TARLAC STATE UNIVERSITY

COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Awarded Level III Status by the Accrediting Agency of Chartered Colleges and Universities in the Philippines

GERIATRIC NURSING
NCM 114 CLINICAL
LABORATORY Case Study:
Covid-19 October 15, 2021

Submitted by:

BSN 3B – Group 1 & 2

Abraham, Zhanne Mae Velasco Alcover, Jannah Mae Sagun

Acosta, Grace Patugan Crisostomo, Micaela Escaño
Aguiflor, Mia Pearl Pauline Dagdag, Jan Coline San Diego
Agustin, Trixie Pablo De Vera, Rochelle Galeon
Antalan, Jasmine Majen Del Mundo, Zyrelle Manaloto
Baldemor, Nicah Mae Dacoco Dela Cruz, Jemima Aleeyah Libed
Basco, Tracy Kate De Guzman Dela Rosa, Angela Reyes
Bautista, Clarissa Mariano Fariñas, Florence Dumawal
Camba, Tricia Mae Moreno Garcia, Crishane Jan Ulan
Castillo, Chloe Pauline Garcia, Princess Mauree Escaño
Cerezo, Cathy Maye Magpantay Gaviola, Kathleen Kyle Concepcion
Constante, Marielle Del Rosario Gayla, Abish Marieza Leybag
Espino, Josh Rean Natividad Rivera, John Benedict Romero
Rarugal, Nadine Asis

Maria Teresa Mendoza, RN., MSN.

Clinical Instructor
I. 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 metre apart from others,
wearing a properly fitted mask, and washing your hands or using an alcohol-based rub frequently.

Get vaccinated when it’s your turn and follow local guidance.

II. NURSING PROCESS A. ASSESSMENT

1. Personal Data
a. Demographic Data
Name: Maria Teresa Mendoza
Age: 65 y/o
Sex: Female
Civil Status: Married
Occupation: Head Nurse
Position in the Family: Mother
Address: 066 Marcos Street Aguso, Tarlac
Date of Birth: July 21, 1956
Place of Birth: Tarlac, Tarlac
Nationality: Filipino
Chief Complaint: Shortness of breath, dry Cough, fever, loss of taste & smell
Date of Admission: October 5, 2021
Admitting Diagnosis: Patient Under Investigation (Covid-19)

b. Environmental Status
The patient is living in an apartment in 066 Marcos Street Aguso, Tarlac that does not

have enough windows resulting to poor ventilation. She lives with her husband and daughter.
c. Lifestyle
Patient M works in the hospital as a head nurse. Therefore, she is
exposed to different kinds of contagious diseases. She plays bingo with her
friends during weekends or whenever she has free time to spare. She shares her
hobbies with her daughter which is shopping clothes during their free time.
2. Family History
 Based on the diagram above, the patient has a history of asthma during her childhood but during the
present time, it became asymptomatic then resulted positive with Covid-19. Her sibling has Asthma but there
are no further complications occurred. Her father is already deceased, but her mother is still well and
alive without any presence of disease. It is seen that both of her parent’s side, paternal and maternal side,
has asthma as a hereditary disease that are being passed to every new generation in the family.

3. History of Past Illness

Patient M, a 65-year-old female, has a medical history of asthma when she was younger. Hence,
the patient had a Bronchoscopy procedure (March 6, 2009) to check the airways, chest and lung
problems that resulted to the shortness of breath and difficulty of breathing of the patient. There was
no allergies, accidents and injuries being noted. Lastly, the patient has no travel history.

4. History of Present Illness

Patient M was admitted to the hospital with a chief complaint of shortness of breath, dry cough, fever
and a loss of taste and smell. She stated that she has been experiencing weakness and gets tired
easily. She claims that she is nonsmoker and has history of asthma. The medications being noted
are Remdesivir, Dexamethasone 5 mg/tab BID, Tocilizumab infusion, Vital signs were taken:
Temperature of 38.7°C, respiratory rate of 32 cpm, heart rate of 110 bpm, blood pressure of
130/90mmHg and O2 sat of 87%. She weighs 138 lbs and stands at 5 ft and 4 inches tall.
5. Physical Assessment (13 Areas of Assessment)
AREA OF ASSESSMENT FINDINGS
1. Social Status Patient M, 65 years old woman,
lives in 066 Marcos Street Aguso,
Tarlac with her husband and
daughter. She was born in Tarlac
on July 21, 1956. The patient is
Roman Catholic. She is working
as a head nurse at Tarlac
Provincial Hospital for 8 years.
She has a good reputation in her
workplace. At their home, she is a
loving wife to her husband and a
loving mother to their daughter.
Due to her present illness, her
work and interaction with others
was affected. She was required to
self-quarantine and isolate
herself from others.
2. Mental Status The patient is conscious, alert,
and coherent. She is very
responsive in verbal stimuli,
noise, light, touch, and pain
stimuli. She is oriented to current
time, date, and place. She is very
responsive and collaborative.
During the interview, signs of fear
and anxiety was noted.
NORMS
Social status includes family
relationships /friendships that state
the patient’s support system in
time of stress and in time of need.
It meets a fundament human need
for social ties, making life less
stressful and social support buffers
the negative effects of stress, thus
indicating indirectly contributing to
good health outcomes (Friedman
and Smith 1988).
The content of the patient’s
message should make sense. The
ability to read and write should
match the patient’s educational
level. The patient should be able to
correctly respond to questions and
to identify all the objects as
requested. The patient should be
able to evaluate and act
ANAYLYSIS
Based on the above statements,
Patient M has a good relationship
with her husband, daughter, and
colleagues. But due to Patient’s
M condition her social status is
affected. COVID-19 is mostly
spreads from person to person
through respiratory droplets that are
released when you breathe, talk,
cough, or sneeze, therefore her
condition strictly forces her to
restrain interactions from her family
and outside their home.
Patient M is very responsive upon
interaction. These are the major
determinants that the patient’s
mental capabilities are functioning
well. The signs of fear and anxiety
was due to Patient M’s positive
result in the COVID-19 antigen test
and the thought of transmitting the
virus to her family. COVID-19 related
 appropriately in situations requiring fears recruit not only fear of the
judgment (Health Assessment and unknown but also the anxiety that
Physical Examination 3rd Edition accompanies situations that are
by Mary Ellen Zator Estes). unpredictable and uncontrollable
(Coelho, C. M., et al., 2020).
3. Emotional Status Patient M has a good support The integrity versus despair stage Based on the statements above,
system from her family. She is begins as the aging adult begins to although she is worried about her
very cooperative during the tackle the problem of his or her current health condition, it shows

interview. According to Patient M, mortality (Erik Erikson’s stage that the patient is able to express her
she is worried that she might theory of psychosocial feelings properly. She is also able to
have transmitted the COVID-19 development). share her feelings with the people in
virus to her family and that her family.
because she is already old, she is
afraid of the complications that
can arise from it.
4. Sensory Perception

Sense of Sight In assessing the vision, patient is The eyes must be symmetrical The patient’s eyes are symmetrical
instructed to look straight to during the six cardinal gaze’s with no lesion or swelling assessed,
observe the general appearance tests. The sclera should be white sclera is white and papillary
of her eyes. Thepatient has a
with some small blood vessels. response is normal. Patient M’s
pinkish palpebral conjunctiva,
Papillary constrictions should occur blurring of vision is due to aging
black irises, white sclera,
eyebrows, and eyelashes that are when struck by light (Health process.
evenly distributed. When light is Assessment and Physical
being directed to her eyes, her Examination, Mary Ellen Zator
pupil constricts and dilates when
the light has been taken away. Estes).
Both eyes move symmetrically in
each 6 cardinal
movements. Patient M is using
reading glasses due to
blurring of
 vision.

Sense of Taste

Sense of Hearing

Sense of Smell
The patients’ tongue is pink Taste is intact in the posterior one Less research has been done on
with whitish coating which is third of the tongue (Health how COVID-19 specifically affects
normal; there are no lesions Assessment and Physical taste. Since loss of smell and loss of
noted. Patient M reported no Examination, Mary Ellen Zator taste often occur together, it’s
sense of taste. Estes). currently believed that people with
COVID-19 likely experience loss of
taste as a consequence of loss of
smell.

The patient’s ears are For auditory acuity, the patient Upon assessment, the patient’s ear
symmetrical in shape and have should be able to repeat the words and auditory accuracy is normal.
the same color with the skin. whispered from a distance of two There are also no signs of ear
There is no redness or swelling feet (Health Assessment and infection.
on her ears. There was no Physical Examination, Mary Ellen
complain of pain upon the Zator Estes).
assessment of her ears. No
presence of discharge or any foul
odor noted. Ears were both clean
and no earwax found. Based on
the 2ft whisper test, she was able
to repeat the words clear and
correctly.

The patient’s nose is located Nose must be symmetrical and Temporary loss of smell, known as
on the midline of the face. There along of the face. Each nostril must anosmia, is a commonly reported
are
 no swelling, masses, and
discharges noted. The nasal
structure is firm but both of her
nostrils are congested. Patient M
reported no sense of smell.
Tactile The patient is very responsive in
noise, light, touch and pain
stimuli. She was also able to
identify the things we let her hold
such as: coins, keys, and phone.
be patent and recognize the smell
of an object (Health Assessment
and Physical Examination, Mary
Ellen Zator Estes).
The skin contains receptors for
pain, touch, pressure, and
temperature. These receptors
originate in the dermis and
terminate as either free nerve
endings throughout the skin’s
surface or as special touch
receptors that are encapsulated
and found predominantly in the
fingertips and lips. Sensory signals
indicator of COVID-19. The novel
coronavirus likely changes the sense
of smell in patients not by directly
infecting neurons, but by affecting
the function of supporting cells.
(Sandeep Robert Datta, 2021) A
stuffy nose—aka, "congestion or
runny nose"— is classified as a
symptom of the
coronavirus, according to the
Centers for Disease Control and
Prevention, but it's not necessarily
considered "the quintessential
symptom". Based on the patient’s
environmental status, congestion
can be the result of poor ventilation
because the patient is constantly
breathing re-circulated air.
The patient’s sense of touch
is functioning well because she was
able to respond well during
interaction and is able to recognize
objects with her eyes close.

5. Motor Stability During assessment, the patient is
experiencing a mild shortness of
breath therefore, she was not
comfortable in any position other
than the Semi-Fowler’sThere should be absence of
position. She finds walking,
sitting, or changing positions
difficult. She also feels unwell that
is why she needs the help or
assistance of another person
when she needs to do certain
things like going to
the bathroom.
6. Body Temperature Upon assessment, the patient’s
temperature is 38.7⁰C.
that help determine precise
locations on the skin are
transmitted along rapid sensory
pathways, and less distinct signals
such as pressure or poorly
localized touch are sent via slower
sensory pathways (Health
Assessment and Physical
Examination, Estes 2006).
The patient remains erect and Based on the assessment, she
balanced during all stages of gait. moves limitedly due to her present
The patient should be able to condition. The semi-fowler’s
transfer easily to various positions. position decreases work of
breathing, increases lung volume
discomfort during range of motion and ventilation, and lung dilation is
exercise (Health Assessment and promoted; these changes can
Physical Examination, Mary Ellen improve oxygenation and increase
Zator Estes). oxygen saturation.
Normal axillary temperature is
Patient M’s temperature is above
within 36.4⁰C to 37.4⁰C (Health the normal range. Fever is often
Assessment and Physical referred to as the most common
Examination 3rd edition by Mary symptom of COVID-19. Fever is one

Ellen Bator Estes). of the ways your body tries to fight

off
infection.
7. Respiratory Status The patient’s respiratory rate is Normal respiratory rate for adults is Shortness of breath is one of the
32cpm and O2 sat of 87%. 12-20cpm. Average is 18. In terms hallmark symptoms of COVID-19
 During assessment, Patient M
had episodes of dry cough and
showed signs of breathing
difficulty.
8. Circulatory Status Patient M’s blood pressure is
130/90mmHg and her cardiac
rate is 110 bpm. During the
assessment of her capillary refill,
the color returned immediately
after 2 seconds.
9. Nutritional Status Based on the assessment, the
patient weighs 138 lbs and stands
at 5 ft and 4 inches tall. The
calculated BMI is 24. According to
Patient M, she usually drinks 8
glasses of water and eats 3 times
a day but due to loss of taste
her appetite was
affected. Patient M stated that
of pattern, normal respirations must
be regular and even in rhythm. The
normal depth of respirations is non-
exaggerated and effortless (Health
Assessment and Physical
Examination 3rd edition by Mary
Ellen Zator Estes).
The normal cardiac rate for an
adult is 60-100 beats per minute
while the normal blood pressure is
120/80mmHg. The normal capillary
refill test is 2-3 seconds and upon
capillary refill test was done it
returns to normal state within 2-3
seconds (Kozier, Fundamentals of
Nursing 7th Edition).
The main diet focus for COVID
patients is to consume foods that
would help rebuild muscle,
immunity and energy levels. Whole
grains like ragi, oats or amaranth
are rich sources of complex
carbohydrates. Chicken, fish, eggs,
paneer, soya, nuts and seeds are
some good sources of protein.
and the lungs are the organs most
affected by COVID-19. With COVID-
19, the immune response disrupts
normal oxygen transfer in the lungs,
and fluid can build up. Nearly half of
patients with COVID-19 have a
cough. This cough is dry, persistent
and can make it hard to breathe.
The blood pressure is slightly
elevated, however, in older patients,
there's a reduction in elastic tissue in
the arteries, causing them to
become stiffer and less compliant,
thus increasing blood pressure as a
person age. Therefore, the blood
pressure is within normal limits. And
a result of low oxygen saturation the
heart rate increases as the body
attempts to compensate for the low
levels of oxygen in the blood.
The BMI of the patient is within
normal limits. The patient drinks
adequate fluids, however, food
intake was affected due to loss of
taste. The patient was given foods
high in carbohydrates to help battle
the fatigue that is commonly felt in a
post-COVID patients, high in protein
to boost immune system, and High-
 she has no allergies to
foods. During admission, the food
served to Patient M is foods that
are rich in protein, fiber, and
carbohydrates.
10. Elimination Status According to Patient M, she
usually pees 3 times a day. With
regards with her bowel
movement, she defecates once a
day and said that’s it’s not
loose/watery. Urine color
assessed was yellowish and with
no foul odor.
11. Reproductive Status According to Patient M, she had
her first menstruation at the age
of 16 and got pregnant at the age
of 28. She menopaused at the
age of 48 and has no history of
sexually transmitted
infection/disease.
12. Sleep Rest Pattern The patient usually sleeps at least
5-6 hours depending on her
working shift. Patient M reported
difficulty in sleeping due to her
present condition: fever, dry
Healthy fats like walnuts, almonds, fiber diet that plays a role in
olive oil, mustard oil are controlling the inflammation
recommended during these days. associated with COVID-19.
To boost one’s immunity, one
should take turmeric milk once a
day (Times of India, 2021).
Normal bowel movement of a The patient’s elimination status is
person must be 1 to 2 times a day normal based on the norms. No
and voiding in 3 to 4 times a day abnormalities of urine or stool.
with an output of 1200 to 1500mL a
day. A normal stool is brown in
color and well formed, urine is clear
to yellowish in color (Fundamentals
of Nursing, Kozier,
2007).
Menarche, which is the first Based on the assessment, she has a
menstruation occur at an average normal reproductive status and has
age of onset between 9 to 17 years no sexually transmitted disease
old. Pregnancy may occur from noted.
stage of menarche up to cessation
of menstrual period. Menopause
occurs with age range of 40 to 55
(Maternal and Child Health nursing
fourth Edition by Pilliterri).
Sleep refers to altered Her sleep-rest pattern is not normal
consciousness with general based on the norms stated. Her
slowing of physiological process sleep pattern is compromised due to
while rest refers to relaxation and her line of profession and present
calmness, both mental and condition. “Coronasomnia” is a new
 cough, nasal congestion, and physical. A typical sleeper will pass term that refers to sleep problems
feeling unwell. Patient M also through 7 to 9 hours of sleep and related to the pandemic. With
states that due to stress and take a rest using some relaxation increased stress and anxiety, there
anxiety she cannot sleep activities such as reading, telling is a definite impact on our sleep and
properly. stories and others (Nursing mental health
Fundamentals by Rick Daniels). (www.sleepfoundation.org).
13. State of Skin Patient M has a light brown The palpebral conjunctiva should Patient M has a normal state of skin
Appendages complexion. She has pink and appear pink and moist. Normally, appendages based on the norms
moist conjunctiva. Her fingernails the skin is a uniform whitish pink or stated.
and toenails are all clean and brown color, depending on the
neat. No skin rashes and allergies patient’s race. Normally, the
noted upon inspection. nails have a pink cast in light-
skinned individuals and are brown
in dark- skinned individuals (Health
assessment and physical
examination 3rd edition by Mary
Ellen Zator Estes).
 6. Laboratory and Diagnostic Procedures

Diagnostic/ Analysis and Nursing responsibilities prior to,

laboratory Indication/ Purposes Result interpretation of results
during, and after the procedure
procedure (related to the disease)
Antigen Rapid Antigen rapid test is A visible red line on the test When a sample swab Before:
Test (Antigen done when the client (T) and control (C) lines.
taking form nose is placed Make sure to disinfect the area
Test) shows recent on lateral flow test, similar where sample is prepared.
symptoms or had to structure of pregnancy Ask the patient getting swab
exposure to people test and created two
test if they have recent
infected with Covid- vertical lines, it signals that
symptoms of covid-19.
19. the sample is positive.
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.
Tell the patient that the test may
take some minutes and be felt
uncomfortable especially when it
is taken form nasopharynx.

During:
Ask the client to stay still and not
make unnecessary movements
until the procedure is done.
 After:
Label and send the
sample immediately to
Polymerase The PCR test was A detection of virus was A nasal swab test was the laboratory for
Chain Reaction developed to detect present. collected from the back of analysis.
(PCR Test) live organisms in a the client's nose and put Collaborate with other healthcare
sample obtained by members, particularly medical
a into a PCR machine for technologist.
nasopharyngeal Before:
swab detection; the result came
Establish rapport with the
(commonly known as back as positive, indicating
patient and S/O.
a nose swab). that the virus had been
During the swab test, inquire if
found.
the patient has experienced any
recent symptoms of covid-19.
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.
Preparation of the necessary
and equipment and materials.

Preparation of a consent

form, if necessary.
During:
Use conventional precautions
or sterile procedure. During
the procedure, request

Chest X- An imaging test that Bilateral air space opacification
ray (CXR) helps doctors to
discern the condition Normal result:
of the lungs, heart Hollow structures containing
and blood vessels. 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.
Arterial Te meas th
that the client remain
motionless and refrain from
making needless movements
until the treatment is completed
and assess its response.
Assuring that the specimen
is properly labeled, stored,
and transported.
After:
Compare the results of
past and current tests.
Collaborate with the appropriate
members of the healthcare team,
particularly the medical
technologist.
Presence of viral lung Before:
infection causing Instruct the patient
inflammation and fluid regarding the procedure.
build-up in the lungs. Assist the patient to the x-
ray room.
Instruct the patient to wear
x-ray gown and remove any
jewelry or metallic objects.
Assess the patient’s ability
to hold her breath.
Educate the patient about
the procedure.
Blood st ures e (ABG) dity H) nd e
Gas aci (p a th levels of oxygen and
carbon dioxide in the After:
blood from an artery. Collaborate with other
This test is used to healthcare member,
find out how well particularly to a
the
pH: 7.20 The result indicates radiologist.
lungs are able to
PaO2: 70 mmHg increase level of carbon Before:
move oxygen into
PaCO2: 48 mmHg dioxide in the blood Explain the procedure to
the
HCO3: 24 mEq/L (hypercarbia) resulting the patient.
blood and remove
to respiratory acidosis
carbon dioxide from Tell the patient that the test
with hypoxemia or
the blood. Normal values: requires a blood sample.
decrease level of
pH: 7.35 - 7.45 Explain to the patient, who will
oxygen in the blood.
PaO2: 80 - 100 mmHg perform the arterial puncture,
PaCO2: 35 - 45 mmHg when it will occur, and where
HCO3: 22 - 26 mEq/L the puncture site will be; radial,
brachial, or femoral artery.
Inform the patient that she may
not need to restrict food and
fluids. Instruct
the patient to breathe
normally during the test, and
warn her that she may
experience a brief pain at the
puncture site.

After:
Monitor puncture site for oozing
blood or hematoma formation.
Ensure correct labeling, secure
and deliver the specimen to the
laboratory immediately.
7. Anatomy and Physiology The Upper Respiratory Tract
The upper respiratory system, or upper respiratory tract, consists of the nose and nasal
cavity, the pharynx, and the larynx. These structures allow us to breathe and speak. They warm
and clean the air we inhale mucous membranes lining upper respiratory structures trap some
foreign particles, including smoke and other pollutants, before the air travels down to the lungs.

The Lower Respiratory Tract

The lower respiratory system, or lower respiratory tract, consists of the trachea, the bronchi and
bronchioles, and the alveoli, which make up the lungs. These structures pull in air from the upper
respiratory system, absorb the oxygen, and release carbon dioxide in exchange. Other structures, namely
the thoracic cage (or rib cage) and the diaphragm, protect and support these functions.

Mechanics of Breathing
Breathing or pulmonary ventilation is a mechanical process that depends on
volume changes occurring in the thoracic cavity. There are two phases of breathing-
inspiration, where air flows into the lungs, and expiration, when air leaves the lungs.
Inspiration (inhalation) is the process of taking air into the lungs. It is the active
phase of ventilation because it is the result of muscle contraction. During
inspiration, the diaphragm contracts and the thoracic cavity increases in volume.
This decreases the intra-alveolar pressure so that air flows into the lungs.
Expiration (exhalation) is the process of letting air out of the lungs during the
breathing cycle. In healthy people is largely a passive process that depends on
the natural elasticity of the lungs rather than muscle contraction.

Respiratory Sounds
Breath sounds may be heard with a stethoscope during inspiration and expiration—a
practice known as auscultation. As air flows onto and out of the respiratory tree, it produces
two recognizable sounds that can be picked up with a stethoscope.
Bronchial Sounds – produced by air rushing through the large respiratory
passageway (trachea and bronchi).
Vesicular Breathing Sounds – occur as air fills the alveoli, they are soft
murmurs that resemble a muffled breeze.

Normal Respiratory Rate

The range of normal respiratory rates for an adult is 12-20bpm. Children breathe at 15 to 30 times
a minute. The newborn can even have a rate of up to 60 BPM. To determine respiratory rate, counts the
rise and fall of the patient’s chest for one minute. (Remember that the patient may become self-conscious
and alter his breathing rate if he knows you are watching.) For a patient in distress, respirations less than
ten per minute or greater than 24/min need to be supplemented with high flow oxygen.
8. Pathophysiology [Book-based Pathophysiology]
[Client-based Pathophysiology]
B. PLANNING

NURSING CARE PLANS

NURSING CARE PLAN NO. 1

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE: Impaired gas exchange SHORT TERM: INDEPENDENT: SHORT TERM:
“hirap akong huminga related to ventilation- Within 2-4 hours of - Introduce self to the - To establish rapport After 2-4 hours of nursing
nitong nakaraang araw, perfusion inequality due to nursing intervention, the client. Use calm, and ensure intervention, the patient
pakiramdam ko hinang fluid build-up in the lungs patient will be able to: reassuring approach; cooperation. The was able to:
hina ako” as verbalized by as evidenced by - Demonstrate Explain all procedures, patient’s feeling of - Demonstrate
the patient shortness of breath and improved ventilation including sensations stability increases in a improved ventilation
alteration in vital signs. and adequate likely to be calm and non- and adequate
OBJECTIVE: oxygenation as experienced during the threatening oxygenation as
- Dyspnea evidenced by blood procedure environment. evidenced by blood
- hypoxemia gas levels within gas levels within
- Fatigue normal parameters normal parameters
- Use of accessory - Relaxed breathing - Monitor the patients - To monitor - Relaxed breathing
muscle upon - Sustain v/s within vital signs, especially effectiveness of - Maintain v/s within
breathing/retractions normal range: the oxygen saturation interventions and normal range:
- Chest x-ray shows and characteristics of medical treatment
bilateral opacification RR 12-20 cpm respiration q 30 RR 12-20 cpm
of airspace PR: 60-100bpm minutes PR: 60-100bpm
- ABGs test BP: 120/80mmHg BP: 120/80mmHg
interpretation - T: 36.1°C – 37.2°C T: 36.1°C – 37.2°C
respiratory acidosis - Determine level of - Decreased level of
- Alteration in LONG TERM: consciousness and consciousness can be LONG TERM:
physiologic status After the client’s stay at mentation changes an indirect After the client’s stay at
the hospital, the client will using Glasgow Coma measurement of the hospital, the client was
VITAL SIGNS: be able to: scale impaired oxygenation able to:
BP: 130/90 - Maintain clear lung - Maintain clear lung
RR: 32 cpm fields and remain free fields and remain free
HR:110 bpm of signs of respiratory - Elevate patient bed - Positioning helps of signs of respiratory
TEMP: 38.7 C distress into semi fowler’s maximize lung distress
O2Sat:87% position as necessary expansion and
decreases respiratory GOAL WAS MET.
effort.

- Observe for cyanosis - Central cyanosis of

of the skin; especially the tongue and oral
note color of the mucosa is indicative of
tongue and oral serious hypoxia and is
mucous membranes. a medical emergency.

- Cool, pale skin may

- Observe for the skin, be secondary to a
nail beds, and mucous compensatory
membranes for pallor vasoconstrictive
or cyanosis response to
hypoxemia

- Controlled coughing
- Help the client deep uses the
breath and perform diaphragmatic
controlled coughing. muscles, which makes
Have the client inhale the cough more
deeply, hold the breath forceful and effective.
for several seconds,
and cough two or
three times with the
mouth open while
tightening the upper
abdominal muscles as
 tolerated.

- Routinely check the -

patient’s position
so that she does
not slump down in
bed

-
- Change the client’s
position every 2 hours

- The hy
- Schedule nursing care
to provide rest and
minimize fatigue

DEPENDENT: -
- Deliver humidified
oxygen as prescribed
through an appropriate
device (nasal cannula
or venture mask per
the HCP’s order)
and monitor the
patient’s response.
compliance.
COLLABORATIVE:
- Monitor oxygen - To det
saturation
continuously using
pulse oximetry. Note
blood gas results as
available

- Assist in performing -
slow deep breathing,
using an incentive
spirometer as
indicated

- Anticipate the need for -

intubation and
mechanical ventilation
prevent full
decompensation of
the patient. It provides
a supportive care to
maintain adequate
oxygenation and
ventilation

ASSESSMENT
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:
Temperature: 38.2°C
Respiratory rate: 32 cpm
Heart rate of 130 bpm
Blood pressure:
180/100mmHg
O2 sat: 87%
DIAGNOSIS
Ineffective breathing
pattern related to covid-19
as evidence by shortness
of breath
NURSING CARE PLAN NO. 2
PLANNING INTERVENTION RATIONALE EVALUATION
SHORT TERM: INDEPENDENT: SHORT TERM:
After 3-4 hours of proper - Established rapport. - By developing a After 4 hours of proper
nursing interventions the positive relationship nursing interventions the
patient will be able to: with a patient and SO patient was able to:
- Establish effective enables the health - Establish effective
breathing pattern care practitioner to breathing pattern as
manifested by normal elicit pertinent evidenced by
vital signs and oxygen information and make respiratory rate of 16
saturation informed clinical cpm, pulse rate of 72,
- Demonstrates decisions about their BP of 120/80 mmHg
maximum lung treatment. and oxygen saturation
expansion with of 95%
adequate ventilation. - Demonstrated
- Position the patient - Sitting position can maximum lung
LONG TERM: with a proper body maximum lung expansion with
After 1-2 days of proper alignment for excursion and chest adequate ventilation.
nursing interventions the maximum breathing expansion.
patient will be able to: pattern. LONG TERM:
- ABG levels return to After 2 days of proper
and remain within nursing interventions the
established limits. - Evaluate skin color, - Lacking of oxygen will patient was able to:
- Verbalize proper ways temperature, capillary cause blue/cyanosis - Return ABG to and
on how to follow refill by observing the coloring to the lips, remained within
protocols such as; central versus tongue, and fingers. established limits .
wearing mask and peripheral cyanosis. Cyanosis to the inside - Verbalized proper
face shield, of the mouth is a ways on how to follow
importance of medical emergency. protocols such as;
vaccine, and use wearing mask and
alcohol/sanitizer when face shield,
going out. - Encourage deep - A controlled breathing importance of vaccine,
- Verbalize breathing techniques method may also aid and use
understanding of once stable slow respirations in
various breathing tachypneic patients.
techniques to Which a prolonged
establish eupnea expiration prevents air
during episodes of trapping
respiratory distress.

- Stay with the patient - This will reduce the

during acute episodes patient’s anxiety,
of respiratory distress. thereby reducing
oxygen demand.

- Ensure optimal room - To aid in establishing

ventilation by effective breathing
inspecting equipments pattern,
that supply air.

DEPENDENT:
- Initiate oxygen therapy - To increase oxygen
as indicated by the supply to the body
physician

- Administer - To address the

medications problem that causes
prescribed by the ineffective breathing.
physician

COLLABORATIVE:
- Check the availability - In case of emergency
 of intubation procedure, equipment
equipment and ready for intubation should
to assist. be readily available.

NURSING CARE PLAN NO. 3

ASSESSMENT DIAGNOSIS EVALUATION
PLANNING INTERVENTION RATIONALE
SUBJECTIVE: Hyperthermia related to SHORT TERM:
SHORT TERM: INDEPENDENT:
“ilang araw na pong disease process as Within 1-2 hours of
Within 1-2 hours of - Monitor vital signs. - Vital signs provide
mataas ang lagnat ko” as evidenced by temperature
nursing intervention, the more accurate proper nursing
verbalized by the patient. higher than normal. patient will manifest indication of core intervention, the patient
decrease in body temperature. manifested decrease in
OBJECTIVE: body temperature from
temperature from 38.7°c
Warm to touch 38.7°c to 37°c.
to 37°c.
Chills
- Place the patient - To prevent the
Restlessness
LONG TERM: under appropriate transmission of the
LONG TERM:
Within the 8 hours of isolation. disease.
Vital signs were Within the 8 hours of
nursing intervention, the
taken as follows: nursing intervention,
patient will be able to:
BP: 130/90mmHg the patient was able to:
RR: 32cpm PR: 110 bpm
Maintain normal body - Place patient in a cool - Environment factors
temperature. and quiet environment. relatively minor
Temp: 38.7°c O2 SAT: 87% Maintain normal
Will have adequate rest infections can produce
body temperature.
and appear relax much higher
have adequate rest
temperature.
and appeared relax.
Goal was met.
- Provide tepid sponge - Enhances heat loss
bath. by evaporation &
conduction.

- Eliminate excess - To decrease warmth

clothing and covers. and provide comfort.
- Provide adequate rest.

- Monitor/record all
sources of fluid loss.

- Instruct patient to
increase oral fluid
intake.

- Monitor vital signs and

recheck

DEPENDENT:
- Administer
medications as
ordered by the
physician.
 COLLABORATIVE: response
- Administer -O2 SAT: to
replacement fluids and 87% physical
electrolytes. -The
patient
will have
- Facilitate laboratory
workups.

NURSING CARE PLAN NO. 4

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION
SUBJECTIVE: Activity intolerance related SHORT-TERM: INDEPENDENT:
“Hindi po ako to limited ROM due to After 1-2 hours of - Monitor vital and
komportable gumalaw.” bedrest secondary to proper nursing cognitive signs, watching
As stated by the patient. COVID-19. intervention, the patient for changes in
- Chief complaints: will be able to: blood pressure, heart, and
shortness of breath, Dry respiratory rates; note skin
Cough, and a Fever -Report measurable pallor and/or cyanosis and
- Hyposmia & ageusia increase in activity presence of confusion.
- difficulty in sleeping due tolerance.
to feeling unwell and nasal -Demonstrate a decrease
congestion. in physiological signs of
- weakness intolerance (pulse,
- easily getting tired respirations, and blood
pressure will improve) -Note client reports of
OBJECTIVE: -diminish shortness of weakness, fatigue, pain,
VS: breath difficulty accomplishing
-BP: 1300/90mmHg tasks, and/or insomnia.
-RR 32 cpm LONG-TERM:
-PR: 110 bpm After 24 hours of proper
-T: 38.7°C nursing intervention: - Assess cardiopulmonary
- To support circulating
volume and Tissue
perfusion.

- To relay to the
physician for further
medical interventions.
 RATIONALE EVALUATION
SHORT-TERM:
-Alteration in vital signs After 1-2 hours of
may be the contributing proper nursing
factors in the activity intervention, the patient
intolerance of the patient. was able to:
The stated parameters are
helpful in assessing -Report measurable
physiological responses to increase in activity
the stress of activity and, if tolerance.
present, are indicators of -Demonstrate a decrease
overexertion. in physiological signs of
intolerance (pulse,
respirations, and blood
-Symptoms may be a pressure will improve)
result of or contribute to -diminish shortness of
intolerance of activity. breath

GOALS WERE
ACHIEVED.
- Dramatic changes in
heart rate and rhythm, LONG-TERM:
After 24 hours of proper
-limited ROM due to stable vital signs while kness
bedrest being active. and
-dyspneic -The patient will exhibit fatigue.
-conscious tolerance of increased -The
-coherent physical activity. patient will
-alert -The patient will maintain be free of
normal level of signs of
consciousness, respirat
coherence, and alertness. ory
 activity, including vital - Assist with activities and provide/monitor client’s
distress.
signs, before, during,
and after activity. Note
Accelerating fatigue.

- Determine the client’s

current activity level and
physical
condition with
observation, exercise-
capacity testing, or use
of a functional level
classification system (e.g.,
Gordon’s), as appropriate.

- Reduce intensity
level or discontinue
activities that cause
undesired
physiological changes.

- Plan care to carefully

balance rest periods
with activities
changes in usual blood nursing intervention: signs of n. ACHIEVED.
pressure, and weakness
progressively worsening -The patient demonstrated and
fatigue result from an stable vital signs while fatigue.
imbalance of being active. -The
oxygen supply and -The patient has exhibited patient was
demand. tolerance of increased free of -To reduce fatigue.
physical activity. signs of
-The patient has respirator
- This provides a baseline maintained normal level of y
for comparison and consciousness, distress.
an opportunity to track coherence, and alertness. -To prevent GOALS - To protect client from injury.
changes. - The patient was free of overexertio WERE
use of
assistive devices (e.g., COLLABORA
crutches, walker, -
wheelchair, or oxygen physiologist, psychological counseling/therapy,
tank). occupational/physical therapists, and recreation/leisure
specialists, as indicated.

- Assist client/SO(s)
with planning for changes that may
become necessary,
such as use of
supplemental oxygen.

DEPENDENT:
-Administer oxygen device
as ordered.
- To improve the client’s ability to participate in desired activities.

-Supplemental oxygen is
needed to reach partial
pressure of oxygen’s
acceptable level.

- To develop individually appropriate therapeutic regimens.

 C. IMPLEMENTATION

1. DRUG SUDY
Route, Dosage Mechanism of Nursing
Name of the Drug Side Effects / Adverse Effects
and Frequency Indication Contraindication responsibilities
Generic name: Route: Action Cardiovascular: Before:
Remdesivir IV Remdesivir (GS- Treatment for Hypersensitivity to Hypotension, Observe
5734) is a patients with drug or any arrhythmias, and proper aseptic
Brand name:
Day 1 loading phosphoramidite coronavirus disease ingredient cardiac arrest technique and
Veklury dose: prodrug of a 2019 (COVID 19) Patients with Pulmonary: Dyspnea, wearing of
Dosage: monophosphate infection. alanine Acute respiratory failure, PPE before
Drug classification 200 mg nucleoside analog aminotransferase acute respiratory handling the
Anti-Viral Drug (GS-441524) and (ALT) levels >5- distress, pneumothorax, patient.
Frequency: acts as a viral RNA- times upper limit of pulmonary embolism Identify patient
infused over dependent RNA normal or severe Hematological: Determine

30-120 min polymerase (RdRp) hepatic dysfunction Anemia, lymphopenia eGFR

inhibitor, targeting the Patient with severe Endocrine: (Estimated
Day 2: viral genome renal impairment. Hyperglycemia glomerular
Dosage: replication process. Infectious: Pneumonia, filtration rate).
100mg septic shock Determine
Frequency: Gastrointestinal: (ALT
q.d elevated lipase, nausea, prothrombin
vomiting, diarrhea, time.
constipation, poor Monitor
appetite, gastroparesis,
vital signs.
and lower GI bleeding
Hepatic: Hepatic During:
manifestation Observe
characterized by Grade patient's
1-4 increase in serum reaction
transaminases (ALT during the
and/or AST) are the administration
most common adverse of drug.
 effects seen in patients
treated with remdesivir. After:
Other abnormalities Note patient's
include response to
hyperbilirubinemia the drug.
Renal and Metabolic: Dispose PPE
Acute kidney injury or to proper
worsening of underlying receptacle
chronic kidney disease, after use.
hypernatremia, Perform
hypokalemia aseptic
Neurological: technique.
Headache,
lightheadedness
Skin: Rash, contact
dermatitis, pruritus
Generic name: Route:
Psychiatric: Delirium
Dexamethasone Oral Other adverse effects :
Pyrexia, insomnia, multi-
Generic name: Dosage: organ dysfunction, DVT,
Intensol 5 mg/tab and
hypersensitivity/anaphyl
Drug Frequency:
actic reactions
Classification: BID (twice a day)
related to the infusion
Corticosteroid/ anti- Side effects (systemic): Before:
Action is to decrease Dexamethasone is Hypersensitivity to drug
of inflammation of the a type of steroid or any ingredient. Insomnia Observe
neutrophil migration used to shutdown Patient with cerebral Edema in the Face proper aseptic
suppression and cytokines storms or Edema Abdominal distension technique and
reverses the High the massive amount Patient with Appetite(Increased) wearing of PPE
Capillary of inflammation that Hypertension, Renal, Diaphoresis before handling
permeability. This can damage the Respiratory, and Rash, Urticaria the patient.
Check Vital Signs
primary used as an lungs of the Rheumatic Disorders. Psychological changes such
Immunosuppressant patients. Monitor vital signs.

inflammatory agent (Anti- Therapeutic Effect : Infl amm

atory) for Hallucination Prepare the
various illness and Decrease medication
Adverse effects (Long-term
Observe 5 rights
Diseases Inflammation
Therapy): of medication
Osteoporosis administration.
Muscle Wasting Health education
Spontaneous must be given
Fractures Cataracts prior with the
Peptic Ulcers administering of
Severe Joint Pain the medication

During:
Administer the
Medication being
prescribed.
Advised to take
the medication
as needed.
Make sure that the
patient ingested
the given
medication by not
leaving the room
and wait for the
patient to swallow
the medication.

After:
Advised the
patient to notify
the health care
provider if side
effect is present.
 Document the
medication
given in the
patient’s chart
Regularly Monitor
Patients Vital
Signs. Because
administering
Dexamethasone
for elderly patients
has the higher risk
Generic name: Route:
in developing
Tocilizumab IV hypertension

Brand name: Dose: It is a recombinant It is indicated to Patients with the following Upper respiratory Before:
monoclonal antibody treat moderate to conditions: tract infections Check
Actemra 500 mg
used to treat cytokine severe rheumatoid Active tuberculosis Nasopharyngitis patient’s
(standard dose:
Drug Classification 8mg/kg [not to storms (a massive arthritis, giant cell Invasive fungal Headache medical
amount of arteritis, infections Hypertension record if
Il-6 inhibitor / exceed
inflammation that can polyarticular Bacterial and viral Increased ALT he/she is
immunomodulator / 800mg/dose])
Dizziness contraindicate
monoclonal cause damage to the juvenile idiopathic infections
Bronchitis d to the
antibodies Frequency: lungs and other arthritis, systemic Pneumonia
Rash medication.
STAT organs in the body). It juvenile idiopathic Cancer or malignancy
Mouth ulceration Assess
(immediately or at binds soluble and arthritis, and High cholesterol
Abdominal pain patient’s
once) membrane bound IL- cytokine release High amount of
Gastritis respiratory
6 receptors, syndrome. triglyceride in the blood
Increased transaminase status. Check
preventing IL-6 Low levels of
to see if
mediated neutrophils (a type of
he/she is
inflammation. This white blood cell)
under
medication is called Liver problems
respiratory
trackers for the
decompensati
severity of the
on and taking
COVID-19.
vasopressor.
Observe
proper aseptic
technique and
wearing of
PPE before
handling the
patient.
Explain the
importance of
the medication
to the patient
and how it can
help improve
his/her
condition.
Note for the 5
rights of
medication
administration.
Check if there
is an active
infection
including
localized
infections
present in the
patient.
Assess patient
for history of
active
tuberculosis,
pneumonia
 and cancer or
malignancy.
Check for
patient’s
laboratory
values,
including liver
enzymes,
absolute
neutrophil
count, and
platelet count.

During:
Observe
patient's
reaction
during the
administration
of drug.
Report
immediately if
unnecessary
reaction
occurs.
Maintain
dressings,
tubings, and
line integrity
of the patient
when giving
IV infusions.
After:
Observe and
note patient's
significant
responses to
the drug.
Instruct
him/her to
inform HCP
immediately if
unnecessary
reactions
occur.
Monitor
vital signs.
Dispose PPE
to proper
receptacle
after use.
Perform
aseptic
technique.
2. MEDICAL MANAGEMENT [IVFs, BT, nebulization, oxygen therapy, etc.]
GENERAL RESPONSIBILITIES
Medical management/ Date performed/
treatment changed/ General description
discontinued
Supplemental oxygen via October 10, 2021 Oxygen therapy refers to
high-flow nasal cannula the administration of
supplemental oxygen as
part of managing illness. It
may be administered as a
medical intervention to
manage short-term (acute)
or emergency situations or
as part of long-term
patient
Client’s reaction to Nursing responsibilities
Indication/ purpose treatment prior to, during, and
after administration
To increase the The client was able to Before:
amount of oxygen tolerate the therapy well. Determine the need
your lungs receive for oxygen therapy by
and deliver to blood verifying the written
To maintain normal order from the
hemoglobin saturation Physician, and
To facilitate normal hospital policy
oxygen delivery to Verify the patient’s
peripheral tissues identity using 2 patient
identifiers
Perform respiratory
assessment to
determine level of O2
therapy
Explain to the patient
the need for oxygen
per physician order
and hospital protocol
During:
Administer oxygen via
high-flow nasal
cannula
Be alert for skin
breakdown over the
 ears and in nostrils
from too tight an
application
Observe for
mucosal dryness
Check frequently
that both progs are
in client’s nares
Observe patient’s
response throughout
the therapy

After:
Document
administration of
therapy the route, time
Plain normal saline October 10, 2021 Normal Saline is a The following are primary The client was able toBefore:
solution (0.9% saline) prescription medicine indications for the use of tolerate the therapy well. Follow 10 rights
used for fluid and normal saline infusion: of administration.
electrolyte replenishment Extracellular fluid Review patient’s
for intravenous replacement (e.g., history of
administration. Normal dehydration, allergies before
Saline may be used alone hypovolemia, the administration
or with other medications. hemorrhage, sepsis) of medication
Treatment of Address patient’s
Normal Saline belongs to metabolic alkalosis in concerns regarding
the medication
a class of drugs called the presence of fluid
before administering
Crystalloid Fluid. loss
Document baseline
Mild sodium depletion data, assess
patient’s vital signs
Double check the

expiration date of
 medication to be
administered
Monitor intake and
output. Output ratio
must be maintained at
least 100 mL/4 hour.
Perform hand hygiene
and other infection
control procedures.

During:
Monitor vital signs
throughout the
administration.
Monitor the neurologic
status throughout the
therapy.
Invert container and
carefully inspect the
solution for
cloudiness, haze, or
particulate matter.
Only use if the
solution is clear and
container is sealed.

After:
Document
administration of the
medication the route,
time, and dosage.
Observe for possible
 adverse reactions
regarding the
medication that was
administered.
Instruct client or
significant others to
report any adverse
3. SURGICAL MANAGEMENT [No surgical management done.]
reactions occurred to
4. DIET primary care provider.
NAME OF PROCEDURE DATE PERFORMED BRIEF DESCRIPTION
Protein Rich Foods October 11, 2021 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 INDICATION/ PURPOSES
The nurse should be aware and
to help a patient overcome post-COVID
knowledgeable enough with the
weakness.
patient's nutritional requirements.

The nurse should be able to

High fiber foods October 11, 2021 The gut is an area where the immune
system thrives and so it is important to answer all the queries
keep the healthy gut bacteria thriving. accurately regarding the diet.
Probiotics such as curd can support
The nurse must provide the
healthy gut. Consuming dietary fibre that
client with an environment with
can be found in large quantities fresh
clean surface for equipment
fruits and vegetables for a healthy
and adequate light.

The nurse must understand the

importance of basic nutrition
and be able to give examples of
healthy food choices to the

stomach.
M O Fresh
 icro-Nutrients ctober 11, 2021 fruits are a great source of micro- patient.
nutrients like antioxidants, folate,
vitamins and minerals. Including all kindsThe nurse should ensure
of fruits and vegetables that are nutrient-the patient’s nutritional
rich like pineapples, apples, bananas,needs are met.
kiwis, leafy greens and others.
The nurse must inform and give
Taking some supplements for meetingadditional health teachings to the
nutrient needs of the body while patient and/or significant others
recovering since the total appetite of theabout the chosen diet with
patient is less. indications, to minimize
discouragement and help to
Carbohydrate rich foods October 11, 2021 Including carbohydrate rich foods in a
understand the current situation.
daily diet will help battle the fatigue that
is commonly felt in a post-COVIDThe nurse must ensure
patients. Carbohydrates provide your optimal nutrition and hydration
brain with energy for regeneration andfor the patient and family by
protein/muscle breakdown prevention.coordinating with a dietician.
Fluids October 11, 2021 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
5. ACTIVITY & EXERCISE strengthen defense of
GENERAL INDICATION/ the immune the body for
TYPE OF EXERCISE system.
DESCRIPTION PURPOSE For Adults Viral
Short Walks and It is essential to Exercise is 30 Infections
Stretching recognize physical recommended for minutes per
activity for COVID-19 patient to strengthen day will do
Patients. Evidence their immune system and 1hour is
shown that having and breathing. Immune enough for
Physical Activity System is the primary children.
CLIENT’S RESPONSE

The pain is relieved and the patient displays comfort.

 6. NURSING MANAGEMENT

SOAPIE CHARTING NO. 1

S “Hirap po akong huminga nitong nakaraang araw, pakiramdam ko hinang hina ako”
as verbalized by the patient

Hypoxemia
Fatigue
Restlessness
Use of accessory muscle upon breathing/retractions
Chest x-ray shows bilateral opacification of airspace
ABGs test interpretation – respiratory acidosis
Alteration in physiologic status

Vital signs:
BP: 130/90 mmHg
RR: 32 cpm
HR: 110 bpm
TEMP: 38.7 C
O2 SAT: 87%
A Impaired gas exchange related to ventilation-perfusion imbalance due to fluid build-up in
the lungs as evidenced by shortness of breath and alteration in vital signs
P Short term goal:
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
Allay restlessness
Sustain v/s within normal range:
o RR: 12-20 cpm
o PR: 60-100 bpm
o BP: 120/80 mmHg
o T: 36.1 C-37.2 C

Long term goal:

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
I Independent:
Introduce self to the client. Use calm, reassuring approach; Explain all
procedures, including sensations likely to be experienced during the procedure
 Monitor the patient’s vital signs, especially the oxygen saturation and
characteristics of respiratory q 30 minutes
Determine level of consciousness and mentation changes using Glasgow Coma scale
Elevate patient bed into semi fowler’s position as necessary
Observe for cyanosis of the skin; especially note color of the tongue
and oral mucous membranes for pallor or cyanosis
Help the client deep breath and perform controlled coughing. Have the client
inhale deeply, hold the breath for several seconds, and cough two or three times
with the mouth open while tightening the upper abdominal muscles as tolerated
Routinely check the patient’s position so that she does not slump
down in bed Change the client’s position every 2 hours
Schedule nursing care to provide rest and minimize fatigue

Dependent:
Deliver humidified oxygen as prescribed through an appropriate device (nasal
cannula or venture mask per the HCP’s order) and monitor the patient’s response

Collaborative:
Monitor oxygen saturation continuously using pulse oximetry. Note
blood gas results as available.
Assist in performing slow deep breathing, using an incentive spirometer as
indicated Anticipate the need for intubation and mechanical ventilation
E Short term goal:
After 2-4 hours of nursing intervention, the patient was able to:
Demonstrate improved ventilation and adequate oxygenation as evidenced
by blood gas levels within normal parameters
Relaxed breathing
Relieved restlessness
Maintain v/s within normal range:
o RR: 12-20 cpm
o PR: 60-100 bpm
o BP: 120/80 mmHg
o T: 36.1 C-37.2 C

GOAL WAS MET.

Long term goal:

After the client’s stay at the hospital, the client was able to:
Maintain clear lung fields and remain free of signs of respiratory distress.
 GOAL WAS MET.

SOAPIE CHARTING NO. 2

S "Nurse kanina pa ho sa bahay namin inirereklamo na ng nanay ko na nahihirapan
po siyang huminga..." verbalized by the son of the patient.
O (+) ABG's results indicates increase level of carbon dioxide in the blood
(hypercarbia). (+) X-ray shows a bilateral air space opacification
(+) Dyspnea

Vital signs:
BP: 130/90 mmHg
RR: 32 cpm
HR: 110 bpm
TEMP: 38.7 C
O2 SAT: 87%
A Ineffective breathing pattern related to covid-19 as evidence by shortness of breath
P Short term goal:
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 goal:

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
I Independent:
Established rapport.
Position the patient with a proper body alignment for maximum breathing pattern.
Evaluate skin color, temperature, capillary refill by observing the central
versus peripheral cyanosis.
Encourage deep breathing techniques once stable
Stay with the patient during acute episodes of respiratory distress.
Ensure optimal room ventilation by inspecting equipments that supply air.

Dependent:
Initiate oxygen therapy as indicated by the physician
Administer medications prescribed by the physician
Collaborative:
 Check the availability of intubation equipment and ready to assist.
E Short term goal:
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.

GOAL WAS MET.

Long term goal:

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.

SOAPIE CHARTING NO. 3

S “Ilang araw na pong mataas ang lagnat ko” as verbalized by the patient.
O Warm to touch Chills
Restlessness

BP: 130/90 mmHg

RR: 32 cpm
HR: 110 bpm
TEMP: 38.7 C
O2 SAT: 87%
A Hyperthermia related to disease process as evidenced by temperature higher than normal.
P 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
I Dependent:
Monitor vital signs.
 Place the patient under appropriate
isolation. Place patient in a cool and quiet
environment. Provide tepid sponge bath.
Eliminate excess clothing and
covers. Provide adequate rest.
Monitor/record all sources of fluid loss.
Instruct patient to increase oral fluid
intake. Monitor vital signs and recheck

Dependent:
Administer medications as ordered by the physician.

Collaborative:
Administer replacement fluids and
electrolytes. Facilitate laboratory workups.
E Short term goal:
Within 1-2 hours of proper nursing intervention, the patient manifested decrease
in body temperature from 38.7°c to 37°c.

GOALS WERE ACHIEVED.

Long term goal:

Within the 8 hours of nursing intervention, the patient was able to:
Maintain normal body temperature.
have adequate rest and appeared relax.

GOALS WERE ACHIEVED.

SOAPIE CHARTING NO. 4

“Hindi po ako komportable gumalaw.” As stated by the patient.
O Chief complaints” shortness of breath, dry cough, and a fever
Hyposmia and ageusia
Difficulty in sleeping due to feeling unwell and
nasal congestion Weakness
Easily getting tired

Vital signs:
BP: 130/90 mmHg
RR: 32 cpm
PR: 110 bpm
 T: 38.7 C
O2 SAT: 87%
Limited ROM due to
bedrest Dyspneic
Conscious
Coherent
Alert

A Activity intolerance related to limited ROM due to bedrest secondary to COVID-19

P Short term goal:
After 1-2 hours of proper nursing intervention, the patient will be able to:
Report measurable increase in activity tolerance
Demonstrate a decrease in physiological signs of intolerance (pulse,
respirations, and blood pressure will improve)
Diminish shortness of breath

Long term goal:

After 24 hours of proper nursing intervention:
The patient will have stable vital signs while being active
The patient will exhibit tolerance of increased physical activity
The patient will maintain normal level of consciousness, coherence, and
alertness The patient will be free of signs of weakness and fatigue
The patient will be free of signs of respiratory distress
I Dependent:
Monitor vital and cognitive signs, watch for changes in blood pressure, heart, and
respiratory rates; note skin pallor and/or cyanosis and presence of confusion
Note client reports of weakness, fatigue, pain, difficulty accomplishing tasks, and/or insomnia
Assess cardiopulmonary response to physical activity, including vital signs, before, during,
and after activity. Note accelerating fatigue.
Determine the client’s current activity level and physical condition with
observation, exercise- capacity testing, or use of a functional level
classification system (e.g., Gordon’s), as appropriate
Reduce intensity level or discontinue activities that cause undesired
physiologic changes Plan care to carefully balance rest periods with activities
Assist with activities and provide/monitor client’s use of assistive
devices (e.g., crutches, walker, wheelchair, or oxygen tank)
Assist client/SO(s) with planning for changes that may become
necessary, such as use of supplemental oxygen

Dependent:
 Administer oxygen device as ordered

Collaborative:
Provide referral to other disciplines, such as exercise physiologist, psychological
counseling/therapy, occupational/physical therapists, and recreation/leisure specialists, as
indicated.
E Short term goal:
After 1-2 hours of proper nursing intervention, the patient was able to:
Report measurable increase in activity tolerance
Demonstrate a decrease in physiological signs of intolerance (pulse,
respirations, and blood pressure will improve)
Diminish shortness of breath.

GOALS WERE ACHIEVED.

Long term goal:

After 24 hours of proper nursing intervention:
The patient demonstrated stable vital signs while being active
The patient has exhibited to tolerance of increased physical activity
The patient has maintained normal level of consciousness, coherence,
and alertness The patient was free of signs of weakness and fatigue
The patient was free of signs of respiratory distress.

GOALS WERE ACHIEVED.

 D. EVALUATION
In terms of the patient's health, one of the most important responsibilities of nurses is to
ensure that patients receive vital information to preserve their health and receive high-quality care.

Methods of Approach:

A. Medication:
Remdesivir (Brand name: Veklury) – it is administered intravenously one the
1st day, dosage is 200mg, infused over 30-120mins and on the 2 nd day 100mg,
q.d. This medication is used to treat patients with COVID-19
Dexamethasone (Brand name: Intensol) – this is administered orally, BID with a dosage of
5mg/tab. Dexamethasone is a type of steroid being used to help decrease inflammation.
Tocilizumab (Brand name: Actemra) – this medication is taken STAT (immediately or at once)
to treat rheumatoid arthritis, giant cell arteritis, polyarticular juvenile idiopathic arthritis, systemic
juvenile idiopathic arthritis, and cytokine release syndrome in patients with moderate to severe
rheumatoid arthritis, giant cell arteritis, polyarticular juvenile idiopathic arthritis, and systemic
juvenile idiopathic arthritis. Dosage of this medication is 200mg/10ml solution.

B. Diet:
Protein Rich Foods – to protect the body from muscle loss and to restore the harm that has
been done to the muscles and tissues. Protein also helps to strengthen the immune system. and
gives energy, which aids in the recovery of patients who have had post-COVID weakness.
High fiber foods – assists in the management of COVID-19-related inflammation.
Micro-Nutrients – aids to boost the immune system and increases the speed of recovery.
Carbohydrate rich foods – helps in fighting the weariness that many post-
COVID patients experience. Carbohydrates offer energy to the brain, allowing it
to regenerate and prevent protein/muscle breakdown.
Fluids – it is critical to stay hydrated when fighting a virus in addition to drinking
at least 6 to 8 glasses of water every day.

C. Activity:
Short Walks and Stretching – patients should exercise to enhance their immune
systems and improve their breathing.

III. CONCLUSION
Coronavirus Disease (COVID-19), an infectious disease is caused by the SARS-CoV-2 virus. The
majority of those infected with the virus will have mild to moderate respiratory symptoms and will recover
without the need for medical attention. Some, on the other hand, will become critically unwell and require
medical assistance. Serious sickness is more likely to strike the elderly and those with underlying medical
disorders such as cardiovascular disease, diabetes, chronic respiratory disease, or cancer.

According to the gathered data, a client, 65 y/o female got admitted with a chief complaint of
shortness of breath, dry cough, and fever. The patient mentioned, she has been feeling weak and that
she gets fatigued easily. She also claimed to be a nonsmoker and has a history of asthma. Vital Signs
were taken and recorded: Temperature of 38.7°C, respiratory rate of 32 cpm, heart rate of 110 bpm,
blood pressure of 130/90 mmHg and O2 sat of 87%. Her primary health care physician, prescribed her
medications which include: Remdesivir, Dexamethasone 5 mg/tab BID, and Tocilizumab infusion,

During their six to eight-hour shift, the student nurses completed independent,
dependent, and collaborative interventions with long-term and short-term goals, as well
as some additional health teachings:
Independent Interventions
Establish rapport.
Place the patient on appropriate isolation and ensure optimal room ventilation by
inspecting equipment that supplies air.
Keep an eye on vital indicators including blood pressure, heart rate, and
respiration rate, as well as skin pallor and/or cyanosis, presence of confusion
and oxygen saturation. Note for any abnormalities found.
Determine the patient’s level of consciousness and mentation changes
Elevate patient’s bed into semi fowler’s position as necessary
Encourage deep breathing techniques once stable
Provide tepid sponge bath to lower elevated body
temperature. Instruct the patient to drink plenty of
fluids to prevent dehydration Provide adequate rest
Assist the patient with tasks and as well as providing and monitoring the usage of assistive
devices (such as crutches, a walker, a wheelchair, or an oxygen tank) by the client.
Assist client and companion with regards to adjusting like giving supplemental oxygen.

Dependent Interventions
Deliver humidified oxygen as prescribed through an appropriate device like nasal
cannula or venture mask per the HCP’s order and monitor the patient’s response.
Administer medications as ordered by the physician.

Collaborative Interventions:
Assist in performing slow deep breathing, using an incentive spirometer as indicated
Provide referral to other disciplines, such as exercise physiologist, psychological
counseling/therapy, occupational/physical therapists, and recreation/leisure
specialists, as indicated.
Refer to appropriate resources for assistance and/or equipment as needed.
 Check for availability of intubation equipment and ready to assist
We, the student nurses, have learned new knowledge and a better grasp of how to handle
and care for COVID-19 patients in terms of prevention, therapy, and a healthy diet. As a result of the
information and help offered by this case study. As a result, we were able to set goals and
objectives for providing suitable and effective nursing interventions to achieve the desired results.

IV. RECOMMENDATION
Based on what was stated on the study’s conclusion, the following
recommendations should be observed:

1. For Student Nurses

The research is advised for reference in the future and assists our fellow student nurses in
improving knowledge and abilities for giving proper nursing care for our patients. Case studies are
important as they're a key tool for enhancing and expanding our knowledge and abilities in acquiring and
communicating understanding of specific cases. As a result, it is advised for both creating relationships
with our patients and our classmates. One of the finest experiences a student nurse may have in this 4-
year program is being engaged in learnings like this while attempting to successfully finish a case study.

2. For Patients
Currently, COVID-19 is still spreading even when there are already vaccines being administered to

the people. If the patient follows the healthcare provider’s order. This case study will
help the patients to further recognize the different signs and symptoms and be aware
they need to seek a healthcare professional immediately. Also, the diets, care plans,
activities, and laboratory test, stated from the study would be beneficial to people
suffering from COVID-19 for them to boost their immune system and feel well.

3. For Health Care Providers

It is suggested that health care practitioners acknowledge and address the patient's health status.
Understanding the client's current circumstances will help them provide better care and fulfill their
responsibilities as they provide effective nursing care. Aside from that, regardless of the personality they
portray, they should have a professional, therapeutic, but personable attitude with their client. Given the
patient's current condition, more intensive care and surveillance should be provided, with the airway
being prioritized to reduce the patient's risk of complications or, in the worst-case scenario, death.
V. REVIEW OF RELATED LITERATURE/ STUDIES

Tan, et.al (2021) stated that Covid-19 precautionary measures have been increased to ensure
the prevention of virus spread. Lockdowns and policy actions to curtail the transmission of COVID-19
have widespread health system, economic, and societal impacts. Health systems of low-to-middle-
income countries may have fewer buffering resources and capacity against shocks from a pandemic. In a
study conducted on the collateral health systems impact of COVID-19 in the Philippines through review of
academic and grey literature, supplemented by a qualitative survey, community quarantines alongside
transport and boarder restrictions have universally impacted health service access and delivery, affecting
patients requiring specialist care the most. Existing record-keeping and surveillance measures were
hampered as existing resources were tapped to perform COVID19-related tasks. Local health systems
reinforced gatekeeping mechanisms for secondary and tertiary care through referral systems and
implemented telemedicine services to reduce face-to-face consultation. The health system impacts in the
Philippines have been variegated across municipal income class and topography, contributed by long-
standing symptoms of inequitable resource allocation.

Home isolation is the first step to manage person with mild symptoms and no underlying
chronic conditions. Hospitalization may be considered if rapid deterioration is anticipated or if
the patient is not able to urgently return to hospital when signs and symptoms of complicated
disease arise. Moderate cases should be managed in hospital, monitoring vital signs and
oxygen saturation. Supportive care for these persons includes temperature control with
antipyretics, bed rest, hydration, and good nutrition. Routine antibiotics and antifungal drugs
must be avoided and used only when coinfections are proven or strongly suspected.

According to Grace van Leeuwen, in hypoxic patients, oxygen therapy should be immediately

initiated. Several devices can be used according to the centers’ experience. Caution
must be taken, since all noninvasive techniques bear the risk of aerosol contamination;
strict personal protection equipment (PPE) must be used when caring for these patients.

A small portion of human with COVID-19 developed septic shock; thus, this condition must be
always suspected and managed according to the current guidelines since specific issues for COVID-19
have not been reported so far. Corticosteroids should not be used in pediatric patients, except when
required for other indications, such as asthma exacerbations, refractory shock, or evidence of cytokine
storm (Grace van Leeuwen, Alessandra Loreti, Yit Guner, Franco Locatelli & Vito Ranieri, 2021).
I. BIBLIOGRAPHY Book
NANDA International & Herdman, T. H. (2012). NANDA International
Nursing diagnoses: Definitions and classification 2012-14.
Saunders (2021). Nursing Drug Handbook. Publisher: Elsevier, Inc.
Saladin, K. (2018). Anatomy and Physiology: The Unity of Form and Function (8th Edition)

Journal
Tan et.al. (2019). Health Systems Impacts of Covid-19 in the Philippines. OCHA Services – World
Health Organization. https://reliefweb.int/report/philippines/health-systems-impact-covid-19-
philippines?gclid=Cj0KCQjw5JSLBhCxARIsAHgO2See88vg6UduMllpf3ImcKEGwP0dYFDdqwgKR
wrzWWuGtYgIRUZ1husaAkOaEALw_wcB

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