Group 2 – Case 2

Nursing Care Plan (NCP)

Assessment Nursing Scientific Objectives Interventions Rationale Expected

Diagnosis Explanation Outcome

Subjective: Ø Ineffective Short term:  Establish rapport  To gain Short term:

breathing After 1-2 hours patient’s trust After 1-2 hours
Objective: pattern r/t of nursing and cooperation of
The patient pain AEB interventions, nursing
manifested the tachypnea the patient  Assess general  To obtain interventions,
following: secondary to will be able to condition general data on the patient will
 Fever COVID-19 demonstrate patient’s have
 Tachypnea infection appropriate condition demonstrated
 Positive RT- coping appropriate
PCR swab behaviors.  Monitor vital signs  To obtain coping
test baseline data behaviors.
 The patient Long term:
reports pain After 1-2 weeks  Assess breath  To note for Long term:
in of nursing sounds, respiratory respiratory After 1-2 weeks
hypogastric interventions, rate, depth and abnormalities of
region, like the patient rhythm that may nursing
uterine will be able to indicate early interventions,
contractions establish a respiratory the patient will
of low normal, compromise have
intensity effective established a
 Unexplained breathing  Direct client in  To assist client normal,
tiredness pattern, as breathing efforts as in “taking effective
 Difficulty of evidenced by needed. Encourage control of the breathing
breathing relaxed slower and deeper situation, pattern, as
breathing at inspirations and especially when evidenced by
 Vital Signs
normal rate and use of the pursed- condition is relaxed
taken as
depth and lip technique associated with breathing at
follows:
absence of anxiety and air normal rate and
tachypnea. hunger depth and
Blood Pressure:
absence of
120/80 mmHg tachypnea.
 Elevate the head of  To promote
Pulse Rate: 100 bpm the bed and/or physiological
have the client sit and
Respiratory Rate: 26 up in a chair, as psychological
bpm appropriate ease of maximal
inspiration
Temperature: 38.7
degrees  Encourage  To prevent
ambulation/exercis onset or reduce
Patient may e severity of
manifest: respiratory
 Decrease in complications
inspiratory or and to improve
expiratory respiratory
pressure muscle strength
 Decrease in
minute  To maximize
ventilation or  Emphasize the respiratory effort
vital capacity importance of good
 Pursed-lip posture and
breathing effective use of
accessory muscles
 For the
 Administer pharmacological
prescribed management of
medications as the patient’s
ordered condition

Interventions that
Interventions that reflect reflect Filipino values
Filipino values and and culture
culture

 To limit the level

 Maintain a calm of anxiety.
attitude while
dealing with the
patient and
significant other(s)
  Non-distracting
 Provide for a quiet environment
environment that is provides optimal
adequately opportunity for
ventilated, dimly lit, rest and
and free of relaxation.
unnecessary
personnel.
 This will reduce
 Stay with the the patient’s
patient during acute anxiety, thereby
episodes of reducing
respiratory distress. oxygen
demand.

 Presence may
 Keep environment trigger allergic
allergen free (dust, response that
feather pillows, may cause
smoke, pollen) increase in
mucus
secretion.