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Task 1. My Plan For You!: Assessment Diagnosis Planning Intervention Rationale Evaluation
Task 1. My Plan For You!: Assessment Diagnosis Planning Intervention Rationale Evaluation
Instructions: Craft at least two Nursing Care Plan based on the Nursing Diagnoses listed below. Follow the standard format set by the College.
(see rubrics for scoring)
Ineffective Airway Clearance related to Excessive and Tenacious secretions
Impaired Gas Exchange related to Activity Intolerance
Anxiety related to Breathlessness
Powerlessness related to feelings of loss of control
High risk for Ineffective Therapeutic Regimen Management related to lack of Knowledge
a. Echinacea
is a genus of herbaceous flowering plants in the daisy family. It has ten species, which
are commonly called coneflowers. They’re linked to many health benefits, such as
reduced inflammation, improved immunity and lower blood sugar levels.
b. Goldenseal
is a popular natural treatment for upper respiratory tract infections, including the
common cold.
c. Zinc
is considered an essential nutrient, meaning that your body can’t produce or store it.
Health education
● Reducing contact with people
who have SARS - until at least 14
days after their fever and other
symptoms are gone.
● Wash hands or clean with an
alcohol based instant hand
sanitizer especially after
touching surfaces.
● Cover the mouth and nose
when sneeze or cough. Droplets
that are released when a person
sneezes or coughs are infectious.
● Use surgical mask and glove.
● Do not share food, drink, or
utensils.
● Clean commonly touched
surfaces with an EPA approved
disinfectant.
● Avoid mass gatherings and
activities.
● Avoid touching the face in
general.
● Check body temperature at
least twice a day.
● Avoid travel to places where
there is an uncontrolled SARS
outbreak.
MERS
Overview Clinical Manifestation Pathophysiology Medical/Nursing Management
● Another example of a disease that ● Patients with MERS typically report MERS-CoV establish infection ● There is no specific treatment
could cause a pandemic. respiratory symptoms in monocyte for MERS.
● MERS is caused by a “novel” or new ● Symptoms may be mild or progress Derived macrophages (MDMs) ● Supportive care is used to
virus from the large family of rapidly to multi-system organ failure, and macrophages. manage and prevent
coronaviruses. sepsis, and death The virus induces the release complications.
● Viruses from this family cause many ● With severe distress, arterial blood gas of proinflammatory cytokines, ● The patient may need
respiratory illnesses such as the analysis is performed to determine the leading to severe mechanical ventilation and
common cold. need for oxygen therapy and possible inflammation. fluids.
● They also can cause critical infections ventilation support. MERS-CoV infected Vascular ● If kidney function is severely
such as severe acute respiratory ● Cough endothelial cells located in the reduced, dialysis is performed.
syndrome (SARS). ●Shortness of breath pulmonary interstitium and ● Hemorrhage from
● MERS was first identified in Saudi ● Fever infection may occur. disseminated intravascular
Arabia and has now been reported in ● Pneumonia Lymphopenia noted in most coagulation is managed with
26 countries. ●GI problems, such as diarrhea patients infected with MERS- blood products.
● Although most of human cases of CoV ● “Convalescent serum,” which
MERS-CoV infections have been Due to cytokine-induced is the serum taken from a
attributed to human-to-human immune cell sequestration patient who has recovered from
infections in health care settings, Release and induction of the disease, is a potential
current scientific evidence suggests monocyte chemotactic treatment but requires that the
that dromedary camels are a major protein-1 (MCP-1) and patient have the same blood
reservoir host for MERS-CoV and an interferon-gamma-inducible type as the convalescent
animal source of MERS infection in protein-10 (IP-10), which patient.
humans.(WHO) suppresses the proliferation of ● Patients being treated for
● The most recent outbreak started in human myeloid progenitor MERS must be maintained in
2015 in the South Korea cells. Contact and Airborne
● Only two cases of MERS have been Precautions (CDC, 2015g).
confirmed in North America, and both
patients were health care workers who
lived in Saudi Arabia and traveled to
North America (WHO,2015b)
2009 H1N1
Overview Clinical Manifestation Pathophysiology Medical/Nursing Management
● Also known as swine flu ● Cough Influenza virus ● The antiviral drugs oseltamivir
● Mutated and became highly ● Fever Enters the body (Tamiflu) and zanamivir (Relenza)
infectious to humans ● Sore throat Enters cell in the respiratory should be widely distributed.
● These drugs may reduce the
● Most recently it caused a pandemic ● Shortness of breath tract severity of the infection and the
in 2009, spreading to 215 countries ● ● Pneumonia Replicates inside cell mortality rate.
In the United States, the number of ● Diarrhea Leaves host cell in search for ● Infected patients must be cared for
people infected during the pandemic ● Vomiting another in strict isolation.
was estimated at 61 million with more ● Abdominal pain Most cell die ● Ask any patient with these
than 12,000 deaths (CDC, 2015e) ● Bleeding from the nose and gums symptoms if he or she has recently
(within the past 10 days) traveled to
● A vaccine was developed in 2009 and
areas of the world affected by H5N1.
was administered separately from the ● These precautions remain until the
seasonal influenza vaccine diagnosis of H5N1 is ruled out or the
● Now the seasonal vaccine contains threat of contagion is over.
the H1N1 antigen ● No effective treatment for this
● A new avian virus is the H5N1 strain, infection currently exists.
known as “avian influenza” or “bird Interventions are supportive to allow
the patient's own immune system to
flu.”
fight the infection.
● This virus has infected millions of ● Oxygen is given when hypoxia,
birds, especially in Asia, and now has breathlessness, or a sudden change
started to spread by human to human in cognition is present.
contact ● Respiratory treatments to dilate
● Another avian strain, H7N9, has the bronchioles and move
appeared in China, resulting in several respiratory secretions are used.
● If hypoxemia is not improved with
deaths. This virus seems to be able to
oxygen therapy, intubation and
spread from person to person in mechanical ventilation may be
limited situations. Travelers have needed.
brought the virus outside of China, but ● Antibiotics are used to treat a
there are no cases originating outside bacterial pneumonia that may occur
of that country (CDC, 2015e). with H5N1
● Patient with H5N1 may have
severe diarrhea and need fluid
therapy.
Avian Flu
Overview Clinical Manifestation Pathophysiology Medical/Nursing Management
Avian Flu- A highly contagious viral Headache Influenza can be transmitted
disease with up to 100 percent Sore throat through small or large particle Assess respiratory status for
mortality in domestic fowl. Caused by Shortness of breath aerosols or through contact with rate, depth, ease, use of
influenza A virus sub-types H5 and H7. Cough contaminated surfaces. accessory muscles, and
All types of birds are susceptible to the Fever work of breathing
virus, but outbreaks occur most often If not neutralized by mucosal Administer oxygen as
in chickens and turkeys. The infection DIAGNOSTIC TEST antibodies, virus attacks ordered.
may be brought by migratory wild Nasal swab Samples of fluids from your respiratory tract epithelium. Position patient in high
birds which can carry the virus, but nose or throat can be tested for evidence Fowler’s or semi-Fowler’s
show no signs of disease. Humans are of bird flu virus. These samples must be Infection of respiratory tract position, if possible.
only rarely affected. Also known as taken within the first few days after epithelial cells leads to cellular
fowl plague, avian flu, and bird flu. symptoms appear. dysfunction, viral replication, and
TREATMENT
Chest x-ray X-rays may be useful in release of viral progeny. Amantadine and Rimantadine
assessing the condition of your lungs, (Flumadine)
MODE OF TRANSMISSION which can help determine the proper Release of inflammatory mediators ● 100mg BD
through direct contact with an infected diagnosis and the best treatment options contributes to systemic ● To treat influenza virus
bird’s saliva, nasal secretions, and for your signs and symptoms. manifestations of disease. infection
excreta or through contact with ● Oseltamivir (Tamiflu)
contaminated surfaces (such as cages) ● 75mg BD
or materials (such as water or feed) ● Blocks the actions of influenza
virus types A and B in body
● Zanamivir (Relenza)
● 10mg (2 inhalations) BD
● Antiviral medicine that blocks
the actions of viruses in your
body
HEALTH EDUCATION
● Avoid contact with live poultry
and birds, especially for
children.
● Avoid crowded areas and stay
in places with good ventilation.
● Wash hands thoroughly with
soap and water after handling
live poultry and birds, and after
coughing and sneezing.
● Build up a strong immunity
system in your body. Start by
having a regular exercise regime
and a well-balanced diet that
includes two servings of
vegetables and two servings of
fruits daily. Make sure to get
adequate rest, reduce your
stress levels and do not smoke.
COVID-19
Overview Clinical Manifestation Pathophysiology Medical/Nursing Management
● Also named as Severe Acute ● Coronaviruses are common in ● There is no specific antiviral
Respiratory Syndrome Coronavirus 2 ● The symptoms of COVID-19 infection many different species of animals, medication yet is recommended for
(SARS-CoV-2) appear after an incubation period of including bats, camels, cats, and COVID-19 infection, and no current
● Identified as the cause of an approximately 5.2 days. cattle. vaccine to prevent it.
outbreak first discovered at a local ● The period from the onset of COVID-19 ● Most coronaviruses infect ● Hand hygiene. Wash hands often
seafood /wild animal market in symptoms to death ranged from 6 to 41 animals, but not people; in the with soap and water for at least 20
seconds; if water and soap are not
Wuhan, China. days with a median of 14 days . This future, one or more of these other
available, use an alcohol-based
● An outbreak of pneumonia of period is dependent on the age of the coronaviruses could potentially
hand sanitizer.
unknown etiology in Wuhan City was patient and status of the patient's evolve and spread to humans, as
● Keep hands off your face. Avoid
initially reported to WHO on immune system. It was shorter among has happened in the past (zoonotic touching the eyes, nose, and
December 31, 2019. patients > 70-years old compared with transmission). mouth with unwashed hands.
● The COVID-19 has been declared by those under the age of 70. ● Evidence indicates the new virus ● Maintain social distancing. Avoid
the World Health Organization (WHO) COVID-19 is spread via the route of close contact with people at least 3
as a pandemic where it is reported Stages of illness: human-to-human transmission feet (1 meter) who are sick, and
that around 5,000,000 people are because there are infections of stay at home when you are sick.
affected in more than 200 countries 1. Replicative stage – Viral replication people who did not visit Wuhan ● Proper cough and sneeze
around the world. occurs over a period of several days. but had close contact with family etiquette. Cover your cough or
● An innate immune response occurs, members who had visited Wuhan sneeze with a tissue, then throw
High risk group but this response fails to contain the and got infected. the tissue in the trash.
● Age above 60 years old virus. ● Supportive care. People infected
●Smoker ● Relatively mild symptoms may occur with COVID-19 should receive
supportive care to help relieve
● Cardiovascular disease due to direct viral cytopathic effect and
symptoms.
● Diabetes innate immune responses.
● Severe cases. For severe cases,
● Hypertension
treatment should include care to
● Immune deficiency 2. Adaptive immunity stage – An support vital organ functions.
adaptive immune response eventually is Antiviral Treatment - there is no
initiated clinical evidence for effective
● This leads to falling titres of virus. antiviral drugs, currently the
However, it may also increase levels of antiviral strategies based on the
inflammatory cytokines and lead to tissue characteristics of SAR-CoV-2 are
damage – causing clinical deterioration. adopted according to Protocols for
● This progression may explain the Diagnosis.
clinical phenomenon wherein patients
are relatively okay for several days, but
then suddenly deteriorate when they Treatment of COVID-19
enter the adaptive immunity stage ● Usage of Glucocorticoids -
appropriate and short-term use of
corticosteroids to inhibit cytokine
cascade and to prevent disease
progression should be considered
for patients with severe COVID-19
● Oxygen Therapy for hypoxemia
● Use of Antibiotics to Prevent
Secondary Infection - The options
of antibiotics include quinolones,
the second or third generation
cephalothins, lactamase inhibitor
compounds,
● Balance of Intestinal
Microecology and Nutritional
Support
● Convalescent Plasma Therapy
3. You are caring for a patient who has been mechanically ventilated for 2 weeks.
Physically, the patient meets all the criteria to begin weaning from mechanical
ventilation. What parameters should the nurse monitor to assess tolerance of
weaning?
Systolic Blood Pressure (SBP) between 90-170 mmHg and within ± 20%
of pre-trial SBP
Exhaled TV ≥ 5 cc/ kg IBW ( ≈ 300 – 400 ml )
SpO2 ≥ 92 %
Patient showing no diaphoresis, paradoxical respiration, retractions, nasal flaring,
agitation, or complaining of SOB, or use of accessory muscles
Serial assessment of tolerance are made 5,15,30,60,and 120 minutes after the initial
setting and and any subsequent ventilator setting change