Student: Christian James A.

Mata Year and Section: BSN 1L Date: 02/21/2022

Patient: 007 Sex: Male
Address: Sta Ana
FOCUS: COVID-19 MANAGEMENT
ASSESSMENT PLANNING IMPLEMENTATION EVALUATION DOCUMENTATION
Travel History: Out of 1. Restore patient’s 1. Isolate the patient in a room to prevent Nursing Goals are met Days 2-11: Disease develops
Town Vacation to health back to the spread of the infection. - Patient is weak but slowly
Manila normal within 2. Instruct the patient to keep his mask on Patient was able to: and gradually gaining his
14-20 days especially when coughing or sneezing. 1. Prevent the strength as the day
Physical Examination: 2. Prevent the Also, advice those who will enter the room transmission progresses
A. Temperature: Spread of to wear proper PPE to avoid getting of the disease - Response: regularly
38.8°c Infection infected 2. Improve body monitoring patient’s vital
B. Mild to 3. Restore 3. Keep tissues at the patient’s bedside and temperature signs every 12hr
Moderate breathing dispose secretions properly. levels - Increase IV fluids
Cough pattern back to 4. Teach the patient to observe proper hand 3. Restore - Given oxygen to aid the
C. Impaired normal hygiene whenever or after they cough to breathing patient’s breathing pattern
Breathing 4. Reduce Anxiety prevent the transmission of the virus. pattern back - Administered antipyretic
Pattern: 5. Improve Body 5. Monitor the patient’s vital signs to normal medications every 4-8 hours
Shortness of Temperature (Temperature, Respiratory Rate) 4. Restore sense as prescribed
Breath (manage 6. Monitor the patient’s oxygen saturation of taste and
D. Chills hyperthermia) 7. Manage Fever or Hyperthermia by using smell Day 12-18: Patient 007 started to
E. Headache 6. Learn more on proper therapy for increased level of body 5. Reduce recover his strength gradually.
F. Sore Throat the management temperature to maintain normal anxiety Continues his medications as
G. Anosmia & of the disease temperatures. 6. Learn more prescribed. Regularly monitoring his
Ageusia (COVID-19) 8. Educate the patient by providing about the Vital signs for improvements
H. information on the disease transmission, disease and its
its disease process, diagnostic testing, management Day 19: Patient 007 fully recovered
Had a close contact complications, and protection from the and ready for discharge.
to an individual who virus
is positive in COVID- Day 20: Patient Discharged and
19 Virus. Teaching plan implemented.

Anxious
References:

Belleza, R. M. N. (2021, February 11). Coronavirus Disease 2019 (COVID-19). Nurseslabs. Retrieved February 21, 2022, from https://nurseslabs.com/coronavirus-
disease-covid-19/#nursing_care_planning_and_goals

Editorial Team. (2022, January 21). Nursing Management of COVID-19. EveryNurse.Org. Retrieved February 21, 2022, from https://everynurse.org/nursing-
management-covid-19/