appropriate to his age. The mother of the client rates his child’ s health as 9/10 with chief complaints of a cough that worsens at night, difficulty in breathing, running nose, and audible wheeze. In one year, the mother of the client would want to fully develop and strengthen the immune system of her client.

The mother of the client stated that her child’ s immunizations are up to date. Client’ s mother states that she visits the GP when she feels the child is unwell. On the other hand, she admitted that she and the father of the child smoke 5 -10 sticks of tobacco per day making the child exposed to tobacco smoke while the parents are at home. The client is lying with his upper torso elevated in bed.

He had not bathed for 2 days because his mother is so anxious about his condition. The client has crying spells, shortness of breath, and is not friendly. Salbutamol 6 puffs were administered as charted with good effect. Vital signs: Temperature 36.8 degrees Celsius, HR 169, RR 52, and oxygen saturation was 95% on the right arm in room air. The client lives in a rural area, and both parents are a smoker for 18 years old. His father works in a toy factory and his mother works part-time in the toy factory.

Both parents consult 5 – 10 sticks of cigarettes per day, and this is considered as the major precipitating factor for the development of recurring lung problem of the client. The mother of the client denies the presence of birthmarks and history of allergies. The mother reported that the client had episodes of prickly heat and diaper rash, especially on summertime. The  mother denies applying sunscreen and lotion. On inspection, a mole at the right lower thigh was noted. An IV line is noted in the right upper arm.

The skin is pink and noncyanotic. The texture of the skin is soft with no apparent lesions. No swelling or edema noted.  

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preview essay on Nursing Health History and Care Plan
  • Pages: 17 (4250 words)
  • Document Type: Essay
  • Subject: Nursing
  • Level: Masters
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