URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: PERALTA, MARICHU T. Year Level and Group: BSN
3GROUP C
Affiliating Agency/Area: Month/Year of Exposure:
Diagnosis:
Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation
(at least 10)

Subjective: Problem, Etiology, Short Term Goal: Independent: Independent: Short Term Goal
Signs Evaluation
“Pagod na pagod S.M.A.R.T. + Evidence Assessment Assessment
ako at hindi na (P.E.S.) format
This is to detect decreased or
maganda ang
adventitious breath sounds. After 24hrs of nursing
pakiramdam ko” Within 24hrs of Auscultate breath sounds at
intervention. Goal
As verbalized by Ineffective airway nursing intervention least every 4 hours.
successfully met; the pt.
the patient. clearance related to the pt. will maintain
express that he has
acute respiratory clear, open airways as
feeling okay cause of
distress secondary to evidence by normal
normal breath sounds,
covid-19 as manifested breath sounds, normal
normal heart rate and
by rapid shallow heart rate and depth
depth of respirations and
breathing. of respirations and
ability to effectively
ability to effectively
 cough up secretions Therapeutic Therapeutic cough up secretions.
after treatments and
deep breaths.
Objective: Ask if they are “short of Sometimes anxiety can cause
breath” and note any dyspnea. dyspnea, so watch the patient
(at least 5)
INFERENCE Long Term Goal: for “air hunger,” which is a sign Long term Goal
that the cause of shortness of Evaluation
Scientific Explanation S.M.A.R.T.+ Evidence
breath is physical.
-Body Temp: (Diagram Form)
101*6 F (38.9 C)
After 7 days of nursing
Within 7 days of
-PR: 125 bpm Educative intervention. Goal
Ineffective airway nursing intervention
successfully met, as the
-RR: 35 bpm clearance the pt. will be Educative The most convenient way to
pt. see comfortable and
comfortable and remove most secretions is
-BP: 130/80 Teach the patient the proper feeling rested each day
feeling rested each day coughing. So, it is necessary to
mmHg ways of coughing and cause of negative swab
acute respiratory cause of negative swab assist the patient during this
breathing.  test on sars- covid 19.
-O2 SAT: 84% distress secondary to test on sars- covid 19. activity. Deep breathing, on the
covid-19 other hand, promotes
oxygenation before controlled
coughing.
rapid shallow
breathing.
Dependent:
Assessment
To establish the safety of the pt.
Dependent: when taking medicine

Assessment
Assess allergic reaction of the
patient. Therapeutic
Understanding prescriptions
promote safe and
 effective medication
administration.
Therapeutic
Provide patient understanding
about the proper use of
prescribed medications and
Educative
inhalers.
Patient will understand the
underlying principle and proper
techniques to keep the airway
clear of secretions.
Educative
Educate patient on coughing,
deep breathing, and splinting
techniques.
Interdependent/Collaborative
Assessment
Fatigue is contributing factor to
ineffective coughing requires
enough energy and may
consume an extra effort to the
Interdependent/Collaborative pt.

Assessment
Pace activities especially for Therapeutic
pt. with reduced energy.
Increasing humidity of inspired
Maintain planned rest
air will reduce thickness of
periods. Promote energy-
secretions and aid their
conservation methods.
removal.

Therapeutic
Educative
Maintain humidified
oxygen as prescribed. An upright position is the
natural position for voiding and
uses the force of gravity.

Educative

Teach the patient to achieve

an upright position on the
toilet in possible.
 URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

FDAR
Name of Student: Year Level and Group:
Affiliating Agency/Area: Month/Year of Exposure:
Diagnosis:
Date and Time Focus Progress Note

October 12, 2022 Ineffective airway clearance D (data):

13:00 Receive Patient A, reports feeling very tired and
unwell, he also has a history of hypertension. Th pt.
appeared diaphoretic and in acute respiration
distress with rapid, shallow breathing. Also, he has a
swab that comes into a positive of SARS- CoV2
Body Temp; 38.9 C ……………………
__________________________
BP; 130/80 mmHg ……………………
_____________________________
RR; 35 bpm ………………………
_____________________
PR: 125 bpm ……………………………….
02Sat; 84% ……………………………………..
________________________

A (action):
Vital signs taken and recorded for every 4hrs.

R (response):
Ended pt. with continually care.
 URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

DRUG STUDY
Name of Student: Year Level and Group:
Affiliating Agency/Area: Month/Year of Exposure:
Diagnosis:
DRUG CLASSIFICATION INDICATION SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES

Generic Name: Pharmacologic: For the treatment of Dizziness, 1-10% Asses if he is allergy to enalapril
essential or lightheadedness,
Enalapril Ace inhibitor Dizziness (4-8%)
renovascular weakness, dry cough
hypertension and Hypotension (0.9- Monitor pt. on diuretics therapy for excessive
symptomatic 6.7%) hypotension after the first few dose
congestive heart
failure. It may be used Headache (2-5%)
Brand Name:
alone or in Chest pain (2%) Be careful if any situation that may lead to a
Vasotec combination with drop- in blood pressure (diarrhea. Sweating.
thiazide diuretics. Cough (1-2%)
Therapeutic: Vomiting and dehydration)
Rash (1.5%)
ACE inhibitor that is
commonly prescribed
The pt. may experience GI upset, loss of
to treat high blood
appetite changes in taste perception.
Dosage: pressure as well as
heart failure and
5mg some cases of kidney
10 Right Drug Administration
disease. 

MECHANISM OF CONTRAINDICATI
ACTION ONS
Normally, angiotensin Pt who are
I is converted to hypersensitive to this
angiotensin II by an product and pt with
angiotensin history of angioedema
converting enzyme
(ACE). It is the active
 metabolite of
enalapril, inhibits
ACE decreases levels
of angiotensin II
leading to less
vasoconstriction and
decreased blood
pressure.

Route:
PO

Therapeutic effects:
Angiotensin-
converting enzyme
(ACE) inhibitors are
medications that help
relax the veins and
arteries to lower
blood pressure. ACE
inhibitors prevent an
Frequency: enzyme in the body
from producing
angiotensin II, a
substance that
qDAY
narrows blood vessels.
 
 URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

DRUG STUDY
Name of Student: Year Level and Group:
Affiliating Agency/Area: Month/Year of Exposure:
Diagnosis:
DRUG CLASSIFICATION INDICATION SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES
Hydroxychloroquine
is indicated for the
Generic Name: Pharmacologic: Nausea, vomiting, loss blurred vision, trouble Monitor for signs and symptoms of
prophylaxis of
of focusing, trouble reading; DRESS (fever, rash, lymphadenopathy,
Hydroxychloroqui antimalarials. malaria where
appetite, diarrhea, diz and/or facial swelling, associated with
ne chloroquine resistance distorted vision, blind
ziness, involvement of other organ systems
is not reported, spots;
or headache may Discontinue therapy if signs occur.
treatment of
occur. If any of these changes in your color
uncomplicated Assess for rash periodically during
effects last or get vision;
malaria therapy. May cause Stevens-Johnson
Brand Name: worse, tell your doctor
Therapeutic: hazy or cloudy vision; syndrome.
or pharmacist prompt
Plaquenil ly Assess for suicidal tendencies, depression,
Hydroxychloroquine seeing light flashes or
may work to treat streaks, seeing halos or changes in behavior periodically during
rheumatoid arthritis around lights; or therapy.
 and systemic lupus increased sensitivity to
erythematosus by light.
decreasing the activity
Dosage: of the immune system. 10 Right Drug Administration
400-600 mg
MECHANISM OF CONTRAINDICATI
ACTION ONS
The exact mechanisms Chloroquine should
of not be used in patients
hydroxychloroquine with retinal or vision
are unknown. It has changes unless
been shown that treating acute
hydroxychloroquine malaria. Chloroquine
accumulates in the is also contraindicated
lysosomes of the in patients who suffer
malaria parasite, from a known
raising the pH of the hydroxychloroquine
vacuole sensitivity.

Therapeutic effects:
Route: Death of plasmodia
PO responsible for
causing malaria.
Also has anti-
 inflammatory
properties.

Frequency:

qDAY

 
 URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

DRUG STUDY
Name of Student: Year Level and Group:
Affiliating Agency/Area: Month/Year of Exposure:
Diagnosis:
DRUG CLASSIFICATION INDICATION SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITIES
 Treatment of
coronavirus 2019
Generic Name: Pharmacologic: Increased liver Seizures Monitor for signs and symptoms of
(COVID-19) infection
enzyme levels that COVID-19 infection (fever, cough,
Antivirals in patients requiring skin rash
may indicate possible shortness of breath) before and
Remdesivir hospitalization.
liver damage periodically during therapy.
Monitor for signs and symptoms of
Brand Name: hypersensitivity reactions (hypotension,
tachycardia, bradycardia, dyspnea,
Therapeutic: wheezing, angioedema, rash, nausea,
Veklury vomiting, diaphoresis, shivering) during
Interferons are a therapy. Slowing infusion rate to
group of antiviral maximum time of 120 min may prevent
cytokines that are reactions. If clinically significant
being evaluated to symptoms occur, immediately discontinue
Dosage:
treat COVID- infusion and begin symptomatic
400-600 mg 19. Ivermectin is an treatment.
antiparasitic drug
that is being evaluated
to treat COVID-19. 10 Right Drug Administration
MECHANISM OF CONTRAINDICATI
ACTION ONS
Hypersensitivity
COVID-19 is caused reactions, including
by the positive-sense anaphylaxis and
RNA virus severe infusion related
acute respiratory reactions
syndrome coronavirus
2 (SARS-CoV-2).
Replication of the
viral genome is a key
step in the infectious
cycle of RNA viruses,
 including those of
the Filoviridae, 

Route:
PO
Therapeutic effects:
Reduced time to
recovery (hospital
discharge,
hospitalized but not
requiring
supplemental oxygen
and no longer
requiring ongoing
care) from SARS-
CoV-2 infectio

Frequency:

qDAY