NURSING CARE PLANS

NCP 1 – Priority Nursing Diagnosis

This nursing care plan was done on September 17, 2020
– Thursday. Patient was admitted in the Negative Pressure Isolation Room with the diagnosis of MERS-CoV.
Patient was received awake, conscious, coherent, oriented to time, place, and person. Patient was lying on the bed, in a blanket. OKS NA TO THANK U AUBS!! OKIII!!! WUV U ALL!
SHORT TERM
NURSING LONG TERM PLAN OF
ASSESSMENT CUES OBJECTIVES OF RATIONALE EXPECTED OUTCOMES
DIAGNOSIS OBJECTIVES OF CARE INTERVENTIONS
CARE

S: “Difficulty of breathing”
“Cough” “Fever”
related to excessive
O: Venoclysis with D5LR
1L x 8 hours hooked at
RMCV received at 500cc;
with O2 inhalation
2.5Lpm via nasal cannula
V/S:
T: 38.6 C HR: 88bpm
RR: 23cpm O2 Sat: 95%
BP: 140/90mmHg
breathing, abnormal
(+) rhinorrhea
(+) nasal flaring
(+) pale nail beds
(+) pallor on palms &
soles
(+) use of accessory
muscles for breathing
(+) rhonchi & rales lower
lung field
Impaired Gas 1. To promote and maintain Within the 8-hour shift, Diagnostic: This serves as the Short-term outcome:
Exchange patent airway the patient will be able To monitor V/S before comparative baseline 1. The patient will be able to
to participate in and after initiating an measurement in engage in procedures to
secretions 2. To facilitate maintenance procedures in activity. assessing the physical optimize oxygenation.
secondary to of regulatory mechanisms optimizing oxygenation activity level of the
MERS-CoV as and functions. patient. 2. The patient will be able to
manifested by Within the shift, the recall and recite the essence
pallor, difficulty of patient will verbalize To monitor Oxygen A significant change in of oxygenation and other
breathing, nasal understanding of saturation continuously oxygenation indicates therapeutic interventions.
flaring, rhinorrhea, oxygen and other using pulse oximeter. oxygenation problems.
use of accessory therapeutic Long-term outcomes:
muscles for interventions. 1. The patient will be able to
establish a stable patent
lung sounds, and airway.
fatigue.
2. The patient will be able to
manifest resolution or
absence of complaints and
symptoms

Therapeutic: Retained secretions

To assess the patient’s weakens gas exchange.
 ability to cough out
secretions. Take note
of the quantity, color,
and consistency of the
sputum.
Ambulation facilitates
To assist the patient in lung expansion,
ambulation as per secretion clearance, and
doctor’s order. stimulates deep
breathing.

appropriate medications
Administer medications ease the symptoms and
as prescribed. prevent other
complications.

Educative:
To teach the patient the This is to ensure the
Breathing exercises patent airway of the
and coughing. (Inhale patient.
deeply. hold it for 2
seconds, and cough 2
to 3 times in
succession to remove
the sputum)
NCP 2

This nursing care plan was done on September 17, 2020 – Thursday. Patient was admitted in the Negative Pressure Isolation Room with the diagnosis of MERS-CoV.
Patient was received awake, conscious, coherent, oriented to time, place, and person. Patient was lying on the bed, in a blanket. OKS NA TO THANK U CHENG & AUBS
PLAN OF
ASSESSMENT CUES NURSING LONG TERM SHORT TERM RATIONALE
INTERVENTIONS EXPECTED OUTCOMES
DIAGNOSIS OBJECTIVE OF CARE OBJECTIVES OF CARE Cheng & Cruz
Cheng & Cruz

S: “Fever” “Generalized
Body Malaise” “
O: Venoclysis with D5LR
1L x 8 hours hooked at
RMCV received at 500cc;
with O2 inhalation
2.5Lpm via nasal cannula
V/S:
temperature of 38.6
T: 38.6 C HR: 88bpm
RR: 23cpm O2 Sat: 95%
BP: 140/90mmHg
respirations, and
(+) tachycardia
(+) headache
1. To regulate body Within the 8-hr shift, the Diagnostic: Short-term Outcome:
Hyperthermia temperature within patient’s temperature will Monitor V/S specifically Any significant At the end of the shift,
related to normal limits decrease from 38.6 C the temperature of the alterations on patient’s temperature will
ineffective to 37 C. patient. temperature can reach the normal range of
temperature 2. To limit activities with indicate potential 36.4-37.5 °C.
regulation high energy demands complications.
secondary to thereby facilitating Long-term Outcomes:
MERS-CoV as conservation of energy Monitor fluid intake and Fluid resuscitation may
manifested by for recovery UO. be required to 1. Patient will be able to
acknowledge
maintain normal body
dehydration.
C, tachycardia, temperature.
increased
Avoid close contact
Put the patient in 2. Patient will be able to
headache. isolation room with the patient to conserve energy for rest and
prevent possible recovery by avoiding
transmission. strenuous tasks.

Raise the side rails at

all times. To ensure safety and
prevent accidents from
happening.
 Therapeutic: Antipyretic medications
Give antipyretic lower body temperature
medications as per by blocking the
doctor’s order synthesis of
prostaglandins.
Modify a cool room
temperature as per A very cool room can
patient’s physical cause shivering, which
response. can increase the use of
energy and metabolic
rate to produce heat.
Encourage and assist
the patient in a Tepid This can reduce body
sponge bath. temperature.

Educative:
Advice the patient to Exposure to air can
wear loose clothes. decrease warmth and
facilitate evaporative
cooling sensation.
Educate the patient and
the family members To provide knowledge
about the disease. about the possible
procedures that may
occur in the future.
Instruct the patient to
have adequate fluid Hyperthermia causes
intake dehydration
NCP 3

This nursing care plan was done on September 17, 2020 – Thursday. Patient was admitted in the Negative Pressure Isolation Room with the diagnosis of MERS-CoV.
Patient was received awake, conscious, coherent, oriented to time, place, and person. Patient was lying on the bed, in a blanket. HELLO KAY CY NA DAW ITU to complete hehe
NURSING LONG TERM SHORT TERM PLAN OF
ASSESSMENT CUES RATIONALE EXPECTED OUTCOMES
DIAGNOSIS OBJECTIVES OF CARE OBJECTIVES OF CARE INTERVENTIONS

S: “Generalized body Fatigue related to 1. To promote rest and Within the 8-hr shift, the Diagnostic: Short-term Outcome:
malaise” “Fever” hypermetabolic state recovery for the patient. patient will verbalize To monitor client’s V/S Any alteration or At the end of the shift, the
“Nausea and vomiting” secondary to MERS- improved sense of energy as well as the O2 sat. significant changes patient will verbalize
CoV as manifested 2. To promote conduct of and will participate in the may indicate possible improved sense of energy
O: Venoclysis with D5LR by generalized body activities that conserve facilitation of activities at complication as well as and participate in the
1L x 8 hours hooked at malaise, fever, energy to prevent the her level of ability. contributing factor to facilitation of activities at her
RMCV received at 500cc; nausea, and aggravation of fatigue. the fatigability of the level of ability.
with O2 inhalation vomiting. patient.
2.5Lpm via nasal cannula Long-term Outcomes:
To record fatigue levels
V/S: each hour during a 24- Recording fatigue 1. The patient will identify
T: 38.6 C HR: 88bpm hr period using Rhoten levels during a 24-hr the importance of having
RR: 23cpm O2 Sat: 95% fatigue scale wherein period will identify the adequate rest, thus
BP: 140/90mmHg the patient will rate times of peak energy, promoting recovery from
from the scale of 0 times of exhaustion, as fatigue.
being ‘not tired’ to 10 well as the activities
indicating ‘total that possibly aggravate 2. The patient will be able to
exhaustion’. fatigue. conduct activities that
It will also help in conserve energy, preventing
identifying which time possible aggravation of
of the day it will be fatigue.
suitable to conduct
certain interventions.
To assess the
emotional response of
 the patient to fatigue. Emotional responses
such as stress can have
an impact on the
metabolic demand of the
body.

Therapeutic:
To plan and schedule This will allow the
important tasks and patient to take periods
interventions during of rest in between
periods of high energy. activities, prevent
exhaustion and
promote maximum
participation.

To assist the patient in

prioritization and
facilitation of activities.
This will help limit the
metabolic demand of
the body and instead
conserve energy for
desired activities.

To discuss with the

patient some tasks
which can be delegated
to others.
Educative:
To inform the patient
about energy
Delegating non-
essential tasks to
others such as family
and relatives will help
conserve energy,
promoting rest and
recovery.
 conservation This will help conserve
techniques such as energy and thus,
placing work items promoting rest and
within reach, reducing recovery.
trips up and down the
stairs, and distributing
difficult tasks
throughout the week.

To emphasize the
importance of good Eating food made up of
nutrition and adequate complex
rest carbohydrates, and rich
in vitamins and
minerals will promote
faster recovery. The
same goes for having
To educate the patient an adequate rest
about the effects of periods.
stress on energy levels.
This will enhance a
patient's knowledge on
how energy is being
utilized when stressed.
NCP 4

This nursing care plan was done on September 17, 2020 – Thursday. Patient was admitted in the Negative Pressure Isolation Room with the diagnosis of MERS-CoV.
Patient was received awake, conscious, coherent, oriented to time, place, and person. Patient was lying on the bed, in a blanket.
HELLO ONLY & MADEL OKS LANG VAH inyo na sana interventions & rationale d2 hehe
NURSING LONG TERM SHORT TERM PLAN OF
ASSESSMENT CUES RATIONALE EXPECTED OUTCOMES
DIAGNOSIS OBJECTIVES OF CARE OBJECTIVES OF CARE INTERVENTIONS

S: Patient is fully aware Risk for Ineffective 1. To foster the After provision of health Diagnostic: Short-term Outcome:
of being hypertensive Self Health willingness of the patient teaching, the patient will Monitor client’s V/S Increase BP- primary Patients will be able to
and shares special Management to practice health verbalize understanding specifically the blood modifiable risk factor recognize the importance of
cravings for lechon and related to insufficient behaviors desired for of the importance of pressure. associated with complying to diet restrictions
chicharon bulaklak. knowledge of recovery from current complying to diet atherosclerotic and regular medical
Patient’s last medical condition and diet condition and restrictions and regular cardiovascular consultations in managing
consultation was a year restrictions. maintenance of HTN. medical consultations in disease. HPN and potential
ago (October 2019). managing HPN and complications.
2. To promote active potential complications.
O: Venoclysis with D5LR participation needed in (pag diagnostic pala Long-term Outcomes:
1L x 8 hours hooked at making necessary VS sha tsaka I&O
RMCV received at 500cc; lifestyle changes. monitoring mga katulad 1. After hospital stay, patient
with O2 inhalation non hehe will exhibit willingness to
2.5Lpm via nasal cannula di kasama lab tests tas initiate necessary lifestyle
pag Therapeutic changes independently.
V/S:
T: 38.6 C HR: 88bpm mga drugs) 2. Patient will exhibit
RR: 23cpm O2 Sat: 95% remarkable compliance in
BP: 140/90mmHg terms of follow up
consultations, diet
restrictions, and
maintenance of HTN
medications.

Therapeutic:

Educative:
Encourage the client to Exercising for 30-60
do aerobic exercise- minutes each day can
moderate to intensity help you lose weight
for 30-60 minutes each which can help to
day decrease the blood
pressure.

Eating a diet that is rich

Encourage the client to in whole grains, fruits,
eat healthy meals and vegetables and low-fat
to lessen foods that dairy products and
contribute to her skimps on saturated fat
hypertension. and cholesterol can
. lower the blood
pressure.

Avoid foods that are Eating too much fat

rich in saturated fats. can cause overweight,
and it may increase
blood pressure and risk
of heart disease and
 stroke. Eating too
much fat, especially
saturated fats, also
raises the amount of
cholesterol in your
blood.