Pamantasan ng Lungsod ng Marikina

Panama St., Greenheights Subd., Concepcion Uno, Marikina City

In Partial Fulfillment of the Requirements in

Nursing Care of Clients with Life Threatening Conditions / Acutely ill / Multi-organ
Problems / High Acuity and Emergency Situations, Acute and Chronic (RLE)

COVID-19
A CLINICAL CASE STUDY

Presented to the Faculty

of the Pamantasan ng Lungsod ng Marikina,
College of Health Sciences

Presented by:
Level IV Bachelor of Science in Nursing, Batch 2022

Mendez, Francis Xavier S.

Evelyn P. Cailao, RN, MAN

November 2021
Table of Contents
 I. INTRODUCTION

II. ETIOLOGY

III. RISK FACTORS

IV. PATHOPHYSIOLOGY

V. LABORATORY AND DIAGNOSTIC TESTS

VI. MEDICAL MANAGEMENT

VII. DRUG STUDY

VIII. NURSING CARE PLAN

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 meter 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. ETIOLOGY

 COVID-19 is caused by infection with the severe acute respiratory syndrome coronavirus

2 (SARS-CoV-2) virus strain.

III. RISK FACTORS

Modifiable Risk Factors:

 Smoking

 Obesity

 Weakened Immune System

 Poor lung Function

 Hypertension

 Heart Diseases

 CKD

 Liver Disease

Non-Modifiable Risk Factors:

 Age (over 60 years old)

 Gender (Male)

 Socioeconomic Deprivation
 IV. PATHOPHYSIOLOGY

ETIOLOGY
SARS-CoV-2 virus strain

MODIFIABLE RISK FACTORS NON-MODIFIABLE RISK FACTORS

 Smoking  Age (over 60 years old)

 Obesity  Gender (Male)
 Weakened Immune System  Socioeconomic Deprivation
 Poor lung Function
 Hypertension
 Heart Diseases
 CKD
 Liver Disease

Virus enter the host body

Respiratory system: attack the alveoli

Virus attached to Type-2 pneumocytes

Cells die Binds in sustentacular cells in nose Viral S-spike binds on to ACE 2 Binds to the sialic acid receptor Degradation of gustatory
particles

Loss of sensory cilia on Virus is engulfed and taken into the cell (endocytosis)
olfactory receptor neurons Ageusia

Binds to ribosome Release of viral contents (+ssRNA) into the Production of RNA-D and RNA-
Odorants fail to bind to cytoplasm Polymerase
neurons’ cilia
Production of polyprotein
Damaged Type 2 pneumocyte release
macrophage Production of more +ssRNA
Anosmia

Broken down via proteinase

into viral component
Macrophage secrete IL-1, IL-6, TNF-alpha Destroyed Type-2 pneumocyte

Pro-inflammatory cytokines into the bloodstream Acts on hypothalamus

Pulling in neutrophils into the lungs ↑ Vasodilation Release prostaglandins (PGE2)

↑ Capillary Permeability

Release reactive oxygen species and protease to destroy the ↑ Body Thermostat
virus Fluid accumulates outside and inside the alveoli

Fever IV Fluids
↑ Alveolar edema
Damaged different Type-1 and Type-2 pneumocyte

IL-6 Receptor Inhibitor

Alveolar collapse
Consolidation Cough
Chest X-Ray: Space Opacification Corticosteroid/Anti-inflammatory
Alveolar collapse
Alter Gas Exchange
Inflammation of the Lungs
↓ Gas Exchange

Systemic inflammatory
Septic Shock
Shortness of Breath Hypercarbia response syndrome

Hypoxemia ARDS
↑ Vasodilation
↑ Capillary Permeability

Low O2 Saturation Mechanical

Ventilation ↓ Blood Volume
↓ Total Peripheral resistance

Stimulates chemoreceptors

↓BP Hypotension
Tachypnea ↑RR ↑HR Tachycardia

↓ Perfusion to multiple different

organs

Supplemental Vasoconstriction
Oxygenation via High
Flow Nasal Cannula

Multi-system organ failure

↑BP Hypertension

Antigen Rapid Test: A visible red line on the (T) and Polymerase Chain Reaction (PCR Test): Virus is Present =
control (C) lines = POSITIVE POSITIVE

COVID-19
 V. LABORATORY REPORT/ DIAGNOSTIC TEST RESULTS

Diagnostic and
Laboratory Indication Result Analysis Nursing Responsibilities
Procedure

Antigen Rapid Test Antigen rapid test is A visible red line on the
(Antigen Test) done when the client test (T) and control (C)
shows recent
symptoms or had
exposure to people
infected with Covid-
19.
When a sample swab Before:
taking form nose is  Make sure to disinfect the area where sample
lines. placed on lateral flow is prepared.
test, similar to structure  Ask the patient getting swab test if they have
of pregnancy test and recent symptoms of COVID-19.
created two vertical  Inform the patient about the procedure like test
lines, it signals that the sample is obtained by inserting a cotton-tipped
sample is positive. 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 the
laboratory for analysis.
 Collaborate with other healthcare members,
particularly medical technologist.

Polymerase The PCR test was A detection of virus was A nasal swab test was Before:
developed to detect live present. collected from the back  Establish rapport with the patient and S/O.
Chain Reaction organisms in a of the client's nose and  During the swab test, inquire if the patient has
(PCR Test) sample obtained by a put experienced any recent symptoms of COVID-
nasopharyngeal swab into a PCR machine for 19.
(commonly known as detection; the result  Explain the procedure to the client on how it
a nose swab). came back as positive, will take some minute of discomfort as it will
indicating be taken from the back of patient’s nose.
that the virus had been  Preparation of the necessary and equipment
found. and materials.
 Preparation of a consent form, if necessary.
During:
 Use conventional precautions or sterile
procedure.
 During the procedure, request 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.

Chest X-Ray An imaging test that Bilateral air space
helps doctors to opacification
discern the condition inflammation and fluid
of the lungs, heart, and
Normal Result:
blood vessels. Hollow structures
containing 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.
Presence of viral lung Before:
infection causing  Instruct the patient regarding the procedure.
 Assist the patient to the x-ray room.
build-up in the lungs.  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.
After:
 Collaborate with other healthcare member,
particularly to a radiologist.
Arterial Blood Test measures the pH: 7.20 The result indicates Before:
Gas (ABG) acidity (pH) and the PaO2: 70 mmHg increase level of carbon  Explain the procedure to the patient.
levels of oxygen and PaCO2: 48 mmHg dioxide in the blood  Tell the patient that the test requires a blood
carbon dioxide in the HCO3: 24 mEq/L (hypercarbia) resulting sample.
blood from an artery. to respiratory acidosis  Explain to the patient, who will perform the
This test is used to Normal Values: with hypoxemia or arterial puncture, when it will occur, and where
find out how well the pH: 7.35 - 7.45 decrease level of oxygen the puncture site will be; radial, brachial, or
lungs are able to move PaO2: 80 - 100 mmHg in the blood. femoral artery.
oxygen into the PaCO2: 35 - 45 mmHg  Inform the patient that he/she may not need to
blood and remove HCO3: 22 - 26 mEq/L restrict food and fluids.
carbon dioxide from  Instruct the patient to breathe normally during
the blood. 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,
VI. MEDICAL MANAGEMENT

 Supplemental Oxygen via high-flow Nasal Cannula

Oxygen therapy refers to 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.

 To increase the amount of oxygen your lungs receive and deliver to blood
 To maintain normal hemoglobin saturation
 To facilitate normal oxygen delivery to peripheral tissues

 Plain Normal Saline Solution (0.9% saline)

Normal Saline is a prescription medicine used for fluid and electrolyte replenishment for intravenous administration. Normal
Saline may be used alone or with other medications.

Normal Saline belongs to a class of drugs called Crystalloid Fluid.

The following are primary indications for the use of normal saline infusion:

 Extracellular fluid replacement (e.g., dehydration, hypovolemia, hemorrhage, sepsis)

 Treatment of metabolic alkalosis in the presence of fluid loss
 Mild sodium depletion

 Diet

 Protein Rich Foods

o 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 to help a patient overcome post-COVID weakness.
 High Fiber Foods
o The gut is an area where the immune system thrives and so it is important to keep the healthy gut bacteria thriving.
Probiotics such as curd can support healthy gut. Consuming dietary fiber that can be found in large quantities fresh
fruits and vegetables for a healthy stomach.
 Micro-Nutrients
o Fresh fruits are a great source of micronutrients like antioxidants, folate, vitamins and minerals. Including all kinds
of fruits and vegetables that are nutrient-rich like pineapples, apples, bananas, kiwis, leafy greens and others.
o Taking some supplements for meeting nutrient needs of the body while recovering since the total appetite of the
patient is less.
 Carbohydrate Rich Foods
o Including carbohydrate rich foods in a daily diet will help battle the fatigue that is commonly felt in a post-COVID
patients. Carbohydrates provide your brain with energy for regeneration and protein/muscle breakdown prevention.
 Fluids
o 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.
 Mechanism of Side Effects/
Drug Indication Contraindication Nursing Responsibilities
Action Adverse Effects

Generic name: Remdesivir (GS- Treatment for patients  Hypersensitivity to drug or Cardiovascular: Hypotension, arrhythmias, Before:
Remdesivir 5734) is a with coronavirus any ingredient and cardiac arrest  Observe proper aseptic
phosphoramidite disease 2019 (COVID  Patients with alanine Pulmonary: Dyspnea, Acute respiratory technique and wearing of
prodrug of a 19) infection. aminotransferase (ALT) failure, acute respiratory  PPE before handling the
Brand name: monophosphate distress, pneumothorax,
levels >5-times upper limit patient.
Veklury nucleoside analog of normal or severe hepatic pulmonary embolism  Identify patient
(GS-441524) and dysfunction Hematological: Anemia, lymphopenia Determine eGFR (Estimated
Drug acts as a viral RNA  Patient with severe renal Endocrine: Hyperglycemia glomerular filtration rate).
Classification dependent impairment. Infectious: Pneumonia, septic shock  Determine (ALT
Anti-Viral Drug RNA polymerase Gastrointestinal: elevated lipase, nausea, prothrombin time.
(RdRp) inhibitor, vomiting, diarrhea, constipation, poor  Monitor vital signs.
targeting the viral appetite, gastroparesis, and lower GI
Route: genome replication bleeding
IV During:
process. Hepatic: Hepatic manifestation
characterized by Grade 1-4 increase in serum  Observe patient's reaction
Dosage: transaminases (ALT and/or AST) are the during the administration of
most common adverse effects seen in drug.
100 mg
patients treated with remdesivir.
Other abnormalities include After:
Frequency:  Note patient's response to
hyperbilirubinemia
q.d Renal and Metabolic: Acute kidney injury the drug.
or worsening of underlying chronic kidney  Dispose PPE to proper
disease, hypernatremia, hypokalemia receptacle after use.
Neurological: Headache, lightheadedness  Perform aseptic technique.
Skin: Rash, contact dermatitis, pruritus
Psychiatric: Delirium
Other adverse effects: Pyrexia, insomnia,
multi-organ dysfunction, DVT, and
hypersensitivity/anaphylactic reactions
related to the infusion

VII. DRUG ANALYSIS

Side Effects
Drug Mechanism of Action Indication Contraindication Nursing Responsibilities
Adverse Effects
Generic name: Action is to decrease of Dexamethasone is  Hypersensitivity to drug Side effects (systemic): Before:
Dexamethasone inflammation of the a type of steroid or any ingredient.  Insomnia  Observe proper aseptic technique
neutrophil migration used to shutdown  Patient with cerebral  Edema in the Face and wearing of PPE before handling
suppression and cytokines storms or Edema  Abdominal distension the patient.
Brand name: reverses the High the massive amount of  Patient with  Appetite (Increased)  Check Vital Signs
Intensol Capillary permeability. inflammation that can Hypertension, Renal,  Diaphoresis  Monitor vital signs
This damage the lungs of the Respiratory, and  Rash, Urticaria  Prepare the medication
Drug Classification primary used as an patients. Rheumatic Disorders.   Psychological changes  Observe 5 rights of medication
Corticosteroid/Anti- Immunosuppressant administration.
such Hallucination
inflammatory agent (Anti- Therapeutic Effect:  Health education must be given
Inflammatory) for Decrease prior with the administering of the
various illness and Adverse effects (Long-term
Route: Inflammation medication
Diseases Therapy):
P.O.  Osteoporosis
 Muscle Wasting During:
Dosage:  Spontaneous Fractures  Administer the Medication being
 Cataracts prescribed.
5 mg/tab
 Peptic Ulcers  Advised to take the medication as
  Severe Joint Pain needed.
Frequency:  Make sure that the patient ingested
BID (twice a day) 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 in developing
hypertension

Side Effects
Drug Mechanism of Action Indication Contraindication Nursing Responsibilities
Adverse Effects

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

VIII. NURSING CARE PLAN

NURSING
ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE NURSING EVALUATION
DIAGNOSIS
SUBJECTIVE: Impaired Gas Exchange SHORT TERM: INDEPENDENT: SHORT TERM:
related to ventilation Within 2-4 hours of nursing o Introduce self to the client. Use calm, reassuring o To establish rapport and ensure cooperation. The After 2-4 hours of nursing intervention, the patient
approach; Explain all procedures, including patient’s feeling of stability increases in a calm was able to:
“hirap akong huminga perfusion intervention, the patient will be able and non- threatening environment.  Demonstrate improved ventilation and adequate
sensations likely to be experienced during the
nitong nakaraang araw, inequality due to fluid to:
pakiramdam ko hinang build-up in the lungs  Demonstrate improved procedure oxygenation as evidenced by blood gas levels within
hina ako” as verbalized by as evidenced of shortness ventilation and adequate o To monitor effectiveness of interventions and normal parameters
o Monitor the patients’ vital signs, especially the medical treatment  Relaxed breathing
the patient of breath and alteration oxygenation as evidenced by
oxygen saturation and characteristics of  Maintain v/s within normal range:
in vital signs. blood gas levels within normal respiration q30 minutes
OBJECTIVE: parameters o Decreased level of consciousness can be an RR 12-20 cpm
 Dyspnea  Relaxed breathing o Determine level of consciousness and mentation indirect measurement of impaired oxygenation PR: 60-100bpm
 Hypoxemia  Sustain v/s within normal range: changes using Glasgow Coma Scale BP: 120/80mmHg
 Fatigue o Positioning helps maximize lung expansion and T: 36.1°C – 37.2°C
o Elevate patient bed into semi fowler’s position decreases respiratory effort.
 Use of accessory muscle RR 12-20 cpm LONG TERM:
as necessary
upon PR: 60-100bpm o Central cyanosis of the tongue and oral mucosa is After the client’s stay at the hospital, the client was
breathing/retractions BP: 120/80mmHg o Observe for cyanosis of the skin; especially indicative of serious hypoxia and is a medical able to:
 Chest x-ray shows T: 36.1°C – 37.2°C note color of the tongue and oral mucous emergency.  Maintain clear lung fields and remain free of signs
bilateral opacification of membranes. of respiratory distress
airspace LONG TERM: o Cool, pale skin may be secondary to a
After the client’s stay at the hospital, o Observe for the skin, nail beds, and mucous compensatory vasoconstrictive response to
 ABGs test interpretation membranes for pallor or cyanosis hypoxemia GOAL WAS MET.
- the client will
respiratory acidosis be able to: o Controlled coughing uses the Diaphragmatic
 Maintain clear lung fields and o Help the client deep breath and perform muscles, which makes the cough more forceful
VITAL SIGNS: remain free of signs of controlled coughing. Have the client inhale and effective.
BP: 130/90 mmHg respiratory distress. deeply, hold the breath for several seconds, and
cough two or three times with the mouth open
RR: 32 cpm while tightening the upper abdominal muscles
HR: 110 bpm as tolerated.
TEMP: 38.7C o Slumped positioning causes the abdomen to
O2Sat: 87% o Routinely check the patient’s position so that compress the diaphragm and limits full lung
she does not slump down in bed expansion
o Repositioning facilitates secretion movement and
o Change the client’s position every 2 hours drainage and decreases atelectasis
o The hypoxic client has limited reserves;
o Schedule nursing care to provide rest and inappropriate activity can increase hypoxia
minimize fatigue
o Delivering O2 with humidity will help in
DEPENDENT: supplying additional oxygen and minimize
o Deliver humidified oxygen as prescribed convective losses of moisture, decreasing dry
through an appropriate device (nasal cannula or mucous membranes and enhancing compliance.
venturi mask as per the HCP’s order) and
monitor the patient’s response. o To detect changes in oxygenation. An oxygen
saturation of less than 88% (normal: 95% to
COLLABORATIVE: 100%) or a partial pressure of oxygen of less than
o Monitor oxygen saturation continuously using 55 mm Hg (normal: 80 to 100 mm Hg) indicates
pulse oximetry. Note blood gas results as significant oxygenation problems
available
o This technique promotes deep inspiration, which
increase oxygenation and prevent atelectasis

o Early intubation and mechanical ventilation are

o Assist in performing slow deep breathing, using recommended to prevent full decompensation of
an incentive spirometer as indicated the patient. It provides a supportive care to
maintain adequate oxygenation and ventilation

o Anticipate the need for intubation and

mechanical 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.
NURSING
NURSING PLANNING NURSING INTERVENTION RATIONALE NURSING EVALUATION
DIAGNOSIS
Ineffective Breathing SHORT TERM: INDEPENDENT: SHORT TERM:
Pattern related to After 3-4 hours of proper nursing o Established rapport. o By developing a positive relationship with After 4 hours of proper nursing interventions the
COVID-19 as evidence of interventions the patient will be able a patient and SO enables the health care patient was able to:
shortness of breath to: practitioner to elicit pertinent information - Establish effective breathing pattern as
- Establish effective breathing and make informed clinical decisions evidenced by respiratory rate of 16 cpm,
pattern manifested by normal about their treatment. pulse rate of 72, BP of 120/80 mmHg and
vital signs and oxygen oxygen saturation of 95%

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:
 Temp: 38.2°C
 RR: 32 cpm
 HR: 130 bpm
 BP: 180/100mmHg
 O2 Sat: 87%
ASSESSMENT
SUBJECTIVE:
“ilang araw na pong
mataas ang lagnat ko” as
verbalized by the patient.
OBJECTIVE:
 Warm to touch
 Chills
 Restlessness
saturation
- Demonstrates maximum lung
expansion with adequate
ventilation.
LONG TERM:
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 ways on how
to follow protocols such as;
wearing mask and face shield,
importance of vaccine, and use
alcohol/sanitizer when going
out.
- Verbalize understanding of
various breathing techniques to
establish eupnea during
episodes of respiratory distress.
NURSING
NURSING PLANNING
DIAGNOSIS
Hyperthermia related to SHORT TERM:
disease process as Within 1-2 hours of nursing
evidenced of temperature intervention, the patient will manifest
higher than normal. 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:
o Position the patient with a proper body
alignment for maximum breathing
pattern.
o Evaluate skin color, temperature,
capillary refill by observing the central
versus peripheral cyanosis.
o Encourage deep breathing techniques
once stable
o Stay with the patient during acute
episodes of respiratory distress.
o Ensure optimal room ventilation by
inspecting equipment that supply air.
DEPENDENT:
o Initiate oxygen therapy as indicated by
the physician
o Administer medications prescribed by
the physician
COLLABORATIVE:
o Check the availability of intubation
equipment and ready to assist.
NURSING INTERVENTION
INDEPENDENT:
o Monitor vital signs.
o Place the patient under appropriate
isolation.
o Place patient in a cool and quiet
environment.
o Sitting position can maximum lung
excursion and chest expansion.
o Lacking of oxygen will cause
blue/cyanosis coloring to the lips, tongue,
and fingers. Cyanosis to the inside of the
mouth is a medical emergency
o A controlled breathing method may also
aid slow respirations in tachypneic
patients. Which a prolonged expiration
prevents air
trapping
o This will reduce the patient’s anxiety,
thereby reducing oxygen demand.
o To aid in establishing effective breathing
pattern,
o To increase oxygen supply to the body
o To address the problem that causes
ineffective breathing.
o In case of emergency procedure,
equipment for intubation should be readily
available.
RATIONALE
o Vital signs provide more accurate
indication of core temperature.
o To prevent the transmission of the disease.
o Environment factors relatively minor
infections can produce much higher
temperature.
o Enhances heat loss by evaporation &
- Demonstrated maximum lung expansion
with adequate ventilation.
LONG TERM:
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.
NURSING EVALUATION
SHORT TERM:
Within 1-2 hours of proper nursing intervention,
the patient manifested decrease in body
temperature from 38.7°c to 37°c.
LONG TERM:
Within the 8 hours of nursing intervention, the
patient was able to:
 Maintain normal body temperature. have
adequate rest and appeared relax.
 o Provide tepid sponge bath. conduction.
Vital signs were taken as  Maintain normal body Goal was met.
follows: temperature. o To decrease warmth and provide comfort.
BP: 130/90mmHg o Eliminate excess clothing and covers.
RR: 32cpm  Will have adequate rest and o To conserve energy which promotes fast
PR: 110 bpm appear relax. o Provide adequate rest. healing.
Temp: 38.7°c
O2 SAT: 87% o Fluids and Electrolytes may be loss due to
o Monitor/record all sources of fluid loss. dehydration.

o Instruct patient to increase oral fluid o Additional fluids help prevent elevated
intake. temperature associated with dehydration.

o To know the effectiveness of nursing

o Monitor vital signs and recheck interventions done and to know the
progress and changes of condition.

DEPENDENT: o For the medical management of COVID –

o Administer medications as ordered by 19.
the physician.

COLLABORATIVE: o To support circulating volume and Tissue

o Administer replacement fluids and perfusion.
electrolytes.
o To relay to the physician for further
o Facilitate laboratory workups. medical interventions.
 FDAR CHARTING
(Focus-Data-Action-Response)

Date,
PROGRESS NOTES
Time, FOCUS
(Data-Action-Response)
And Shift
Data
November 02, Ineffective Breathing - increase respiratory rate of 32 cpm
2021, 1700 Pattern - O2 Saturation of 87%
- (+) Dyspnea
Action
- Initiated the oxygen therapy as indicated by the physician
- Position the patient with a proper body alignment for maximum breathing pattern.
- Monitored respiratory rate, depth, and ease of respiration; noted pattern of respiration;
documented use of accessory muscles, nasal flaring, retractions, irritability, confusion, or
lethargy; auscultated breath sounds, noting decreased or absent sounds, crackles, or wheezes;
observed the color of tongue, oral mucosa, and skin for signs of
cyanosis-----------------------------------------------------------

Response:

- Demonstrated ability to perform pursed-lip breathing and controlled breathing, after 8 hours of
nursing duty; reported ability to breathe comfortably as manifested by not using accessory muscles
and is able to breathe in a supine position; identified and avoided specific factors that can trigger
episodes of ineffective breathing patterns, after 16 hours of nursing
duty-----------------------------------------------------------------------------
 Date,
PROGRESS NOTES
Time, FOCUS
(Data-Action-Response)
And Shift
Data
November 03, Ineffective Breathing - increase respiratory rate of 32 cpm
2021, 1700 Pattern - O2 Saturation of 87%
- (+) Dyspnea
Action
- Initiated the oxygen therapy as indicated by the physician
- Position the patient with a proper body alignment for maximum breathing pattern.
- Monitored respiratory rate, depth, and ease of respiration; noted pattern of respiration;
documented use of accessory muscles, nasal flaring, retractions, irritability, confusion, or
lethargy; auscultated breath sounds, noting decreased or absent sounds, crackles, or wheezes;
observed the color of tongue, oral mucosa, and skin for signs of
cyanosis-----------------------------------------------------------

Response:

- Demonstrated ability to perform pursed-lip breathing and controlled breathing, after 8 hours of
nursing duty; reported ability to breathe comfortably as manifested by not using accessory muscles
and is able to breathe in a supine position; identified and avoided specific factors that can trigger
episodes of ineffective breathing patterns, after 16 hours of nursing
duty-----------------------------------------------------------------------------