CASE#2 COVID-19

ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

T
Objectives: Ineffective Within 1 hr. of Independent: After 1 hr. of nursing
- dyspnea breathing pattern nursing intervention, 1. Instruct the patient to 1.permits maximum lung intervention, the
-look tired and related to the patient’s lean forward over a excursion and chest patients respiratory
restlessness shortness of respiratory rate will bedside table, resting expansion. rate return to its
- tachypnea breath return to its normal elbows on the table if normal range
-cough range tolerated. RR: 22
-nasal flaring
RR: 26 2. Auscultate breath sounds 2. to detect decreased or
at least every 4 hours adventitious breath sounds;
report changes.

3. Teach patient about: 3. These measures allow

– pursed-lip breathing patient to participate in
– abdominal breathing maintaining health status
– performing relaxation and improve ventilation
techniques – taking
prescribed medications

4. Provide small, frequent 4.Small feedings are given

feedings to avoid compromising
ventilatory effort and to
conserve energy.

Dependent:
5. Administer oxygen as 5.Oxygen administration
ordered. has been shown to correct
hypoxemia, which causes
dyspnea.
 ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
T
Objectives: Deficient Within 15 mins.of Independent: 1. to know what needs to be After 15 mins of nursing
- clueless about knowledge nursing 1. Determine priority discussed especially if the patient intervention will note be
how this related to intervention, the of learning needs already has a background about clueless as the patient
disease can unfamiliarity with patient will not be within the overall care the situation. Knowing what to demonstrates
transmit to one disease clueless about plan. prioritize will help prevent understanding about the
another transformation COVID-19 and wasting valuable time. transmission of the
-confuse information demonstrates disease.
understanding 2. Provide an 2.Conveying respect is especially
about the atmosphere of respect, important when providing
transmission of the openness, trust, and education to patients with
disease collaboration. different values and beliefs about
health and illness.

3. Provide clear, 3. Patients are better able to ask

thorough, and questions when they have basic
understandable information about what to
explanations and expect.
demonstrations.

4.Encourage questions 4. Questions facilitate open

communication between patient
and health care professionals and
allow verification of
understanding of given
information

5.Allow repetition of 5.Repeated information allows

the information patient gain confidence in self-
care ability.
 ASSESSMEN DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
T
Objectives: Anxiety related to Within 4-6 hrs. of Independent: After 4-6 hrs. of
- insomnia change in health nursing 1.speak in short 1. this will help the nursing intervention,
-worrying status intervention, the sentences, clear and patient to calm and the patient will state
-facial tension patient will state he calm voice. grasp the information he feels less anxious
feels less anxious clearly.

2. provide for the 2. to lessen the

patient needs. patient’s worrying
about his or her needs.

3. encourage use of 3. it will help the

coping skills patient to handle
negative emotions

4. provide factual, 4. to lessen the

relevant information to anxiousness of the
the patient and at levels patient about her or his
the patient can health status.
understand
F- ineffective airway breathing patter
D- dyspnea A- administer oxygen as ordered, teach different relaxation techniques, encourage sitting position
-look tired and restlessness R- continuity of care
- tachypnea
-cough
-nasal flaring