ILOILO DOCTORS’ COLLEGE

COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN

Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation

Subjective: Ineffective breathing pattern related to shortness of breath as evidenced by Long Term: Independent: ● To gain Goal was partially met as evidenced by patient
“Nabudlayan ako mag ginhawa” as verbalized by the patient elevated respiratory rate and 75-80% O2 sat. After 20 days of nursing intervention, patient ● Establish patient’s trust established normal, effective respiratory pattern and

Objective: Rationale: will establish a normal, effective respiratory

rapport and
O2 saturation improved.

Dry cough with shortness of breath when coughing & upon exertion Ineffective breathing pattern is a condition of inadequate ventilation due to pattern

was observed. impairment in the mechanism of inspiration and expiration. Short Term:
● Monitor vital cooperation.
Chest X-ray result revealed Bilateral Pneumonia with consolidations Coronavirus 2019 (COVID-19) is a disease caused by a new strain of After 3 days of nursing intervention, patient’s signs ● Monitor the
and minimal bilateral pleural effusion. coronavirus called severe acute respiratory syndrome coronavirus respiratory rate and 02 saturation will improve.
● Maintain patient’s
● 02 Sat: 75-80% 2  (SARS-CoV-2)  that can cause symptoms from common cold to more
respiratory temperature;
● Positive RT-PCR Test severe disease such as pneumonia and eventually it may lead to death
isolation
especially those in vulnerable groups such as the elderly, the very young, the infection
● T: 38.0 *C ● Wear personal
and people with an underlying chronic health condition.
usually begins
● P: 90 bpm Reference:
protective with a high
● RR: 25 breaths/min https://nurseslabs.com/coronavirus-disease-covid-19/#nursing_diagnosis
equipment
Note: Nursing Diagnosis should be base from (NANDA- Approved Nursing temperature
Diagnosis) (PPE) ● Instruct the
properly. patient to
● Monitor cover mouth
oxygen when coughing
saturation or sneezing;
using pulse use face mask.
oximetry Keep tissues at
the patient’s
bedside,
● Enforce strict
dispose the
hand hygiene. 
secretion
● Manage properly.
hyperthermia. 
● To prevent the
spread of
 microorganism

● To verify
maintenance/
● Educate the
improvement in 02 saturation.
patient and ● Teach the
folks. patient and
folks to wash
Dependent:

Give oxygen therapy as prescribed.

hands after
● Hi-Flow vent coughing to
at 6 reduce or
liters/minute. prevent the
transmission of
the virus.

● Use
appropriate
● Plain NSS 1 therapy for
liter was elevated
started to run temperature to
for 8 hours. maintain
normothermia
Administer medication as prescribed by the and reduce
physician: metabolic
● Dilatair needs.
(Doxofylline) ● Provide
400 mgs 2x a information on
day disease
8-8 transmission,
diagnostic
● Albuterol testing, disease
Sulfate process,
(Salbutamol) 1 complications,
puff for and protection
Inhalation BID from the virus.
8-8 ● To maintain
● Budesonide adequate tissue
(Symbicort oxygenation
Turbuhaler) 1 while
puff, oral BID minimizing
10-10 cardiopulmona
ry work and to
prevent
hypoxemia.
● Used for fluid
and electrolyte
replenishment.

● Used for the

treatment of
bronchial
asthma
● Relief of
bronchospasm
in bronchial
asthma,
chronic
bronchitis,
emphysema
and other
reversible,
 obstructive
pulmonary
disease.
● Used for the
management of
bronchial
asthma and
symptomatic
management of
seasonal or
perennial
allergic rhinitis
ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City
NURSING CARE PLAN
-
Defining Characteristics Nursing Diagnosis Outcome Identification Nursing Interventions Rationale Evaluation

Subjective: Infection related to failure to avoid Long Term: Independent: ● To gain Goal was met as evidenced by the patient is free from

“Gasakit akon ulo may hilanat ako” as verbalized by patient

pathogen secondary to exposure to After 20 days of nursing intervention, ● Establish patient’s trust infection and patient fever diminished and respiratory
Client will be free of infection,
Objective:
COVID-19 as evidenced by elevated rapport and
rate is stable.
as evidenced by normal
Vital Signs
temperature and WBC vital signs and negative RT ● Monitor cooperation.
● T: 38.0 *C Rationale: PCR test. patient’s ● To enable
● P: 90 bpm
Vulnerable to invasion and multiplication of pathogenic organisms, which Short Term: temperature close
may compromise health. After 3 days of nursing intervention, Client
● RR: 25 breaths/min Coronavirus 2019 (COVID-19) is a disease caused by a new strain of will maintain core temperature within normal
● Maintain observation in
Lab Results coronavirus called severe acute respiratory syndrome coronavirus range. respiratory resolving
WBC 2  (SARS-CoV-2)  that can cause symptoms from common cold to more
isolation hyperthermia.
● Neutrophil: 0.99 severe disease such as pneumonia and eventually it may lead to death

● Lymphocyte: 0.17 especially those in vulnerable groups such as the elderly, the very young,
and people with an underlying chronic health condition. ● Instruct the
Reference: ● Enforce strict patient to
https://nurseslabs.com/coronavirus-disease-covid-19/#nursing_diagnosis hand hygiene.  cover mouth
Note: Nursing Diagnosis should be base from (NANDA- Approved Nursing
when coughing
Diagnosis) ● Manage or sneezing;
hyperthermia.  use face mask.
Keep tissues at
the patient’s
bedside,
dispose the
secretion
properly.
● Teach the
patient and
● Do Tepid
folks to wash
sponge bath
hands after
coughing to
reduce or
prevent the
● Wear personal transmission of
protective the virus.
equipment ● Use
(PPE) appropriate
properly. therapy for
● Educate the elevated
patient and temperature to
folks. maintain
Dependent: normothermia
● Plain NSS 1 liter and reduce
started to run for 8
metabolic
hours. needs.
Administer medication as prescribed by the
physician:
● To promote
● Give Alvedon dispersal of
(Paracetamol) body heat
 q4H when body
8-12-4-8 temperature is
elevated.
● To prevent the
● Give spread of
Azithromycin microorganism
1 vial q8H, Provide
●
IVTT ANST information on
(-) 8-4-12 disease
transmission,
diagnostic
● Give Vitamin testing, disease
C (Ascorbic process,
Acid) 100 mg complications,
Oral OD 8 and protection
from the virus.
● Used for fluid
and electrolyte
replenishment.
● To decrease
the rising body
temperature of
the px.
● Used to treat
chest
infections such
as pneumonia
● Enhance
body’s natural
immune
system