University:
American Career College
Course:
NURS112 | Fundamentals of Nursing
Academic year:

2022
Views:

322

Pages:

1
Author:

ilikemyicons0y5

Pathophysiology Assessment Data- min. of 3 The route of transmission of SARS-CoV-2 could be through coughing and sneezing. The virus enters the lungs through the respiratory tract. The virus then attacks the alveolar epithelial type 2 cells. The invasion of SARS- CoV-2 in the lungs cells, myocytes, and endothelial cells of the vascular system can result in inflammatory changes; oedema, degeneration, and necrotic changes. The virus causes difficulty in breathing, hypoxemia, and cough. Subjective: Nursing Diagnosis/Priority Problem #1 (3-part statement) (In your own words-cite reference) Pt. states feeling fatigue Ineffective airway clearance related to SARS-CoV-2 as evidenced by presence of dyspnea and hypoxemia. Pt. states shortness of breath Pt. states loss of taste and smell 1.Through the use of effective breathing and coughing techniques, as well as using an inhaler, the patient will be able to maintain clear airways as evidenced by clear breath sounds and normal respirations. Objective: Coughing Nausea vomiting Planning- Short Term Goal #1 and Temp of 102.3 F Nursing Diagnosis/Priority Problem #2 (3-part statement) Nausea and vomiting related to SARS-CoV-2 as evidenced by presence of queasy feeling, urge to vomit, and distress. Nursing Interventions for Goal #2- min. of 2 1. Educate the patient on taking prescribed or over the counter medications as needed 2.Allow the patient to take non pharmacological methods to control nausea such as relaxation and deep breathing exercises Diagnostic Procedures: A urinalysis can be performed to check for dehydration or other signs of infection as well as kidney function Planning- Short Term Goal #2 1.By taking prescribed or over the counter medication as well as using non pharmacological methods to treat nausea and vomiting, the patient’s symptoms will subside within 24 hours. Evaluation- Was the goal met, what evidence would support the goal being met. If goal was unmet, what will you do next? STG #1-The goal was met for the patient as evidenced by clear breathing sounds and a normal respiration rate of 18 breaths per minute. STG #2- The goal was not met as the patient still had symptoms of nausea after both medication and nonpharmacological approaches were taken. Further interventions that can be attempted are continued hydration as well as only providing the patient with light and bland foods.