JMJ Marist Brothers

Notre Dame of Marbel University

College of Arts and Sciences
Nursing Department

NURSING CARE PLAN

Name of Patient: Ward/Bed Number: Attending Physician:
Age: Impression / Diagnosis:

Date and Background

Assessment Need Nursing Diagnosis Outcome Criteria Nursing Intervention Evaluation
Time Knowledge

09-16-2020 Subjective: P Impaired gas Impaired gas At the end of 4 Independent: 09-16-2020
1:23 pm “Nurse, nahihilo po H exchange related to exchange is the hours nursing 1. Place in semi- 5:23 pm
ako at Y alveolar-capillary excess or deficit in interventions, the fowler’s position to
nahihirapang S membrane changes oxygenation and/or patient will be able maximize lung After 4 hours of
huminga.” as I secondary to carbon dioxide to improve expansion. nursing interventions,
verbalized by the O respiratory viral elimination at the ventilation and 2. While in oxygen Goal met.
patient. L infection as alveolar-capillary adequate therapy, instruct to
O evidenced by membrane. oxygenation of inhale from the “Medyo nakakahinga
Objective: G dyspnea. (Doenges et. al, tissues. Specifically: nose and hold for 3 na po ako ng mabuti
 RR – 54 I 2016) 1. Re-establish seconds, then nurse.” as verbalized
cpm C normal O2 exhale from the by the patient.
 Tachycardic According to Yale saturation mouth with lips
@ 160 bpm N University (2020), If from 89% to pouted to extent  RR – 22 cpm
 O2 E the immune system >95% oxygen to the  PR – 110 bpm
saturation – E of a COVID-19 2. Demonstrate lungs.  O2 saturation-
89% D patient does not fight optimal gas 3. Monitor respiratory 97%
 Non- off the infection, it exchange as rate, depth, and  (-)
productive can travel to the evidenced by effort every hour to restlessness
cough lungs and cause a unlabored know the adequacy  (-)
 Nasal flaring potentially fatal respirations of alveolar somnolence
condition called at 12-20 cpm ventilation.  (-) diaphoretic
 Restless
acute respiratory and reduced
 Somnolence distress syndrome PR from 160 4. Auscultate breath  Able to
noted (ARDS). In ARDS, bpm to 120 sounds every hour, verbalize 3
 Cyanotic the alveoli (tiny air bpm. note areas of ways to
 Diaphoretic sacs that allow 3. Identify 3 decreased/adventiti improve
oxygen to reach the ways to ous breath sounds ventilation and
blood stream and improve as well as fremitus. adequate
remove carbon ventilation It must be oxygenation of
dioxide) fill with fluid, and evaluated for tissues.
which diminishes the adequate further intervention.
lungs' ability to oxygenation 5. Monitor for signs
provide vital organs of tissues. and symptoms of
with enough oxygen. atelectasis:
bronchial or tubular
breath sounds,
crackles,
diminished chest
excursion, limited
diaphragm
excursion, and
tracheal shift to
affected side.
Collapse of alveoli
increases shunting
(perfusion without
ventilation),
resulting in
hypoxemia.
6. Monitor for
alteration in BP
and HR. BP, HR,
and respiratory rate
all increase with
initial hypoxia and
hypercapnia.
 However, when
both conditions
become severe,
BP and HR
decrease, and
dysrhythmias may
occur.
7. Monitor pulse
oximetry every
hour to detect
changes in
oxygenation.
8. Monitor blood gas
(ABG) results as
available and note
changes.
Increasing
PaCO2 and
decreasing
PaO2 are signs of
respiratory acidosis
and hypoxemia.
9. Perform chest
physiotherapy after
nebulization and/or
every hour to
promote
mobilization of
secretions.
10. Encourage to
change position
every 30 mins for
postural drainage.
11. Encourage deep-
breathing and
coughing exercises
to facilitate
expectoration and
promote optimal
chest expansion.
12. Encourage
adequate rest and
limit activities
within tolerance to
limit oxygen needs
and consumption.
13. Review oxygen-
conserving
techniques such as
sitting aside of
standing, eating
small meals,
performing slower
and purposeful
movement.
14. Advise to increase
fluid intake to
facilitate
expectoration.
15. Keep environment
allergen free to
prevent further
irritation.
16. Assist with ADL
since patient is risk
for fall.
 17. Monitor response
to medications and
report any adverse
effects or drug
interactions.
18. Provide
reassurance and
reduce anxiety for
anxiety increases
dyspnea,
respiratory rate,
and work of
breathing.

Dependent:

1. Provide
supplemental
oxygen therapy as
ordered to aid
respiration.
2. Nebulize as
ordered to loosen
secretions.
3. Administer
medications as
ordered to prevent
and control
symptoms, reduce
frequency and
severity of
exacerbations.
4. Perform suctioning
as ordered to
 suction the
secretions.
5. Assist with
intubation and
mechanical
ventilation as
ordered. Maintain
ventilator settings,
as ordered, and
monitor the
patient's response.
Mechanical
ventilation provides
supportive care to
maintain adequate
oxygenation and
ventilation.
Student’s Name: KIM NATHALIE F. ALISASIS BSN3
Clinical Instructor: ALTHEA A. ALEJANO, RN, MAN