DIAGNOSIS:

SEVERE COVID 19 POSITIVE

Ineffective Airway Clearance Related to Presence of secretions in the tracheobronchial tree secondary to pneumonia
ASSESSMENT EXPLANATION OF OBJECTIVES INTERVENTIONS RATIONALE CRITERIA ACTUAL
THE PROBLEM EVALUATION
Subjective: Ineffective Airway Short term goal: >Assess airway for >Maintaining patent Short term goal: Partially met
> Mayat met Clearance: Inability >After 12 hour of patency. airway is always the Fully met if after because patient Z
bassit, Ngem, to clear secretions nursing Auscultate lungs for first priority, 12 hours of still has crackles
marigatan nak pay or obstructions from interventions the presence of normal especially in cases nursing upon auscultation on
the lung fields but
lang aganges. the respiratory tract client will be able or adventitious like trauma, acute interventions the has been lessened
to maintain a clear to maintain airway breath sounds, as in neurological client will have compared to the first
Objective airway. >Breathing patency by having the following: decompensation, or clear breath day
> Inhalation via comes naturally and clear breath >Decreased or cardiac arrest. sounds Fully met patient Z
high flow venturi effortlessly to sounds absent breath Abnormal breath Partially meet if identified 3 danger
mask attached to everyone. But there After 5 minutes of sounds sounds can be there are still signs
mechanical are some who are nursing >Wheezing heard as fluid and adventitious Fully met patient Z
ventilator incapable of interventions >Coarse Crackles mucus accumulate. breath sounds but identified 3
keeping their patient would >Assess This may indicate has been alterations in lifestyle
>RR of 29, shallow and daily activities
>tachypnea airways clear and identify the respirations. airway is lessened Partially met, patient
>SPo2: 87% their lungs healthy. importance of DBE Note quality, rate obstructed. Not met if the Z’s
>Has episodes of Maintaining a and coughing pattern, depth, >These may adventitious oxygen saturation is
productive patent airway has exercises and flaring of indicate presence of breath sounds are now lingering at 88-
Cough and always been vital to perform DBE and nostrils, dyspnea on a mucous plug or the same or 89%
Dyspnea life. When problem atleast 2-3 exertion, evidence other major worsened Partially met patient
concerning the coughing of obstruction. STO: Z still has abnormal
airway happens, exercises splinting, use of >This may indicate Criteria breath sounds
coughing takes >After 5 minutes of accessory muscles, partial airway Fully met if after 5 (crackles), and
irregular respiration
place, which is the nursing and obstruction or minutes the but is able to cough
main mechanism interventions the position for resistance. patients identifies effectively and
for clearing it. patient will breathing. >This may indicate 3 danger signs expectorate
However, coughing verbalize presence of Partially met if the secretions after
may not always be understanding of 3 >Note for changes secretions along patients identifies treatments and deep
easy to everyone danger signs of in HR, BP, and larger airways. 2-3 danger signs breaths
especially to those pneumonia temperature. >A change in the Not met if the Partially met
patients with >After 5 minutes of >Note cough for usual respiration patient did not because the patient
incisions, trauma, health teaching the may mean identify anything still has abnormal
efficacy and Spo2, and RR but is
respiratory muscle patient will identify productivity respiratory STO 2 able to expectorate
fatigue, or 3 necessary >Note presence of compromise. An Fully met if after 5 secretions
neuromuscular alterations in sputum; evaluate its increase in minutes of health
weakness. lifestyle and daily quality, color, respiratory rate and teaching the
activities to amount, rhythm may be a patient will
chronic cough or manage odor, and compensatory perform DBE and
sputum production. pneumonia consistency. response to airway identify 3
>There is a wide >after 2days of >Use pulse oximetry obstruction. coughing
range of airway nursing to monitor oxygen exercises
clearance interventions the saturation; assess >Increased work of Partially met if the
interventions that patient will have arterial blood gases breathing can lead patient will
nurses can choose normal ranges in (ABGs) to tachycardia and perform DBE and
from when they are her oxygen hypertension. identify 1-2
teaching the saturation (93% >Teach the patient Retained secretions coughing
patients and family and above) the proper ways of or atelectasis may exercises
members the coughing and be a sign of an Not met if the
strategies of LTO: breathing. (e.g., take existing infection or patient does not
secretion removal. >After 3 days of a deep breath, hold inflammatory do DBE and not
In general, these nursing for 2 seconds, and process manifested identify any
interventions are interventions cough two or three by a fever or coughing exercise
done to maintain a Patient will times in increased STO 3
patent airway, maintain clear, succession). temperature Fully met if after 5
improve comfort open airways as >Educate the >Coughing is a minutes
and ease of evidence by patient in the mechanism for The patient
breathing, improve normal breath following: clearing secretions. identifies 3
pulmonary sounds, normal Optimal positioning An ineffective alterations in
ventilation and rate and depth of (sitting position) cough compromises lifestlyle and daily
oxygenation, and to respirations, and Use of pillow or airway clearance activities
prevent risks ability to effectively hand splints when and prevents Partially met if the
associated with cough up coughing mucus from being patient identies 1-
oxygenation secretions after Use of abdominal expelled. 2 alterations
problems. treatments and muscles for more Respiratory muscle Not met if the
>Pneumonia is an deep breaths. forceful cough fatigue, severe patient does not
infection in one or >After 3 day of Use of quad and bronchospasm, or identify anything
both lungs. It can nursing huff techniques thick and tenacious STO 4
be caused by intervention ,the Use of incentive secretions are Fully met if After 2
bacteria, viruses, or client will be able spirometry possible causes of days of nursing
fungi. Bacterial to expectorate Importance of ineffective cough. intervention the
pneumonia is the retained secretions ambulation and >Unusual patient will have
most common type and maintain frequent position appearance of normal range in
in adults. normal breathing changes secretions may be a Oxygen saturation
>Pneumonia measured by >Position the patient result of infection, (93% and above)
causes SPo2, RR, depth upright if tolerated. bronchitis, chronic Partially met if the
inflammation in the and rhythm Regularly check the smoking, or other patients oxygen
air sacs in your patient’s position to condition. A saturation
lungs, which are prevent sliding down discolored sputum increases to 90%
called alveoli. The in bed. remove most is a sign of to 92% or
alveoli fill with fluid secretions is infection; an odor increases from
or pus, making it coughing. So it is may be present. any range higher
difficult to breathe. necessary to assist Dehydration may be than former SPo2
>Normally the lungs the patient during present if patient Not met if the
are free from this activity. Deep has labored patients SPo2
secretions. breathing, on the breathing with thick, decreased or
Pneumonia bacteria other hand, tenacious remained the
are invading the promotes secretions that same
lung oxygenation before increase airway LTO:
parenchymathus, controlled coughing. resistance. Criteria:
producing >The proper sitting >Pulse oximetry is Fully met if after 3
inflammatory position and used to detect days of nursing
process. And these splinting of the changes in interventions
responses leading abdomen promote oxygenation. Patient will
to filling of the effective coughing Oxygen saturation maintain clear,
alveolar sacs with by increasing should be open airways as
exudates leading to abdominal pressure maintained at 90% evidence by
consolidation. The and upward or greater. normal breath
airway is narrowed diaphragmatic Alteration in ABGS sounds, normal
thus wheezes is movement. may result in rate and depth of
being heard. DOB Controlled coughing increased respirations, and
in some cases methods help pulmonary ability to
mobilize secretions secretions and effectively cough
from smaller airways respiratory fatigue. up secretions
to larger airways >The most after treatments
because the convenient way to and deep
coughing is done at remove most breaths.
varying times. secretions is Partially met if
Ambulation coughing. So it is she has normal
promotes lung necessary to assist breath sounds,
expansion, the patient during rate and depth of
mobilizes this activity. Deep respirations but is
secretions, and breathing, on the not able to
lessens atelectasis. other hand, effectively cough
>Upright position promotes up secretions
limits abdominal oxygenation before after treatments
contents from controlled coughing. and deep breath
pushing upward and >The proper sitting Not met if the
inhibiting lung position and patient does not
expansion. This splinting of the improve at all
position promotes abdomen promote LTO:
better lung effective coughing Fully met if after 3
expansion and by increasing days of nursing
improved air abdominal pressure interventions the
exchange. and upward patient will be
diaphragmatic able to
movement. expectorate
Controlled coughing retained
methods help secretions and
mobilize secretions maintain normal
from smaller breathing
airways to larger measured by
airways because SPo2, RR, depth
the coughing is and rhythm
done at varying Partially met if the
times. Ambulation patient is able to
promotes lung expectorate the
expansion, phlegm but
mobilizes breathing
secretions, and Not met if the
lessens atelectasis. patient does not
>Upright position improve at any
limits abdominal factor all till has
contents from abnormal
pushing upward
and inhibiting lung
expansion. This
position promotes
better lung
expansion and
improved air
exchange.
Impaired gas exchange related to ventilation perfusion imbalance.
ASSESSMENT EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE CRITERIA ACTUAL
OF THE EVALUATION
PROBLEM
Subjective- Impaired gas After 12 hours of Independent: After 12 hours of Goal – met when
“marigatan nak exchange r/t nursing nursing intervention patient was able
makaanges” ventilation intervention the 1. Elevated head of 1. To maintain the patient will be to demonstrate
As verbalized by perfusion patient will be able bed/ position client airway able to: improved
the patient imbalance to: appropriately, ventilation and
provide airway 1.Patient maintains adequate
1.Demonstrate adjuncts and optimal gas oxygenation of
improved suction as exchange as tissues by HBGs
ventilation and indicated. evidenced by usual within clients
adequate mental status, normal limits
Objective- Patient oxygenation of 2.Encouraged unlabored
is restless. Rate, tissues by HBGs frequent deep respiration at 12-20
2. Promotes
rhythm and depth within clients breathing/ coughing per minute, oximetry
optimal chest
of breathing is normal limits exercises. results within normal
expansion and
abnormal. Nasal range, blood gases
drainage of
flaring was noted. 2.Participate in within normal range,
secretions.
Inhalation via high treatment and baseline Heart
flow venturi mask regimen(e.g, 3. auscultated Rate for patient.
attached to breathing breath sounds
mechanical exercises, noting crakles, 2.Patient participates
effective coughing, 3. Reveals in procedures to
ventilator wheezes presence of
use of oxygen) optimize
within level of pulmonary oxygenation and in
V/S: congestion/
BP: 140/100 ability/situation. management
collection of regimen within level
mmHg secretion,
T: 36.6 ˚C 3.Verbalize of
indicating need for capability/condition.
P: 160 bpm understanding of
Collaborative: further intervention.
R: 32 cpm causative factors
SpO2- 89% and appropriate
intervention 1. Assisted with
procedures as 1. to improve
individually respiratory function/
indicated ( e.g., oxygen-carrying
transfusion, capacity
phlebotomy,
bronchoscopy
Hyperthermia related to the infectious process.

ASSESSMENT EXPLANATION OBJECTIVES INTERVENTIONS RATIONALE CRITERIA ACTUAL

OF THE EVALUATION
PROBLEM
Subjective: Hyperthermia After 12 hours of INDEPENDENT: After 12 hours of Goal – met when
“Napudot pay lang related to the comprehensive  Provide tepid  Enhances heat comprehensive patient was able
bagi na”, as infectious process nursing sponge bath. loss by nursing to demonstrate
verbalized by the or cerebral edema intervention, the evaporation & intervention, the improved
significant other patient  Assess fluid loss conduction. patient will: ventilation and
temperature will & facilitate oral  Increases  Maintain adequate
Objective: lower down to intake. metabolic rate & normal oxygenation of
 Skin warm to Scientific Basis: normal levels: T:  Promote bed diaphoresis. temperature of tissues by HBGs
touch with a Pyrogens cause a 36.5°C – 37.5°C rest.  Reduces body 37.5°C within clients
temperature of rise in body heat production.  Be free of normal limits
38.3-39.1°C temperature, it  Provide cool  Dissipates heat dehydration
 ↑RR: 32cpm also acts as an circulating air by convection.  Maintain vital
 ↑HR: 102bpm antigen triggering using a fan.  Increases signs at
 Weakness immune system  Assist patient in comfort. normal levels
observed responses. The changing into dry  Be alert and
 Dry mucous hypothalamus clothing.  Prevents herpetic responsive
membranes reacts to raise the  Provide oral lesions of the  Be
Flushed Skin set point and the hygiene. mouth. comfortable in
body respond by  Notes progress & bed.
producing heat.  Monitor vital changes of
signs. condition.
Reference:
Fundamentals of DEPENDENT:  Prevents
Nursing  Maintain IV fluids dehydration.
-Harry & Perry as ordered by
physician.  Reduces fever.
 Administer anti-
pyretic as  Treats underlying
ordered. cause.
 Administer
antibiotic as
ordered.
 Indicates
COLLABORATIVE: presence of
 Monitor infection &
hematologic test dehydration.
& other pertinent
lab records. Ensures continuous
Discuss condition of intervention.
the patient with other
members of the
health care team.
Imbalanced nutrition less than body requirements related to loss of appetite as evidenced by partial loss of taste.
ASSESSMENT EXPLANATION OF OBJECTIVES INTERVENTIONS RATIONALE CRITERIA ACTUAL
THE PROBLEM EVALUATION
Independent:
Subjective: Imbalanced nutrition After 12 hours of After 12 hours of Goal partially met
“Awan pinangraman less than body nursing intervention 1.identify if the client at -to assess causative/ nursing intervention
ko pay lang.” requirements related the patient will be risk for malnutrition Contributing factors the patient will be The client was able
Verbalized by the to loss of appetite as able to: 2.Encourage the client -to evaluate degree of able to: to eat 50% of meal
patient. evidenced by parital to eat and discuss the deficit. served and
loss of taste. Patient presents importance of well Partially met if weakness is lessen.
understanding of balanced nutrition. patient presents
significance of 3.evaluate total daily understanding of
-to establish a
Definition: nutrition to healing food intake significance of
Objective: nutritional plan that
Intake of nutrients process and general nutrition to healing
Weight: 49.5kgs meets individual
insufficient to meet health. process and general
Body weakness needs.
metabolic needs. health.
Consumed 10% of
the meal served. Patient takes
Dependent
Source: adequate amount of Partially met if
1. Give
Nurse’s Pocket Guide calories or nutrients patient takes
omeprazole 40 mg.
-An antisecretory adequate amount of
IVTTonce a day
compound that is a calories or nutrients.
Author: Marilynn E.
gastric acid pump
Doenges et al. Collaborative inhibitor. Suppresses Fully met if patient
Gastric acid secretion. displays nutritional
ingestion sufficient
2. Diet as -to sustain nutritional to meet metabolic
tolerated avoid dark demands. needs as
colored foods. manifested by
stable weight,
3. Assisted on food - to ensure the food is positive nitrogen
distribution and health given to the said balance, tissue
teaching patient and to discuss regeneration and
the benefits of exhibits improved
consuming the right energy level.
amount of food for
faster recovery.