Coronavirus Disease (Covid-19) : College of Nursing

University of Perpetual Help System Laguna-Isabela Campus
Minante 1, Cauayan City, Isabela
College of Nursing
CORONAVIRUS DISEASE (COVID-19)
A Case Study
Presented To
The Faculty of the College of Nursing
University of Perpetual Help System Isabela Campus
Minante Uno, Cauayan City, Isabela
In Partial Fulfilment
of the requirement for the subject
Maternal and Child Health Nursing – Acute and Chronic (NCM109)
Submitted by:
Constantino, King Aldus J.
Submitted to:
Mr. John Richard Bartolome, RN, MSN
Ms. Phoebe Jane Abuan, RN, MSN
Mr. Rommar Macaspac, RN, MSN
Ms. Amie Jane Padolina, RN, MSN
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TABLE OF CONTENTS
I. Case Overview
II. Patient’s Profile
III. General Survey
IV. Nursing History
V. Gordon’s Functional Health Pattern
VI. Physical Assessment
VII. Neurological Assessment
VIII. Diagnostic and Laboratory Tests
IX. Anatomy and Physiology
X. Pathophysiology
XI. Nursing Care Plan
XII. Drug Study
XIII. Discharge Planning
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CASE OVERVIEW
COVID-19 is a respiratory illness caused by the coronavirus SARS-CoV-2, which was
found in 2019. The virus spreads mostly by respiratory droplets created when an infected person
coughs, sneezes, or speaks. Some infected persons may not show any symptoms. Illness can
range from minor to severe in persons who exhibit symptoms. Adults 65 and older, as well as
persons of any age who have underlying medical issues, are at a higher risk of serious disease.
COVID-19 vaccinations should be obtained by anyone aged 5 and up in order to avoid
contracting and spreading the disease. A booster injection is available to everyone above the age
of 16.
CAUSES OF COVID-19
Infection with severe acute respiratory syndrome coronavirus 2, or SARS-CoV-2, causes
coronavirus disease 2019 (COVID-19).
The virus that causes COVID-19 spreads easily among people. Data has shown that the
COVID-19 virus spreads mainly from person to person among those in close contact (within
about 6 feet, or 2 meters). The virus spreads by respiratory droplets released when someone with
the virus coughs, sneezes, breathes, sings or talks. These droplets can be inhaled or land in
the mouth, nose or eyes of a person nearby.
Sometimes the COVID-19 virus can spread when a person is exposed to very small
droplets or aerosols that stay in the air for several minutes or hours — called airborne
transmission.
The virus can also spread if you touch a surface with the virus on it and then touch
your mouth, nose or eyes. But the risk is low.
The COVID-19 virus can spread from someone who is infected but has no symptoms.
This is called asymptomatic transmission. The COVID-19 virus can also spread from
someone who is infected but hasn't developed symptoms yet. This is called presymptomatic
transmission.
It's possible to get COVID-19 twice or more, but this is uncommon.
When a virus has one or more new mutations it’s called a variant of the original virus.
The omicron (B.1.1.529) variant spreads more easily than the original virus that causes
COVID-19 and the delta variant. However, omicron appears to cause less severe disease.
People who are fully vaccinated can get breakthrough infections and spread the virus to
others. But the COVID-19 vaccines are effective at preventing severe illness. This variant
also reduces the effectiveness of some monoclonal antibody treatments. Omicron has a few
major offshoots (sublineages), including BA.5 and BA.2.12.1. BA.5 made up about 54% of
COVID-19 infections that had genetic sequencing in the U.S. during the last week in June,
according to the CDC.
In April, the CDC downgraded the delta variant from a variant of concern to a variant
being monitored. This means that the delta variant isn’t currently considered a major public
health threat in the U.S.
RISK FACTORS OF COVID-19
Risk factors for COVID-19 appear to include:
 Close contact (within 6 feet, or 2 meters) with someone who has COVID-19
 Being coughed or sneezed on by an infected person
People who are older have a higher risk of serious illness from COVID-19, and the risk increases
with age. People who have existing medical conditions also may have a higher risk of serious
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illness. Certain medical conditions that may increase the risk of serious illness from COVID-19
include:
 Serious heart diseases, such as heart failure, coronary artery disease or cardiomyopathy
 Cancer
 Chronic obstructive pulmonary disease (COPD)
 Type 1 or type 2 diabetes
 Overweight, obesity or severe obesity
 High blood pressure
 Smoking
 Chronic kidney disease
 Sickle cell disease or thalassemia
 Weakened immune system from solid organ transplants or bone marrow transplants
 Pregnancy
 Asthma
 Chronic lung diseases such as cystic fibrosis or pulmonary hypertension
 Liver disease
 Dementia
 Down syndrome
 Weakened immune system from bone marrow transplant, HIV or some medications
 Brain and nervous system conditions, such as strokes
 Substance use disorders
ETIOLOGIC FACTORS
COVID-19 develops due to the entry of SARS-CoV-2 into the host cell via ACE2
receptors. Infection due to SARS-CoV-2 has resulted in AMI (acute myocardial injury) and
chronic damage to the cardiovascular system.
 SARS-CoV: Severe Acute Respiratory Syndrome
 MERS-CoV: Middle East Respiratory Syndrome
 ARDS: acute respiratory disease syndrome
 SARS: Severe Acute Respiratory Syndrome
SIGNS AND SYMPTOMS OF COVID-19

Signs and symptoms of coronavirus disease 2019 (COVID-19) may appear 2 to 14 days
after exposure. This time after exposure and before having symptoms is called the incubation
period. You can still spread COVID-19 before you have symptoms (presymptomatic
transmission). Common signs and symptoms can include:
 Fever
 Cough
 Tiredness
 Early symptoms of COVID-19 may include a loss of taste or smell.
Other symptoms can include:
 Shortness of breath or difficulty breathing
 Muscle aches
 Chills
 Sore throat
 Runny nose
 Headache
 Chest pain
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 Pink eye (conjunctivitis)

 Nausea
 Vomiting
 Diarrhea
 Rash
DIAGNOSTICS
 RT-PCR test. Also called a molecular test, this COVID-19 test detects genetic material
of the virus using a lab technique called reverse transcription polymerase chain reaction
(RT-PCR). A health care professional collects a fluid sample by inserting a long nasal
swab (nasopharyngeal swab) into your nostril and taking fluid from the back of your
nose. A sample may be collected by using a shorter nasal swab (mid-turbinate swab) or a
very short swab (anterior nares swab). In some cases, health care professional inserts a
long swab into the back of your throat (oropharyngeal swab). Or you may spit into a tube
to produce a saliva sample.
Results may be available in minutes if analyzed onsite in 1 to 3 days — or longer in

locations with test processing delays — if sent to an outside lab. RT-PCR tests are very
accurate when properly performed by a health care professional, but the rapid test can
miss some cases.
 Antigen test. This COVID-19 test detects certain proteins in the virus. Using a long nasal
swab to get a fluid sample, some antigen tests can produce results in minutes. Others may
be sent to a lab for analysis.
A positive antigen test result is considered accurate when instructions are carefully
followed. But there's an increased chance of false-negative results — meaning it's
possible to be infected with the virus but have a negative result. Depending on the
situation, the health care provider may recommend a RT-PCR test to confirm a negative
antigen test result.
 A RT-PCR test called the Flu SC2 Multiplex Assay can detect any of three viruses at the
same time: the COVID-19 virus, influenza A and influenza B (flu). Only a single sample
is needed to check for all three viruses. This could be helpful during the flu season. But a
negative result does not rule out the possibility of any of these infections. So the testing
process may include more steps, depending on symptoms, possible exposures and your
provider's clinical judgment.
COMPLICATIONS OF COVID-19
Although most people with COVID-19 have mild to moderate symptoms, the disease can
cause severe medical complications and lead to death in some people. Older adults or people
with existing medical conditions are at greater risk of becoming seriously ill with COVID-19.
Complications can include:
 Pneumonia and trouble breathing
 Organ failure in several organs
 Heart problems
 A severe lung condition that causes a low amount of oxygen to go through your
bloodstream to your organs (acute respiratory distress syndrome)
 Blood clots
 Acute kidney injury
 Additional viral and bacterial infections
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TREATMENT AND MEDICATIONS OF COVID-19

The FDA has authorized certain antiviral medications and monoclonal antibodies to treat mild to
moderate COVID-19 in people who are more likely to get very sick.
 Antiviral treatments target specific parts of the virus to stop it from multiplying in the body,
helping to prevent severe illness and death.
 Monoclonal antibodies help the immune system recognize and respond more effectively to
the virus.
The FDA has fully approved COVID-19 vaccines for specific age groups.
 The Pfizer/BioNTech Comirnaty vaccine, 31 December 2020.
 The SII/COVISHIELD and AstraZeneca/AZD1222 vaccines, 16 February 2021.
 The Janssen/Ad26.COV 2.S vaccine developed by Johnson & Johnson, 12 March 2021.
 The Moderna COVID-19 vaccine (mRNA 1273), 30 April 2021.
 The Sinopharm COVID-19 vaccine, 7 May 2021.
 The Sinovac-CoronaVac vaccine, 1 June 2021.
 The Bharat Biotech BBV152 COVAXIN vaccine, 3 November 2021.
 The Covovax (NVX-CoV2373) vaccine, 17 December 2021.
 The Nuvaxovid (NVX-CoV2373) vaccine, 20 December 2021
Booster doses and additional doses of COVID-19 vaccines are available and recommended for adults
and children age 5 and up who were previously fully vaccinated for COVID-19.
STATISTICS
According to WHO, In Philippines, from 3 January 2020 to 5:33pm CEST, 29 July 2022,
there have been 3,764,346 confirmed cases of COVID-19 with 60,704 deaths, reported to WHO.
As of 13 July 2022, a total of 156,547,670 vaccine doses have been administered.
According to NCBI, among the 8212 COVID-19 cases detected in the Philippines up to
29 April 2020, 46.2% were female and 68.8% lived in the NCR. Among these, 768 (9.4%) died
and 2988 (36.4%) recovered. Median age for cases, deaths and recoveries was 46 years (IQR 32–
61), 66 years (IQR 57–74) and 46 years (IQR 32–59).
According to Isabela COVID-19 updates, there are 1,159,900 (92.3%) people have
already been vaccinated with first dose, 1,087,194 (86.5%) with second dose, and 170,210
(15.7%) booster dose. There are 53 new cases as of August 1, 2022, 280 province-wide active
cases, with a total accumulative case of 69,865, 2,279 total deaths.
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PHYSICAL ASSESSMENT
Body Parts Methods Findings Interpretation RATIONALE
Head Inspection - Head is NORMAL Naturally, the normal head shape
symmetrically when viewed from above should
rounded with no look similar to an egg, slightly
lesions and wider at the back than the front.
infestations
Palpation - No presence of Normal head appearance has no
tenderness or lesions and tenderness and no
masses. signs of abnormalities around the
head
Scalp and Inspection - Hair color is NORMAL Healthy scalp should be clear of
Hair Palpation black flakes and irritation or redness,
- Scalp is clean, and it should be free of dryness, or
free from any signs of infection, or
masses, lumps disruption of the skin on the
and dandruff. scalp.” Any itchiness, irritation or
burning sensations might be signs
of an unhealthy scalp.
Face Inspection - No presence of NORMAL The face is symmetric or slightly

abnormalities asymmetric; palpebral fissures
equal in size; symmetric nasolabial
folds.
Palpation - No presence of The face of the client appeared
tenderness or smooth and has uniform
masses. consistency and with no presence
of nodules or masses.
Eyes Inspection - Skin in both NORMAL Normal eyes have eyelashes point
eyelids is outwards and the eyelids will open
without redness, and close easily. The white part of
swelling, or the eye, the sclera, with the
lesions. overlying conjunctiva, is not red
- Eyeballs are and inflamed. The cornea is bright
symmetrically and clear. The pupil is black and
aligned round. If the pupil and iris are well
- Conjunctiva is seen, this confirms that the cornea
clear must be clear. The conjunctiva is
smooth
Palpation - No masses or NORMAL Normal eyes have no bulging or
bulging masses and there’s no indication or
exophthalmos or bulging in the
eyes.
Ears Inspection - Ears are equal in NORMAL Many variations in size and shape
size exist within the label of "normal
ear", but in general, the normal ear
is one which all the structures
(helix, antihelix, tragus, antitragus,
scaphoid/triangular fossa, and
external auditory canal) are all
present and well formed.
Palpation - No masses NORMAL Normal ears upon palpations are
free from tenderness, lesions and
masses.
Nose Inspection - Presence of Due to COVID-19 often begins with
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Palpation mucus COVID-19 symptoms of an upper respiratory

Percussion - Frontal and infection, like sore throat and nasal
maxillary sinuses congestion or runny nose.
are non-tender to
Normal findings might be
palpate documented, nose is symmetrical
- Sinuses are non- with no discoloration, swelling or
tender to malformations. Nasal mucosa is
percuss. pinkish red with no
discharge/bleeding, swelling,
malformations or foreign bodies.
No sinus pain noted. Nose is
patent with good air flow.
Mouth Inspection - There is Due to Patient with COVID-19 have a
presence of COVID-19 cough – which may be dry, or
mucus produce thick yellow, green,
- Lips is smooth brown or blood-stained mucus.
and pinkish. No
suspected lesions In a healthy mouth, the tissues are
pink, firm and moist. If you have a
healthy mouth, your breath will
smell pleasant or neutral. Healthy
gums are firm and pink, not red or
white.
Palpation - No masses on NORMAL Upper and lower gums. They
tongue and gums should appear symmetrical, moist
and pinkish, with well-defined
margins. Dark-skinned people may
have a melanotic line along the
gum margin. And healthy dorsal
tongue is symmetrical, pink, moist,
and slightly rough from the
papillae, possibly with a thin,
whitish coating.
Neck Inspection - Neck is NORMAL The trachea should be midline, and
symmetric there should not be any noticeable
- Normal neck enlargement of lymph nodes or the
movement thyroid gland with normal range of
- Prominent neck motion.
vessels
Palpation - No masses or NORMAL Lymph nodes, if palpable, should
lumps be round and movable and should
not be enlarged or tender
Breast and Palpation - No masses upon NORMAL Upon palpation normal bilateral
Axillary palpation. breasts are symmetrical, no tender,
no suspicious masses, skin or
nipple changes or
lymphadenopathy.
Thorax Inspection - Symmetrical Due to Side to side symmetric chest
(Anterior and respiratory effort COVID-19 shape. Distance from the front to
Posterior) without uses of the back of the chest (anterior-
accessory posterior diameter) less than the
size of the chest from side to side
muscle.
(transverse diameter
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Palpation - No tenderness, Is used to evaluate the symmetry

pain and unusual and extent of thoracic movement
sensation. during inspiration. Is usually
symmetrical and is at least 2.5
centimeters between full
expiration and full inspiration
Percussion - There is The bronchial breath sounds over
resonance upon the trachea has a higher pitch,
percussion. louder, inspiration and expiration
are equal and there is a pause
between inspiration and
expiration.
Auscultation - Upon Whistling sound that happens
auscultation, when breathing through swollen,
there is constricted airways. It most often
wheezing and occurs during exhalations.
high-pitched
sound
Lungs Percussion - There is Due to Dull thuds heard when the chest is
(Anterior/Post resonance and COVID-19 tapped (percussion dullness),
erior) dullness thuds which indicate that there is fluid in
over the lungs a lung or collapse of part of a lung.
Auscultation - Wheezing, Wheezing is a whistling sound that
crackles, and happens when a person breathes
rales sounds through narrowed airway passages
in the lungs. It can occur after
exposure to a trigger that causes
swelling of the airway lining and
tightening of the surrounding
muscles. This can make breathing
difficult
Heart Inspection - The apical pulse NORMAL The external chest is normal in
(Precordium), is visible appearance without lifts, heaves,
Anterior or thrills. PMI is not visible and is
Chest palpated in the 5th intercostal
space at the midclavicular line
Palpation - Upon palpation Palpation includes assessing the
there is no arterial pulse, measuring blood
vibrations pressure, palpating any thrills on
the chest, and palpating for the
point of maximal impulse. Arterial
pulse: When palpating the arterial
pulse, the examiner should be able
to gather the rate, rhythm, and
characteristics.
Auscultation - No extra heart Normal S1 and S2, with regular
sounds and rate and rhythm. S2 > S1 at the
murmurs heard. base, S1 > S2 at apex. No splitting
of the heart sounds heard. No
murmur.
Abdomen Inspection - Smooth skin NORMAL Abdomen is soft, symmetric, and
without lesions non-tender without distention.
There are no visible lesions or
scars.
Auscultation - Gurgling bowel NORMAL Normal peristalsis creates bowel
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sound every 5-10 sounds that may be altered or

minutes absent by disease. Irritation of
serosal surfaces may produce a
sound (rub) as an organ moves
against the serosal surface.
Percussion - Tympanic sound The anterior gas-filled abdomen
over air-filled normally has a tympanic sound to
stomach/intestin percussion, which is replaced by
al section. dullness where solid viscera, fluid,
or stool predominate. The flanks
are duller as posterior solid
structures predominate, and the
right upper quadrant is somewhat
duller over the liver.
Palpation - No tenderness Abdomen is soft, symmetric, and
and masses non-tender without distention
Genitourinary Inspection - Rounded contour NORMAL Flat or rounded contour
- No visible (protuberant in children until age
lesions 4)
Palpation - Absence of pain, Normal findings should include no
tenderness and pain, tenderness and mass upon
mass palpation. In addition, during
- No urgency, palpation patient shall not
frequency or complain of any urgency or
retention retention to urinate
Extremities Inspection - Symmetric and NORMAL Extremities are atraumatic in
(Upper) equal in length. appearance without tenderness or
deformity. Extremities are without
swelling or erythema. Full range
of motion is noted to all joints.
Palpation - No lesions and No signs of deformities and
masses lesions in extremities.
- Capillary refill Colour should return to the nail
(3 seconds) instantly or in less than 3 seconds.
If it takes longer, this suggests
decreased peripheral perfusion and
may indicate cardiovascular or
respiratory dysfunction.
(Lower) Inspection - Symmetric and NORMAL Extremities are atraumatic in
equal in length. appearance without tenderness or
- No signs of deformity. Extremities are without
edema swelling or erythema. Full range
of motion is noted to all joints.
Palpation - No lesions and No signs of deformities and
masses lesions in extremities
Skin Inspection - Temperature: NORMAL Rash in dengue fever is a

36.7°C maculopapular or macular
confluent rash over the face,
thorax, and flexor surfaces, with
islands of skin sparing and also
present skin rash with itching and
swollen palms and soles.
Palpation - Absence of Warm to touch in the skin because
lesions and of fever during acute phase of the
masses on the disease.
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surface of the
skin and warm to
touch.
NEUROLOGICAL ASSESSMENT
NAME CLASSIFICATION MAJOR FUNCTIONS FINDINGS
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I. Olfactory Sensory - Smell - Cannot identify and

smell scent while
eyes are closed
II. Optic Sensory - Vision (acuity and - No signs of visual

field of vision); pupil impairment
reactively to light and - Can read and can
accommodation match colors
(efferent impulse)
III. Oculomotor Motor - Eyelid elevation; most - Both pupils constrict

EOMs; pupil size and - Symmetric eye
reactivity (efferent movement
impulse)
IV. Trochlear Motor - EOM (turns eyes - Equal pupil size

downward and - normal movement of
laterally) the upper eyelids
V. Trigeminal Both - Chewing, facial and - Eyes naturally blink
mouth sensation, when cotton wisp
corneal reflex lightly touched the
(sensory) cornea
VI. Abducens Motor - EOM (turns eyes - Turns eyes laterally
laterally) - No presence of
strabismus
VII. Facial Both - Facial expression; - There is facial
taste, corneal reflex grimace upon
(motor), eyelid and lip inspection. Cannot
closure identify the taste.
VIII. Sensory - Hearing; equilibrium - Maintained balanced
Acoustic/Vestibula without stepping
r cochlear sideways
IX. Both - Gaggling and - Swallowing intact
Glossopharyngeal swallowing (sensory);
taste
X. Vagus Both - Gaggling and - Gag reflex intact
swallowing (motor);
speech (phonation)
XI. Spinal Motor - Shoulder movement; - Symmetrically
Accessory head rotation aligned
XII. Hypoglossal Motor - Tongue movement; - Normal tongue
speech (articulation) movement
DIAGNOSTIC AND LABORATORY TESTS
(SARS-CoV-2) RAPID ANTIGEN (Ag) TEST (Aug 02, 2022)

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BRAND: CLUNGENE
NASOPHARYNGEAL SWAB
TESTED RESULT
Novel Corona Virus (SARS CoV-2) POSITIVE
ANATOMY AND PHYSIOLOGY

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Breathing is the process that brings oxygen in the air into your lungs and moves oxygen
and through your body. Our lungs remove the oxygen and pass it through our bloodstream,
where it's carried off to the tissues and organs that allow us to walk, talk, and move. Our lungs
also take carbon dioxide from our blood and release it into the air when we breathe out.
The SINUSES are hollow spaces in the bones of your head. Small openings connect them
to the nasal cavity. The sinuses help to regulate the temperature and humidity of the air you
breathe in, as well as to lighten the bone structure of the head and to give tone to your voice.
The NASAL CAVITY (nose) is the best entrance for outside air into your respiratory
system. The hairs that line the inside wall are part of the air-cleansing system.
Air can also enter through your ORAL CAVITY (mouth), especially if you have a
mouth-breathing habit or your nasal passages may be temporarily blocked.
The ADENOIDS are overgrown lymph tissues at the top of the throat. When your
adenoids interfere with your breathing, they are sometimes removed. The lymph system,
consisting of nodes (knots of cells) and connecting vessels, carries fluid throughout the body.
This system helps your body resist infection by filtering out foreign matter, including germs, and
producing cells (lymphocytes) to fight them.
The TONSILS are lymph nodes in the wall of your pharynx. Tonsils are not an important
part of the germ-fighting system of the body. If they become infected, they are sometimes
removed. Air can also enter through your ORAL CAVITY (mouth), especially if you have a
mouth-breathing habit or your nasal passages may be temporarily blocked.
The ADENOIDS are overgrown lymph tissues at the top of the throat. When your
adenoids interfere with your breathing, they are sometimes removed. The lymph system,
consisting of nodes (knots of cells) and connecting vessels, carries fluid throughout the body.
This system helps your body resist infection by filtering out foreign matter, including germs, and
producing cells (lymphocytes) to fight them.
The TONSILS are lymph nodes in the wall of your pharynx. Tonsils are not an important
part of the germ-fighting system of the body. If they become infected, they are sometimes
removed.
The PHARYNX (throat) collects incoming air from your nose and passes it downward to
your trachea windpipe. The EPIGLOTTIS is a flap of tissue that guards the entrance to your
trachea. It closes when anything is swallowed that should go into the esophagus and stomach.
The LARYNX (voice box) contains your vocal cords. When moving air is breathed in
and out, it creates voice sounds. The ESOPHAGUS is the passage leading from your mouth and
throat to your stomach. The TRACHEA (windpipe) is the passage leading from your pharynx to
the lungs.
The RIBS are bones supporting and protecting your chest cavity. They move a small
amount and help the lungs to expand and contract. The trachea divides into the two main
BRONCHI (tubes), one for each lung. The bronchi, in turn, subdivide further into bronchioles.
The RIGHT LUNG is divided into three LOBES, or sections, while the left lung is
divided into two LOBES. The PLEURA are the two membranes that surround each lobe of your
lungs and separate the lungs from your chest wall.
The bronchial tubes are lined with CILIA (like very small hairs) that have a wave-like
motion. This motion carries MUCUS (sticky phlegm or liquid) upward and out into the throat,
where it is either coughed up or swallowed. The mucus catches and holds much of the dust,
germs, and other unwanted matter that has invaded your lungs. Your lungs get rid of the mucus
through coughing.
The DIAPHRAGM is the strong wall of muscle that separates your chest cavity from
your abdominal cavity. By moving downward, it creates suction to draw in air and expand the
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lungs. The smallest section of the bronchi is called BRONCHIOLES, at the end of which are the
alveoli (plural of alveolus.
The ALVEOLI are the very small air sacs that are the destination of air that you breathe
in. The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli. Blood
passes through the capillaries, brought to them by the PULMONARY ARTERY and taken away
by the PULMONARY VEIN. While in the capillaries, the blood moves carbon dioxide into the
alveoli and takes up oxygen from the air in the alveoli.
The airways of the lungs consist of the cartilaginous bronchi, membranous bronchi, and
gas-exchanging bronchi termed the respiratory bronchioles and alveolar ducts. While the first 2
types function mostly as anatomic dead space, they also contribute to airway resistance. The
smallest non-gas-exchanging airways, the terminal bronchioles, are approximately 0.5 mm in
diameter; airways are considered small if they are less than 2 mm in diameter.
PATHOPHYSIOLOGY
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NURSING CARE PLAN (1)

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE DATA: Acute pain related to SHORT TERM: Independent: Independent: SHORT TERM:
“Masakit ang tiyan ko, muscle spasms
dito sa bandang gitna” secondary to gastritis as After 30 minutes of nursing 1. Established rapport 1. To ensure compliance of the After 30 minutes of nursing
as verbalized by the evidenced by reports of interventions, the patient patient interventions, the patient will
patient discomfort will report satisfactory pain report satisfactory pain
control on a pain scale of 2. Obtain patient’s vital signs 2. To obtain baseline data control on a pain scale of 3/10
OBJECTIVE DATA: 3/10 parameter
LONG TERM:
V/S TAKEN AS LONG TERM: 3. Provide deep-breathing 3. To improve coping
FOLLOWS: exercises, or progressive mechanisms in dealing with the Within 2 days of nursing
BP: 120/90 Within 2 days of nursing relaxation. stress of pain. interventions, the patient will
PR:101 interventions, the patient demonstrate techniques or
RR: 20 will demonstrate techniques 4. Promote and provide a calm 4. To promote rest and healing. behaviors to manage pain
T: 36.5 or behaviors to manage and quiet environment. with fewer reports of
SPO2: 99% pain with fewer reports of discomfort.
Pain Scale: 8/10 discomfort. 5. Before actually beginning 5. To prepare better for
any procedures, allow the activities and manage - GOAL MET -
- Weak in appearance patients to know about it. discomfort mentally.
- Afebrile
- Conscious and
6. Examine any indications of 6. This approach may indicate
coherent
atypical or intense pain, as well the emergence of tissue
- Facial grimace
as severe, escalating, and ischemia, infection, and
disorientated pain that is not compartmental disease
alleviated by painkillers. problems.
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7. Inform the patient that it is 7. To promote wellness

critical to take medicine before
the discomfort gets unbearable.
Dependent: Dependent:
1. Administer medications as 1. To improve patient
prescribed by the physician. outcomes and prevent chronic
conditions.
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ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE DATA: Activity intolerance SHORT TERM: Independent: Independent: SHORT TERM:
“Nanghihina buong related to body 1. Establish rapport 1. To ensure compliance
katawan ko” as weakness After 4 hours of nursing of the patient. After 4 hours of nursing
verbalized by the intervention, the client will be intervention, the client was
patient able to cope. 2. Obtain patient’s vital 2. To obtain baseline data able to cope.
signs parameter
OBJECTIVE DATA: LONG TERM: LONG TERM:
3. Encourage to change 3. Frequently changing the
V/S TAKEN AS Within 2 days of nursing position in a most position of the client After 2 days of nursing
FOLLOWS: interventions, the patient will comfortable position can relieve stress and interventions, the patient was
BP: 120/90 be able to demonstrate an such as supine or side- promote rest. able to demonstrate an
PR:101 increase in activity tolerance. lying at least every 30 increase in activity tolerance.
RR: 20 mins.
T: 36.5 4. Provide comfort 4. To reduce anxiety and - GOAL MET -
SPO2: 99% measures and fear
Pain Scale: 8/10 psychological support.
- Weak in appearance 5. Recommend quiet 5. Enhance rest to lower

- Frail atmosphere; bed rests if the body’s oxygen
indicated. requirements, and
reduces strain on the
heart and lungs.
6. Explain to the patient 6. To make the patient

the need to call for help comfortable during
dependency
7. Tell patient to drink 7. To control body

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large amounts of water weakness and avoid

dehydration
1. Administer medications 1. To prevent further
as prescribed by the complications.
physician.
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SUBJECTIVE DATA: Acute pain related to SHORT TERM: Independent: Independent: SHORT TERM:
“Masakit po yung ulo headache as Within 15 mins of nursing 1. Establish rapport 1. To ensure compliance After 15 mins of nursing
ko” as verbalized by evidenced by reports intervention, patient will of the patient. intervention, patient will
the patient. of headache. verbalize reduction of pain verbalize reduction of pain
with acceptable pain control 2. Obtain patient’s vital 2. To obtain baseline data with acceptable pain control
OBJECTIVE DATA: at a level of 3 out of 10. signs parameter at a level of 3 out of 10.
V/S TAKEN AS LONG TERM: 3. Teach the patient non- 3. Nonpharmacologic LONG TERM:
FOLLOWS: Within 1 day of nursing pharmacologic pain techniques in the After 1 day of nursing
BP: 120/90 interventions, the patient will management for management of pain interventions, the patient
PR:101 demonstrate techniques or headache. include physical, demonstrated techniques and
RR: 20 behaviors to manage pain cognitive, and behaviors to manage pain
T: 38.2 using applicable diversional behavioral approaches using applicable diversional
SPO2: 99% activities and relaxation skills. and lifestyle pain activities and relaxation skills.
Pain Scale: 8/10 management.
- GOAL MET -
- Weak in appearance 4. Provide comfort
measures and 4. To reduce anxiety and
C - Pain fear
O - 2 days prior check- psychological support.
up
5. Recommend quiet 5. Enhance rest to lower
L - Frontal and retro-
atmosphere; bed rests if the body’s oxygen
orbital
indicated. requirements, and
D - 48 hours
S - Pain scale of 6/10 reduces strain on the
P- Drinking pain heart and lungs
6. Observe any signs of
reliever, when doing 6. To evaluate the
chest pain, difficulty
physical activities physiologic responses
breathing, extreme
to the stress of activity
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A - Dizziness and tiredness, sweating, and the benchmark of

weakness dizziness, and overexertion.
weakness.
7. Introduce diversional 7. To distract the patient

activities like listening and decrease the
to music patient’s anxiety level.
8. Administer medication 8. To prevent further
as ordered. complications.
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NURSING NURSING PLANNING NURSING RATIONALE EVALUATION
ASSESSMENT DIAGNOSIS INTERVENTIONS
SUBJECTIVE: Nausea related to SHORT-TERM: Independent: Independent: SHORT-TERM:

“Nagsuka po ako stomach upset 1. Establish rapport 1. To ensure compliance
kanina” as verbalized secondary to Within 20 minutes of nursing of the patient. After 20 minutes of nursing
by the patient. gastritis interventions, the patient will interventions, the patient has a
have a lower nausea and 2. Obtain patient’s vital 2. To obtain baseline data lower nausea and vomiting
OBJECTIVE DATA: vomiting severity incidence. signs parameter severity incidence.
3. Determine causes of 3. To have a guide the
V/S TAKEN AS LONG-TERM: nausea. LONG-TERM:
choice of interventions
FOLLOWS:
Within 3 days of nursing to be used. After 3 days of nursing
BP: 120/90 4. Provide an emesis basin
PR:101 interventions, the patient will 4. To collect vomit. interventions, the patient has
within easy reach of the
RR: 20 have ho reports of nausea and patient. no reports of nausea and
T: 38.2 vomiting. 5. Educate and assist 5. Oral hygiene helps vomiting.
SPO2: 99% patient about oral alleviate the condition
Pain Scale: 8/10 - GOAL MET -
hygiene. and facilitates comfort.
6. Allow the patient to use 6. These methods have
- Nauseous helped patients alleviate
- Weakness nonpharmacological
nausea control the condition but needs
- Sore throat to be used before it
techniques such as
relaxation, guided occurs.
imagery, music therapy,
distraction, or deep
breathing exercises.
7. Introduce cold water, 7. These aid hydration.
ice chips or ginger
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products
8. Give frequent, small 8. This approach will help
amounts of foods maintain nutritional
status.
9. Tell patient to avoid 9. Strong and noxious
foods and smells that odors can contribute to
trigger nausea. nausea.
10. Instruct the patient to
10. To avoid the
follow strict no acidic
complications of his
drinks condition
Dependent:
1. Administer medication Dependent:
as ordered. 1. To avoid further
complications.

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SUBJECTIVE DATA: Risk for deficient fluid SHORT TERM: Independent: Independent: SHORT TERM:
“Suka po ako nang volume related to 1. Establish rapport 1. To ensure compliance
suka bago po ako na- inadequate intake, Within 20 minutes of nursing 2. Obtain patient’s vital of the patient. After 20 minutes of nursing
admit dito” as vomiting. interventions, the patient will signs 2. To obtain baseline data interventions, the patient has a
verbalized by the have a normal urine output 3. Monitor intake and parameters. normal urine output greater
patient. greater than 30 mL/hr and output 3. To ensure an accurate than 30 mL/hr and normal
normal skin turgor. 4. Maintain adequate picture of fluid status skin turgor.
OBJECTIVE DATA: hydration, and increase 4. To prevent dehydration
LONG TERM: fluid intake. and maintain hydration LONG TERM:
V/S TAKEN AS status.
FOLLOWS: Within 2 days of nursing 5. Urge the patient to 5. For replacement After 2 days of nursing
BP: 120/90 intervention and treatment, drink the prescribed treatment. intervention and treatment,
PR:101 the patient will have normal amount of fluid patient has normal urine
RR: 20 urine output greater than 30 6. Emphasize the 6. A fluid deficit can output is greater than 30
T: 38.2 mL/hr and normal skin turgor. importance of oral cause a dry, sticky mL/hr with normal skin
SPO2: 99% hygiene. mouth. turgor.
Pain Scale: 8/10 7. Educate patient about
possible causes and 7. Enough knowledge aids - GOAL MET -
- Pale lips effects of fluid loss or the patient in taking
- Dry skin decreased fluid intake. part in their plan of
- Sunken eyeballs Dependent: care.
- Dry mucous 1. Administer parenteral
membranes fluids as prescribed. Dependent:
2. Administer medication 1. To maintain hydration
as ordered. status.
2. To avoid further
complications.
College of Nursing
DRUG STUDY (1)
Drug Name Mechanism Dosage Indication Contraindication Adverse effects Nursing Interventions
Generic name: Vitamin B12 is a 1 amp IV The B vitamins Hypersensitivity to H2- CNS: Headache,
cobalt-containing B help enzymes in blockers; hepatic and malaise, dizziness,  Adhere to scheduled
Vit. B COMPLEX Vitamin B12 somnolence, periodic laboratory
complex vitamin our bodies do their renal dysfunction; renal
Deficiency insomnia, vertigo, checkups during
Brand name: Betalin produced by Adult: IM/Deep SC 30 jobs and are failure; PKU;
Streptomyces griseus. mental confusion, ranitidine treatment.
12 mcg/d for 5–10 d, then important for a pregnancy (category
agitation,
Essential for normal 100–200 mcg/mo wide range of B), infants <1 mo,
depression,  Be aware that even if
growth, cell cellular functions, lactation.
hallucinations in symptomatic relief is
reproduction, like breaking down provided by ranitidine,
older adults. CV:
maturation of RBCs, carbohydrates and Bradycardia (with this should not be
nucleoprotein transporting rapid IV push). GI: interpreted as absence of
synthesis, maintenance nutrients Constipation, gastric malignancy.
of nervous system throughout the nausea, abdominal Follow-up examinations
(myelin synthesis), and body. The B pain, diarrhea. will be scheduled after
believed to be involved vitamins play an Skin: Rash. therapy is discontinued.
in protein and inter-related role in Hematologic:
carbohydrate keeping our brains Reversible decrease  Do not supplement
metabolism. Also acts running properly. in WBC count, therapy with OTC
as coenzyme in various thrombocytopenia. remedies for gastric
Body as a Whole: distress or pain without
biologic reactions.
Hypersensitivity physician's advice
Vitamin B12
reactions,
deficiency results in anaphylaxis (rare).  Be alert for early signs of
megaloblastic anemia, hepatotoxicity
dysfunction of spinal
cord with paralysis, GI
lesions.
College of Nursing
DRUG STUDY (2)
Generic name: Semisynthetic third- 16mg 1-tab OD Is an antivertigo agent Betahistine is a Significant: Rarely,  Tell patient if
generation used for the reduction histamine analogue that ventricular there’s any
Betahistine extrasystoles, signs of allergic
cephalosporin of episodes of vertigo is claimed to improve
antibiotic. association with the microcirculation of hypotension, reactions or
Preferentially binds to Ménière's disease. the labyrinth resulting tachycardia. severe adverse
Brand name: Gastrointestinal effects to
one or more of the in decreased
disorders: Diarrhoea, inform the
Nuvert penicillin-binding endolymphatic
dry mouth, dyspepsia, attending nurse.
proteins (PBP) located pressure.
nausea. Rarely, mild  Tell patient that
on cell walls of gastric complaints (e.g. it is best to take
susceptible organisms. vomiting, the drug with or
This inhibits third and gastrointestinal pain, after food.
final stage of bacterial abdominal distension,
cell wall synthesis, thus bloating).
killing the bacterium. Immune system
disorders:
Hypersensitivity
reactions (e.g.
anaphylaxis).
Nervous system
disorders: Headache.
Skin and subcutaneous
tissue disorders:
Rarely, rash, pruritus,
urticaria, angioneurotic
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oedema.
DRUG STUDY (3)
Generic name: Potent anti-ulcer drug 50 mg IV q8 Decreases stomach Hypersensitivity to CNS: Headache,  Tell patient to be
Ranitidine that competitively and acid production and ranitidine; acute malaise, dizziness, aware that even if
reversibly inhibits Adult: PO 150 mg short-term treatment porphyria; OTC somnolence, insomnia, symptomatic relief is
histamine action at H2- b.i.d. or 300 mg h.s. IV of active duodenal administration in vertigo provided by ranitidine,
Brand name: Zantac receptor sites on 50 mg q6–8h; 150–300 ulcer; maintenance children <12 y. CV: Bradycardia this should not be
parietal cells, thus mg/24 h by continuous therapy for duodenal (with rapid IV push). interpreted as absence
blocking gastric acid infusion ulcer patient after GI: Constipation, of gastric malignancy.
secretion. Indirectly healing of acute nausea, abdominal Follow-up
reduces pepsin ulcer; treatment of pain, diarrhea. Skin: examinations will be
secretion but appears to gastroesophageal Rash. Hematologic: scheduled after
have minimal effect on reflux disease; short- Reversible decrease in therapy is
fasting and term treatment of WBC count, discontinued.
postprandial serum active, benign thrombocytopenia.  Adhere to scheduled
gastrin concentrations gastric ulcer; Body as a Whole: periodic laboratory
or secretion of gastric treatment of Hypersensitivity checkups during
intrinsic factor or pathologic GI reactions, anaphylaxis ranitidine treatment.
mucus. hypersecretory (rare).  Note: Long duration of
conditions action provides ulcer
pain relief that is
maintained through
the night as well as the
day.
 Be alert for early signs
of hepatotoxicity
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 Long-term therapy
may lead to vitamin
B12 deficiency.
DRUG STUDY (4)
Generic name: Gliclazide is an Plus 30mg 1-tab OD This medication is an Hypersensitivity to Significant:  Monitor fasting
antidiabetic before breakfast oral hypoglycemic gliclazide, Hypoglycaemia. blood glucose,
Gliclazide Blood and lymphatic glycosylated Hb
sulphonylurea. It (anti-diabetic drug), sulfonylureas or
increases insulin prescribed for type 2 sulphonamides. Type 1 system disorders: based on
sensitivity at peripheral Adult: 40-80 mg daily diabetes. It stimulates diabetes, diabetic pre- Rarely, anaemia, response, signs
Brand name: Flomax leucopenia, and symptoms
target sites by gradually increased to the pancreas, which coma and coma,
thrombocytopenia, of
stimulating insulin 320 mg daily if helps in more insulin diabetic keto-acidosis.
agranulocytosis, hypoglycaemia.
release from the necessary. secretion. Severe renal and
pancytopenia,  Tell patient that
pancreatic ß-cells and hepatic impairment. haemolytic anaemia, it may cause
reducing insulin uptake Concomitant use with erythrocytopenia. dizziness,
and glucose output of miconazole Pregnancy Endocrine disorders: drowsiness or
the liver. and lactation. Hyperglycaemia. loss of
Eye disorders: Rarely, consciousness
visual disturbances. which may
Gastrointestinal indicate a
disorders: Abdominal severe fall of
pain, nausea, vomiting, blood sugar, if
dyspepsia, diarrhoea, affected, do not
constipation, drive or operate
gastrointestinal machinery.
haemorrhage.  Adhere strictly
to diabetic diet.
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Avoid severe or
prolonged
exercise.
College of Nursing
DISCHARGED PLANNING
MEDICATION
 Vit B complex 1 amp IV as incorporated
 Ranitidine 50mg IV q8
 Betahistine 16mg 1 tab OD
 Gliclazide 30mg 1 tab OD
 Vit B complex 1 tab OD
 PNSS 1L 80gtts/min
EXERCISE
 Advise patient to have mild regular exercise
 Advice patient to do cardio exercise. Physical activity such as this will help expel gas that
causes pain and help move digestion along.
TREATMENT
 Increased oral fluid intake
 Bed rest outpatient follow up care
 Instruct the family members to have a check-up or to consult physician once a while to
monitor patient’s condition and for detection of recurrences and other complications that
may arise on to it.
 Take your medication at the same time every day.
 If symptoms persist consult your doctor
HEALTH EDUCATION
 Do not smoke. Nicotine and other chemicals in cigarettes and cigars can make your
symptoms worse and cause lung damage. Ask your healthcare provider for information if
you currently smoke and need help to quit. E-cigarettes or smokeless tobacco still contain
nicotine. Talk to your healthcare provider before you use these products.
 Do not drink alcohol. Alcohol can prevent healing and make your gastritis worse. Talk to
your healthcare provider if you need help to stop drinking.
 Do not take NSAIDs or aspirin unless directed. These and similar medicines can cause
irritation. If your healthcare provider says it is okay to take NSAIDs, take them with
food.
 Do not eat foods that cause irritation. Foods such as oranges and salsa can cause burning
or pain. Eat a variety of healthy foods. Examples include fruits (not citrus), vegetables,
low-fat dairy products, beans, whole-grain breads, and lean meats and fish. Try to eat
small meals, and drink water with your meals. Do not eat for at least 3 hours before you
go to bed.
 Find ways to relax and decrease stress. Stress can increase stomach acid and make
gastritis worse. Activities such as yoga, meditation, or listening to music can help you
relax. Spend time with friends, or do things you enjoy.
DIET
 Encourage nutritious foods like vegetables and non-acidic fruits
 Choose healthy carbohydrates such as fruit, vegetables, whole grains, beans, and low-fat
milk
 Advice patient to avoid fried foods and other foods high in saturated fat and trans-fat
foods high in salt, also called sodium. Sweets, such as baked goods, candy, and ice cream
beverages with added sugars, such as juice, regular soda, and regular sports or energy
drinks.
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 Advice patient to avoid acidic foods, such as tomatoes and some fruits, alcohol,
carbonated drinks, coffee, fatty foods, fried foods, fruit juices, pickled foods, spicy foods,
or tea.
SPIRITUAL
 Always pray for recovery and good health.
 Encourage the client and her family to seek emotional, physical, and mental strength
from God; this will strengthen their spiritual life and not easily give up when problems
arise.
PROGNOSIS
The patient's came to Tomas-Cacal Medical Clinic & Hospital. The patient was admitted
due to body weakness, abdominal pain, and dizziness, seen and examined by the attending
physician. Consent signed and secured. After the hospital's treatment and diagnosis, the patient
was discharged and advised on lifestyle changes and medication maintenance.

Coronavirus Disease (Covid-19) : College of Nursing

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Coronavirus Disease (Covid-19) : College of Nursing

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University of Perpetual Help System Laguna-Isabela Campus

Minante 1, Cauayan City, Isabela

CORONAVIRUS DISEASE (COVID-19)

SIGNS AND SYMPTOMS OF COVID-19

 Pink eye (conjunctivitis)

Results may be available in minutes if analyzed onsite in 1 to 3 days — or longer in

TREATMENT AND MEDICATIONS OF COVID-19

Face Inspection - No presence of NORMAL The face is symmetric or slightly

Palpation mucus COVID-19 symptoms of an upper respiratory

Palpation - No tenderness, Is used to evaluate the symmetry

sound every 5-10 sounds that may be altered or

Skin Inspection - Temperature: NORMAL Rash in dengue fever is a

I. Olfactory Sensory - Smell - Cannot identify and

II. Optic Sensory - Vision (acuity and - No signs of visual

III. Oculomotor Motor - Eyelid elevation; most - Both pupils constrict

IV. Trochlear Motor - EOM (turns eyes - Equal pupil size

DIAGNOSTIC AND LABORATORY TESTS

(SARS-CoV-2) RAPID ANTIGEN (Ag) TEST (Aug 02, 2022)

ANATOMY AND PHYSIOLOGY

NURSING CARE PLAN (1)

7. Inform the patient that it is 7. To promote wellness

NURSING CARE PLAN (2)

- Weak in appearance 5. Recommend quiet 5. Enhance rest to lower

6. Explain to the patient 6. To make the patient

7. Tell patient to drink 7. To control body

large amounts of water weakness and avoid

NURSING CARE PLAN (3)

A - Dizziness and tiredness, sweating, and the benchmark of

7. Introduce diversional 7. To distract the patient

NURSING CARE PLAN (4)

SUBJECTIVE: Nausea related to SHORT-TERM: Independent: Independent: SHORT-TERM:

NURSING CARE PLAN (5)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

DRUG STUDY (1)

DRUG STUDY (2)

DRUG STUDY (3)

DRUG STUDY (4)

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