Francisco, Krisianne Mae L.

BSN III B (group B3)

COVID – 19 Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective
“Nilalagnat na po siya ng Impaired gas exchange After 6hrs of nursing DEPENDENT  For personal  After 6 hrs of
ilang araw tapos inuubo po related to alveolar – intervention the patient  Observed the use of PPE. protection against nursing
siya at nahihirapan na pong capillary membrane will verbalize improved the infection. intervention the
huminga” as verbalized by changes as characterized ventilation such as patient’s breathing
his daughter. by dyspnea, rapid and normal breathing pattern,  Encouraged to perform regular  For the prevention pattern became
Objective shallow breathing, and normal range of cardiac and proper hand hygiene such of infection. normal, his
 oxygen saturation of presence of abnormal and respiratory rate and as washing hands with soap and oxygen saturation
94 percent lung sound. the absence of abnormal the use of alcohol – based was improved
 diaphoretic lung sounds. sanitizer. from 94 into 96
 acute respiratory percent, and the
distress with rapid,  Place patients who are  To improve lung patient’s cardiac
shallow breathing experiencing dyspnea in a high expansion. rate and
 Crackles on both Fowler position. respiratory rate
lungs decreased into
 BT 102.9°F normal rate but
(febrile)  Demonstrated pursed-lip and  It provides patient crackles in both
 BP: 131/74 mm diaphragmatic breathing to the with some means lungs was still
Hg patient. to cope audible. Goal
 RR: 41 bpm with or control partially met.
(tachyneic) dyspnea and
 PR: 110 bpm reduce air-
(tachycardic)
trapping.
  Monitor patient’s vital signs.  To evaluate the
patient’s health
reaction from
medical and
nursing
intervention
INDEPENDENT

 Administer intubation at 4  To increase

L/min via nasal cannula as oxygen level.
prescribed.

 Administer medications as  For the medical

prescribed by the physician management of
such COVID – 19.

 Hydroxychloroquine 400
mg twice on day 1,
followed by 200 mg twice
per day on days 2
 Azithromycin 500 mg once
per day for 5 days
 lopinavir–ritonavir 400/100
mg twice per day
 heparin for prophylaxis of
deep vein thrombosis
 Tocilizumab was
administered by the
intravenous or
subcutaneous route
 Tocilizumab 800 mg IV q
 12hrs

COLLABORATIVE

 Placed the patient under  To prevent the

appropriate isolation. transmission of the
disease

 Collect specific test such as  To evaluate the

swab testing. patient’s health
improvement.

 Advise proper and regular fluid  Good hydration is

intake. crucial for optimal
health and it may
help the patient to
increase defense
mechanism against
the virus.

 Advice healthy diets such as eat  Eating a healthy

fruits and vegetables. diet is very
important during
the COVID-19
pandemic. These
are important for
supporting
immune systems.