2. INTRODUCTION
A novel coronavirus (CoV) named ‘2019-nCoV’ or ‘2019 novel coronavirus’ or
‘COVID-19’ by the World Health Organization (WHO) is in charge of the current
outbreak of pneumonia that began at the beginning of December 2019 near in
Wuhan City, Hubei Province, China. COVID-19 is a pathogenic virus. From the
phylogenetic analysis carried out with obtainable full genome sequences, bats
occur to be the COVID-19 virus reservoir, but the intermediate host(s) has not
been detected till now.
Most people infected with the virus will experience mild to moderate respiratory
illness and recover without requiring special treatment. However, some will
become seriously ill and require medical attention. Older people and those with
underlying medical conditions like cardiovascular disease, diabetes, chronic
respiratory disease, or cancer are more likely to develop serious illness. Anyone
can get sick with COVID-19 and become seriously ill or die at any age.
The best way to prevent and slow down transmission is to be well informed
about the disease and how the virus spreads. Protect yourself and others from
infection by staying at least 1 meter apart from others, wearing a properly fitted
mask, and washing your hands or using an alcohol-based rub frequently.
3.
4.
5. ETIOLOGY
COVID-19 is caused by infection with the
severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) virus strain.
6. Modifiable Risk Factors:
o Smoking
o Obesity
o Weakened Immune System
o Poor lung Function
o Hypertension
o Heart Diseases
o CKD
o Liver Disease
Non-Modifiable Risk Factors:
o Age (over 60 years old)
o Gender (Male)
o Socioeconomic Deprivation
RISK FACTORS
7. I. PATHOPHYSIOLOGY
ETIOLOGY
SARS-CoV-2 virusstrain
MODIFIABLE RISK FACTORS
Smoking
Obesity
Weakened Immune System
Poor lung Function
Hypertension
Heart Diseases
CKD
Liver Disease
NON-MODIFIABLE RISK FACTORS
Age (over 60 years old)
Gender (Male)
Socioeconomic Deprivation
Virus enter the host body
Respiratory system: attack the alveoli
Virus attached to Type-2 pneumocytes
Viral S-spike binds on to ACE 2
Virus is engulfed and taken into the cell (endocytosis)
Release of viral contents (+
ssRNA) into the
cytoplasm
Binds in sustentacular cells in nose
Cells die
Loss of sensory cilia on
olfactory receptor neurons
Odorants fail to bind to
neurons’ cilia
Anosmia
Binds to the sialic acid receptor Degradation of gustatory
particles
Ageusia
Binds to ribosome
Production of polyprotein
Broken dow n via
proteinase into viral
component
Production of RNA-D and RNA-
Polymerase
Production of more +
ssRNA
Destroyed Type-2 pneumocyte
Damaged Type 2 pneumocyte
release macrophage
Macrophage secrete IL-1, IL-6,TNF-alpha
Pro-inflammatory cytokines into the bloodstream
↑ Vasodilation
↑ Capillary Permeability
Fluid accumulates outside and inside the alveoli
↑ Alveolar edema
Alveolar collapse
Alveolar collapse
↓ Gas Exchange
Shortness of Breath
Hypoxemia
Low O2 Saturation
Stimulates chemoreceptors
Tachypnea ↑RR ↑HR Tachycardia
Vasoconstriction
↑BP Hypertension
Pulling in neutrophils into the lungs
Release reactive oxygen species and protease to
destroy the virus
Damaged different Type-1and Type-2 pneumocyte
Consolidation Cough
Alter Gas Exchange
Acts on hypothalamus
Release prostaglandins (PGE2)
↑ Body Thermostat
Fever IV Fluids
IL-6 Receptor Inhibitor
Chest X-Ray: Space Opacification
Hypercarbia
ARDS
Mechanical
Ventilation
Inflammation of the Lungs
Corticosteroid/ Anti-inflammatory
Systemic inflammatory
response syndrome
Septic
Shock
↑ Vasodilation
↑ Capillary Permeability
↓ Blood Volume
↓ Total Peripheral resistance
↓BP Hypotension
↓ Perfusion to multiple different
organs
Multi-system organ failure
Antigen Rapid Test:A visible red line on the (T) and
control (C) lines =POSITIVE
Polymerase Chain Reaction (PCRTest):Virus is Present
=POSITIVE
COVID-19
Supplem ental
Oxygenation via
High Flow Nasal
Cannula
8. Diagnostic and
Laboratory
Procedure
Indication Result Analysis Nursing Responsibilities
Antigen Rapid Test
(Antigen Test)
Antigen rapid test is
done when the client
shows recent
symptoms or had
exposure to people
infected with Covid-
19.
A visible red line on
the test (T) and
control (C) lines.
When a sample swab
taking form nose is
placed on lateral flow
test, similar to structure
of pregnancy test and
created two vertical
lines, it signals that the
sample is positive.
Before:
o Make sure to disinfect the area where sample
is prepared.
o Ask the patient getting swab test if they have
recent symptoms of COVID-19.
o Inform the patient about the procedure like
test sample is obtained by inserting a cotton-
tipped swab into the nostril or the swab may
go toward the back of their nose then once
the swab is inserted, it is usually rotated, and a
sample is often taken from both nostrils.
o Tell the patient that the test may take some
minutes and be felt uncomfortable especially
when it is taken form nasopharynx.
During:
o Ask the client to stay still and not make
unnecessary movements until the procedure
is done.
After:
o Label and send the sample immediately to the
laboratory for analysis.
o Collaborate with other healthcare members,
particularly medical technologist.
9. Diagnostic and
Laboratory
Procedure
Indication Result Analysis Nursing Responsibilities
Polymerase
Chain Reaction
(PCR Test)
The PCR test was
developed to detect
live organisms in a
sample obtained by
a nasopharyngeal
swab
(commonly known
as a nose swab).
A detection of
virus was
present.
A nasal swab test
was collected
from the back of
the client's nose
and put
into a PCR
machine for
detection; the
result came back
as positive,
indicating
that the virus had
been found.
Before:
o Establish rapport with the patient and S/O.
o During the swab test, inquire if the patient has
experienced any recent symptoms of COVID-
19.
o Explain the procedure to the client on how it
will take some minute of discomfort as it will
be taken from the back of patient’s nose.
o Preparation of the necessary and equipment
and materials.
o Preparation of a consent form, if necessary.
During:
o Use conventional precautions or sterile
procedure.
o During the procedure, request that the client
remain motionless and refrain from making
needless movements until the treatment is
completed and assess its response.
o Assuring that the specimen is properly
labeled, stored, and transported.
After:
o Compare the results of past and current
tests.
o Collaborate with the appropriate members of
the healthcare team, particularly the medical
technologist.
10. Diagnostic and
Laboratory
Procedure
Indication Result Analysis Nursing Responsibilities
Chest X-Ray An imaging test that
helps doctors to
discern the condition
of the lungs, heart,
and blood vessels.
Bilateral air
space
opacification
Normal Result:
Hollow
structures
containing
mostly air, such
as the lungs,
normally appear
dark. In a normal
chest X-ray, the
chest cavity is
outlined on each
side
by the white
bony structures
that represent
the ribs of the
chest wall.
Presence of viral
lung
infection causing
inflammation and
fluid build-up in
the lungs.
Before:
o Instruct the patient regarding the
procedure.
o Assist the patient to the x-ray room.
o Instruct the patient to wear x-ray
gown and remove any jewelry or
metallic objects.
o Assess the patient’s ability to hold her
breath.
o Educate the patient about the
procedure.
After:
o Collaborate with other healthcare
member, particularly to a radiologist.
11. Diagnostic and
Laboratory
Procedure
Indication Result Analysis Nursing Responsibilities
Arterial Blood
Gas (ABG)
Test measures the
acidity (pH) and the
levels of oxygen and
carbon dioxide in the
blood from an artery.
This test is used to
find out how well the
lungs are able to
move oxygen into
the
blood and remove
carbon dioxide from
the blood.
pH: 7.20
PaO2: 70 mmHg
PaCO2: 48 mmHg
HCO3: 24 mEq/L
Normal Values:
pH: 7.35 - 7.45
PaO2: 80 - 100 mmHg
PaCO2: 35 - 45 mmHg
HCO3: 22 - 26 mEq/L
The result
indicates
increase level of
carbon dioxide in
the blood
(hypercarbia)
resulting to
respiratory
acidosis with
hypoxemia or
decrease level of
oxygen in the
blood.
Before:
o Explain the procedure to the patient.
o Tell the patient that the test requires
a blood sample.
o Explain to the patient, who will
perform the arterial puncture, when
it will occur, and where the puncture
site will be; radial, brachial, or
femoral artery.
o Inform the patient that he/she may
not need to restrict food and fluids.
o Instruct the patient to breathe
normally during the test, and warn
her that she may experience a brief
pain at the puncture site.
After:
o Monitor puncture site for oozing
blood or hematoma formation.
o Ensure correct labeling, secure and
deliver the specimen to the
laboratory immediately,
12. Diet
• Protein Rich Foods
o Protein intake remains important through all phases during an illness to protect the body against muscle loss and to
repair the damage done to the muscles and tissues. Protein boosts the immune system too. Protein also provides
energy to help a patient overcome post-COVID weakness.
• High Fiber Foods
o The gut is an area where the immune system thrives and so it is important to keep the healthy gut bacteria thriving.
Probiotics such as curd can support healthy gut. Consuming dietary fiber that can be found in large quantities fresh
fruits and vegetables for a healthy stomach.
• Micro-Nutrients
o Fresh fruits are a great source of micronutrients like antioxidants, folate, vitamins and minerals. Including all kinds of
fruits and vegetables that are nutrient-rich like pineapples, apples, bananas, kiwis, leafy greens and others.
o Taking some supplements for meeting nutrient needs of the body while recovering since the total appetite of the
patient is less.
• Carbohydrate Rich Foods
o Including carbohydrate rich foods in a daily diet will help battle the fatigue that is commonly felt in a post-COVID
patients. Carbohydrates provide your brain with energy for regeneration and protein/muscle breakdown prevention.
• Fluids
o Drinking plenty of fluids during the illness and post COVID recovery is very important because staying hydrated is vital
for fighting the infection. Along with drinking at least 6-8 glasses of water every day.
13. Drug
Mechanism of
Action
Indication Contraindication
Side Effects/
Adverse Effects
Nursing Responsibilities
Generic name:
Remdesivir
Brand name:
Veklury
Drug
Classification
Anti-Viral Drug
Route:
IV
Dosage:
100 mg
Frequency:
q.d
Remdesivir (GS-
5734) is a
phosphoramidite
prodrug of a
monophosphate
nucleoside analog
(GS-441524) and
acts as a viral RNA
dependent
RNA polymerase
(RdRp) inhibitor,
targeting the viral
genome replication
process.
Treatment for
patients with
coronavirus disease
2019 (COVID 19)
infection.
o Hypersensitivity to
drug or any ingredient
o Patients with alanine
aminotransferase (ALT)
levels >5-times upper
limit of normal or
severe hepatic
dysfunction
o Patient with severe
renal impairment.
o Cardiovascular: Hypotension,
arrhythmias, and cardiac arrest
o Pulmonary: Dyspnea, Acute
respiratory failure, acute respiratory
distress, pneumothorax, pulmonary
embolism
o Hematological: Anemia,
lymphopenia
o Endocrine: Hyperglycemia
o Infectious: Pneumonia, septic shock
o Gastrointestinal: elevated lipase,
nausea, vomiting, diarrhea,
constipation, poor appetite,
gastroparesis, and lower GI bleeding
o Hepatic: Hepatic manifestation
characterized by Grade 1-4 increase
in serum transaminases (ALT and/or
AST) are the most common adverse
effects seen in patients treated with
Remdesivir. Other abnormalities
include hyperbilirubinemia
o Renal and Metabolic: Acute kidney
injury or worsening of underlying
chronic kidney disease,
hypernatremia, hypokalemia
o Neurological: Headache,
lightheadedness
o Skin: Rash, contact dermatitis,
pruritus
o Psychiatric: Delirium
o Other adverse effects: Pyrexia,
insomnia, multi-organ dysfunction,
DVT, and
hypersensitivity/anaphylactic
reactions related to the infusion
Before:
o Observe proper aseptic
technique and wearing
of PPE before handling
the patient.
o Identify patient
o Determine eGFR
(Estimated glomerular
filtration rate).
o Determine (ALT
prothrombin time)
o Monitor vital signs.
During:
o Observe patient's
reaction during the
administration of drug.
After:
o Note patient's
response to the drug.
o Dispose PPE to proper
receptacle after use.
o Perform aseptic
technique.
14. Drug
Mechanism of
Action
Indication Contraindication
Side Effects/
Adverse Effects
Nursing Responsibilities
Generic name:
Dexamethasone
Brand name:
Intensol
Drug
Classification
Corticosteroid/Ant
i-inflammatory
Route:
P.O.
Dosage:
5 mg/tab
Frequency:
BID (twice a day)
Action is to
decrease of
inflammation of the
neutrophil
migration
suppression and
reverses the High
Capillary
permeability. This
primary used as an
Immunosuppressan
t agent (Anti-
Inflammatory) for
various illness and
Diseases
Dexamethasone is
a type of steroid
used to shutdown
cytokines storms or
the massive amount
of inflammation that
can damage the
lungs of the
patients.
Therapeutic Effect:
Decrease
Inflammation
o Hypersensitivity to drug
or any ingredient.
o Patient with cerebral
Edema
o Patient with
Hypertension, Renal,
Respiratory, and
Rheumatic Disorders.
Side effects (systemic):
o Insomnia
o Edema in the Face
o Abdominal distension
o Appetite (Increased)
o Diaphoresis
o Rash, Urticaria
o Psychological changes
such Hallucination
Adverse effects (Long-term
Therapy):
o Osteoporosis
o Muscle Wasting
o Spontaneous Fractures
o Cataracts
o Peptic Ulcers
Before:
o Observe proper aseptic
technique and wearing of
PPE before handling the
patient.
o Check Vital Signs
o Monitor vital signs
o Prepare the medication
o Observe 5 rights of
medication administration.
o Health education must be
given prior with the
administering of the
medication
During:
o Administer the Medication
being prescribed.
o Advised to take the
medication as needed.
o Make sure that the patient
ingested the given
medication by not leaving
the room and wait for the
patient to swallow the
medication.
After:
o Advised the patient to
notify the health care
provider if side effect is
present.
o Document the medication
given in the patient’s chart
o Regularly Monitor Patients
Vital Signs. Because
administering
Dexamethasone for
elderly patients has the
higher risk in developing
hypertension.
15. Drug
Mechanism of
Action
Indication Contraindication
Side Effects/
Adverse Effects
Nursing Responsibilities
Generic name:
Tocilizumab
Brand name:
Actemra
Drug
Classification
Il-6 inhibitor/
immunomodulator
/
monoclonal
antibodies
Route:
IV
Dosage:
500 mg
(standard dose:
8mg/kg [not to
exceed
800mg/dose])
Frequency:
STAT
(immediately or at
once)
It is a recombinant
monoclonal
antibody
used to treat
cytokine storms (a
massive amount of
inflammation that
can cause damage
to the lungs and
other
organs in the body).
It
binds soluble and
membrane bound
IL-
6 receptors,
preventing IL-6
mediated
inflammation. This
medication is called
trackers for the
severity of the
COVID-19.
It is indicated to
treat moderate to
severe rheumatoid
arthritis, giant cell
arteritis,
polyarticular
juvenile idiopathic
arthritis, systemic
juvenile idiopathic
arthritis, and
cytokine release
syndrome.
Patients with the following
conditions:
o Active tuberculosis
o Invasive fungal
infections
o Bacterial and viral
infections
o Pneumonia
o Cancer or malignancy
o High cholesterol
o High amount of
triglyceride in the
blood
o Low levels of
neutrophils (a type of
white blood cell)
o Liver problems
o Upper respiratory tract infections
o Nasopharyngitis
o Headache
o Hypertension
o Increased ALT
o Dizziness
o Bronchitis
o Rash
o Mouth ulceration
o Abdominal pain
o Gastritis
o Increased transaminase
Before:
o Check patient’s medical record if
he/she is contraindicated to the
medication.
o Assess patient’s respiratory
status. Check to see if he/she is
under respiratory
decompensation and taking
vasopressor.
o Observe proper aseptic
technique and wearing of PPE
before handling the patient.
o Explain the importance of the
medication to the patient and
how it can help improve his/her
condition.
o Note for the 5 rights of
medication administration.
o Check if there is an active
infection including localized
infections present in the patient.
o Assess patient for history of
active tuberculosis, pneumonia
and cancer or malignancy.
o Check for patient’s laboratory
values, including liver enzymes,
absolute neutrophil count, and
platelet count.
During:
o Observe patient's reaction during
the administration of drug.
o Report immediately if
unnecessary reaction occurs.
o Maintain dressings, tubing, and
line integrity of the patient when
giving IV infusions.
After:
o Observe and note patient's
significant responses to the drug.
o Instruct him/her to inform HCP
immediately if unnecessary
reactions occur.
o Monitor vital signs.
o Dispose PPE to proper receptacle
after use.
o Perform aseptic technique.
16. ASSESSMENT
NURSING
DIAGNOSIS
NURSING PLANNING NURSING INTERVENTION RATIONALE NURSING EVALUATION
SUBJECTIVE:
“hirap akong huminga
nitong nakaraang araw,
pakiramdam ko hinang
hina ako” as verbalized by
the patient
OBJECTIVE:
Dyspnea
Hypoxemia
Fatigue
Use of accessory
muscle upon
breathing/ retractions
Chest x-ray shows
bilateral opacification
of airspace
ABGs test
interpretation -
respiratory acidosis
VITAL SIGNS:
BP: 130/ 90 mmHg
RR: 32 cpm
HR: 110 bpm
TEMP: 38.7C
O2Sat: 87%
Impaired Gas
Exchange
related to ventilation
perfusion
inequality due to fluid
build-up in the lungs
as evidenced of
shortness of breath
and alteration in vital
signs.
SHORT TERM:
Within 2-4 hours of nursing
intervention, the patient will be
able to:
Demonstrate improved
ventilation and adequate
oxygenation as evidenced
by blood gas levels within
normal parameters
Relaxed breathing
Sustain v/ s within normal
range:
RR 12-20 cpm
PR: 60-100bpm
BP: 120/ 80mmHg
T: 36.1°C – 37.2°C
LONG TERM:
After the client’s stay at the
hospital, the client will
be able to:
Maintain clear lung fields
and remain free of signs of
respiratory distress.
INDEPENDENT:
o Introduce self to the client. Use calm,
reassuring approach; Explain all
procedures, including sensations likely to
be experienced during the procedure
o Monitor the patients’ vital signs,
especially the oxygen saturation and
characteristics of respiration q30 minutes
o Determine level of consciousness and
mentation changes using Glasgow Coma
Scale
o Elevate patient bed into semi fow ler’s
position as necessary
o Observe for cyanosis of the skin;
especially note color of the tongue and
oral mucous membranes.
o Observe for the skin, nail beds,and
mucous membranes for pallor or
cyanosis
o Help the client deep breath and perform
controlled coughing. Have the client
inhale deeply, hold the breath for several
seconds, and cough tw o or three times
w ith the mouth open w hile tightening the
upper abdominal muscles as tolerated.
o Routinely check the patient’s position so
that she does not slump dow n in bed
o Change the client’s position every 2 hours
o Schedule nursing care to provide rest and
minimize fatigue
DEPENDENT:
o Deliver humidified oxygen as prescribed
through an appropriate device (nasal
cannula or venturi mask as per the HCP’s
order) and monitor the patient’s response.
COLLABORATIVE:
o Monitor oxygen saturation continuously
using pulse oximetry. Note blood gas
results as available
o Assist in performing slow deep breathing,
using an incentive spirometer as
indicated
o Anticipate the need for intubation and
mechanical ventilation
o To establish rapport and ensure
cooperation. The patient’s feeling of
stability increases in a calm and non-
threatening environment.
o To monitor effectiveness of interventions
and medical treatment
o Decreased level of consciousness can be
an indirect measurement of impaired
oxygenation
o Positioning helps maximize lung expansion
and decreases respiratory effort.
o Central cyanosis of the tongue and oral
mucosa is indicative of serious hypoxia and
is a medical emergency.
o Cool, pale skin may be secondary to a
compensatory vasoconstrictive response to
hypoxemia
o Controlled coughing usesthe
Diaphragmatic muscles, w hich makes the
cough more forceful and effective.
o Slumped positioning causes the abdomen
to compress the diaphragm and limits full
lung expansion
o Repositioning facilitates secretion
movement and drainage and decreases
atelectasis
o The hypoxic client has limited reserves;
inappropriate activity can increase hypoxia
o Delivering O2 w ith humidity w ill help in
supplying additional oxygen and minimize
convective losses of moisture, decreasing
dry mucous membranes and enhancing
compliance.
o To detect changes in oxygenation.An
oxygen saturation of less than 88%(normal:
95%to 100%) or a partial pressure of oxygen
of less than 55 mm Hg (normal: 80 to 100
mm Hg) indicates significant oxygenation
problems
o This technique promotesdeep inspiration,
w hich increase oxygenation and prevent
atelectasis
o Early intubation and mechanical ventilation
are recommended to prevent full
decompensation of the patient.It provides
a supportive care to maintain adequate
oxygenation and ventilation
SHORT TERM:
After 2-4 hours of nursing intervention, the patient
w as able to:
Demonstrate improved ventilation and
adequate oxygenation as evidenced by
blood gas levels w ithin normal parameters
Relaxed breathing
Maintain v/ s w ithin normal range:
RR 12-20 cpm
PR: 60-100bpm
BP: 120/ 80mmHg
T: 36.1°C – 37.2°C
LONG TERM:
After the client’s stay at the hospital, the client w as
able to:
Maintain clear lung fields and remain free of
signs of respiratory distress
GOAL WAS MET.
17. ASSESSMENT
NURSING
DIAGNOSIS
NURSING PLANNING NURSING INTERVENTION RATIONALE NURSING EVALUATION
SUBJECTIVE:
"Nurse kanina pa ho sa
bahay namin inirereklamo
na ng nanay ko na
nahihirapan po siyang
huminga..." verbalized by
the son of the patient.
OBJECTIVE:
(+) ABG's results
indicates increase
level of carbon
dioxide in the blood
(hypercarbia).
(+) X-ray shows a
bilateral air space
opacification
(+) Dyspnea
Vital signs were taken:
Temp: 38.2°C
RR: 32 cpm
HR: 130 bpm
BP: 180/ 100mmHg
O2 Sat: 87%
Ineffective Breathing
Pattern related to
COVID-19 as evidence
of shortness of breath
SHORT TERM:
After 3-4 hours of proper nursing
interventions the patient will be
able to:
- Establish effective
breathing pattern
manifested by normal vital
signs and oxygen saturation
- Demonstrates maximum
lung expansion with
adequate ventilation.
LONG TERM:
After 1-2 days of proper nursing
interventions the patient will be
able to:
- ABG levels return to and
remain within established
limits.
- Verbalize proper ways on
how to follow protocols
such as; wearing mask and
face shield, importance of
vaccine, and use
alcohol/ sanitizer when
going out.
- Verbalize understanding of
various breathing
techniques to establish
eupnea during episodes of
respiratory distress.
INDEPENDENT:
o Established rapport.
o Position the patient with a proper
body alignment for maximum
breathing pattern.
o Evaluate skin color, temperature,
capillary refill by observing the
central versus peripheral cyanosis.
o Encourage deep breathing
techniques once stable
o Stay with the patient during acute
episodes of respiratory distress.
o Ensure optimal room ventilation by
inspecting equipment that supply
air.
DEPENDENT:
o Initiate oxygen therapy as indicated
by the physician
o Administer medications prescribed
by the physician
COLLABORATIVE:
o Check the availability of intubation
equipment and ready to assist.
o By developing a positive relationship
with a patient and SO enables the
health care practitioner to elicit
pertinent information and make
informed clinical decisions about
their treatment.
o Sitting position can maximum lung
excursion and chest expansion.
o Lacking of oxygen will cause
blue/ cyanosis coloring to the lips,
tongue, and fingers. Cyanosis to the
inside of the mouth is a medical
emergency
o A controlled breathing method may
also aid slow respirations in
tachypneic patients. Which a
prolonged expiration prevents air
trapping
o This will reduce the patient’s anxiety,
thereby reducing oxygen demand.
o To aid in establishing effective
breathing pattern,
o To increase oxygen supply to the
body
o To address the problem that causes
ineffective breathing.
o In case of emergency procedure,
equipment for intubation should be
readily available.
SHORT TERM:
After 4 hours of proper nursing interventions
the patient was able to:
- Establish effective breathing pattern as
evidenced by respiratory rate of 16
cpm, pulse rate of 72, BP of 120/ 80
mmHg and oxygen saturation of 95%
- Demonstrated maximum lung
expansion with adequate ventilation.
LONG TERM:
After 2 days of proper nursing interventions
the patient was able to:
- Return ABG to and remained within
established limits.
- Verbalized proper ways on how to
follow protocols such as; wearing
mask and face shield, importance of
vaccine, and use alcohol/ sanitizer
when going out.
- Verbalized understanding of various
breathing techniques to establish
eupnea during episodes of respiratory
distress.
GOAL WAS MET.
18. ASSESSMENT
NURSING
DIAGNOSIS
NURSING PLANNING NURSING INTERVENTION RATIONALE NURSING EVALUATION
SUBJECTIVE:
“ilang araw na pong
mataas ang lagnat ko” as
verbalized by the patient.
OBJECTIVE:
Warm to touch
Chills
Restlessness
Vital signs were taken as
follows:
BP: 130/ 90mmHg
RR: 32cpm
PR: 110 bpm
Temp: 38.7°c
O2 SAT:87%
Hyperthermia related
to disease process as
evidenced of
temperature higher
than normal.
SHORT TERM:
Within 1-2 hours of nursing
intervention, the patient will
manifest decrease in body
temperature from 38.7°c to 37°c.
LONG TERM:
Within the 8 hours of nursing
intervention, the patient will be
able to:
Maintain normal body
temperature.
Will have adequate rest and
appear relax.
INDEPENDENT:
o Monitor vital signs.
o Place the patient under appropriate
isolation.
o Place patient in a cool and quiet
environment.
o Provide tepid sponge bath.
o Eliminate excess clothing and
covers.
o Provide adequate rest.
o Monitor/ record all sources of fluid
loss.
o Instruct patient to increase oral fluid
intake.
o Monitor vital signs and recheck
DEPENDENT:
o Administer medications as ordered
by the physician.
COLLABORATIVE:
o Administer replacement fluids and
electrolytes.
o Facilitate laboratory workups.
o Vital signs provide more accurate
indication of core temperature.
o To prevent the transmission of the
disease.
o Environment factors relatively minor
infections can produce much higher
temperature.
o Enhances heat loss by evaporation &
conduction.
o To decrease warmth and provide
comfort.
o To conserve energy which promotes
fast healing.
o Fluids and Electrolytes may be loss
due to dehydration.
o Additional fluids help prevent
elevated temperature associated
with dehydration.
o To know the effectiveness of nursing
interventions done and to know the
progress and changes of condition.
o For the medical management of
COVID – 19.
o To support circulating volume and
Tissue perfusion.
o To relay to the physician for further
medical interventions.
SHORT TERM:
Within 1-2 hours of proper nursing
intervention, the patient manifested
decrease in body temperature from 38.7°c to
37°c.
LONG TERM:
Within the 8 hours of nursing intervention,
the patient was able to:
Maintain normal body temperature.
have adequate rest and appeared
relax.
Goal was met.
