Saint Louis University

Baguio City
School of Nursing

Case Presentation:

Maria Odette A. Carpio, COVID Confirmed with Moderate Pneumonia

Presented by:
Peralta, Keanu Gybs
Aladin, Nathalie Maurise
Obillo, Sherryl Joy
Sumbad, Kyla Emelyn I.

BSN 4C Clinical Group 4

Background about the patient:

Her condition started 11 days PTA when she experienced intermittent undocumented fever
for 3 days and congested nose. There were no other symptoms noted like cough, colds, anosmia,
loss of appetite and loose stools. No consultation nor medications were taken. 7 days PTA, patient's
symptoms persisted and is now accompanied with anosmia with no other others signs and
symptoms (vomiting, loose stools and cough). This prompted a teleconsult and was prescribed
with Azithromycin 500mg OD 5 days. 5 days PTA, still with above signs and symptoms
intermittent fever, anosmia, and congested nose, an RT-PCR swab test was done and the result
was positive. 2 days PTA, the patient woke up from sleep due to distressing dry cough and
shortness of breath. 1 day PTA still with intermittent undocumented fever and cough, the patient
now experienced chills. This prompted the patient to seek consult at the ER and was advised for
admission, but refused. Chest xray, ABG, CBC, Urinalysis, Na, K, BUN, Creatinine, SGPT, LDH,
Ferritin, Procalcitonin, D-Dimer, CRP, CBG, 12 Lead ECG were requested. For the medications,
the patient was prescribed with cefixime 200mg twice a day, dexamethasone 3 mg/tab 2 tabs taken
once a day.

Mrs. Carpio lives in with her husband. Married for 20 years, husband is apparently well.
Lives in a two-storey, well-lit and well-ventilated house. Water supply is from BWD. She is non-
smoker and alcoholic. No regular exercise, drinks 3 cups of coffee daily. No food [Link]
history of sexually transmitted infection or drug abuse.
 GUIDE QUESTIONS

1. List the different areas that should be addressed in comprehensive COVID care
(promotion, prevention, treatment, rehabilitation and palliation) and define the role
of nurses (Caregiver, Client Advocate, Educator, Case Manager, Collaborator and
Researcher).

Promotion ● Encourage them to get vaccinated to be protected by the

virus. Inform them that will help in boosting their
immunity. Emphasize also that the best vaccine is the
one that is available.

Prevention ● This can be done by conducting a health teaching. The

nurse may give them knowledge regarding:
-Wearing a mask that should cover the entire nose and
mouth.
-Proper Handwashing
-Difference between COVID to flu and cold.
-Social Distancing

Treatment ● Ensure the patient’s adherence to the following

medications:
-Vitamin C + Zinc

● Administer the following medications as ordered by the

physician:
-Ceftriaxone
-Remdesivir
Rehabilitation ● Instruct the patient regarding proper breathing
technique
-Controlled breathing
● Educate the patient in managing breathlessness
-Position to ease breathlessness
-High side lying, forward lean sitting
● Emphasize about Exercise Safety
● Inform in managing eating, drinking and swallowing
-Side upright whenever you are eating or drinking
● Instruct on how to manage problem with voice
-Use other way of communication like writing or using
gesture
-Do not strain your voice
-Sip water throughout the day
● Provide information that will aid in managing stress,
anxiety or depression
● Tell the client to take care of one’s basic needs
-Get enough quality sleep
-Eat healthy foods.
-Rest yourself and don’t over work

Palliation ● Cough
-Morphine
● Fever
Acetaminophen, NSAID
● Breathlessness
-Pharmacologic (oxygen, morphine)
-Non-Pharmacologic: using cool wipes on the face, the
nurse is calm so that the patient will do it as well.
● Agitation and Anxiety
-Severe agitation (Benzodiazepines)
-Delirium such as disoriented (Antipsychotic)

If the patient with severe COVID-19 expresses a fear of dying.

● Ask them what they need and ask if there is someone to
talk to with their condition.
● Reassure them that they have correct treatment to
improve their condition but be honest on what is going
on with them that this condition can cause death.
 Caregiver ● Direct Nursing Care
● Health Assessment
● Health Maintenance
● Specialist care: Midwifery, dialysis, palliative.

Client Advocate ● Interviewing patient

● Identifying problem
● Making referrals to appropriate health services
● Direct patient complains
● Explaining policies
● Assisting in choosing a doctor
● Discussing treatment option
● Keeping a prescription and accompanying patients to
doctors appointment.

Educator ● Health Teaching about vaccine and its effect

● First Aid
● Simple discussion regarding the virus’ evolution
● Risk and Safety of Older people, children and person
with comorbidities
● Community Lectures about COVID 19 like using mask,
handwashing, using alcohol and social distancing

Case Manager ● Coordination of Service

-Patient Advocacy

Collaborator ● Nurse collaborate with other health care providers,

patients and significant others to improve the patient's
condition and to give correct quality care for the patient.

Researcher ● Studying different health and interventions to improve

health status that the patient needs. So that we have
evidence based on what we are going to do with our
patient.
2. What are special issues for nurses who are involved in caring for patients with
communicable diseases?

Edemekong and Huang (2021) stated that communicable diseases are illnesses caused by
viruses or bacteria that people spread to one another through contact with contaminated surfaces,
bodily fluids, blood products, insect bites, or through the air. Infectious waste is waste capable of
producing an infectious disease. Exposure to the waste by a susceptible host could result in an
infectious disease. Hence, handling of the infectious wastes must be minimized. The proper control
of infection depends on the proper disposal of contaminated wastes. With this, safe handling and
control of infectious wastes are the common special issues for nurses who are handling patients
with communicable diseases. Appropriate handling and control of infectious wastes is paramount
to the safety of both the client and the nurse. With this, one possible issue under the safety handling
and disposal of infectious wastes is the proper handwashing after contact with the client or with
potentially contaminated articles and before care of other clients. In addition to this, another issue
is the correct bagging and discarding of articles contaminated with infectious material into an
appropriately labeled container before it is sent for decontamination. One issue also is the
appropriate use of proper personal protective equipment while dealing with an individual in
isolation.
3. Discuss the pathophysiology COVID-19/Pneumonia and its relationship to
pharmacologic and nonpharmacologic intervention.

A separate file for this item is uploaded. Kindly open “COVID-19

[Link]” Thank you very much.
4. What is the relevance of the diagnostic procedures ordered by the doctor in this
case? What test(s) would you anticipate to be added for further investigation?

5. Find one (1) evidence-based journal on updates related to the care of patients in
COVID-19/Pneumonia and write the findings and recommendations.

Comparative efficacy and safety of pharmacological interventions for the

treatment of COVID-19: A systematic review and network meta-analysis

Authors: Min Seo Kim, Min Ho An, Won Jun Kim1,5, Tae-Ho Hwang
Published: December 30, 2020

Objective: Numerous clinical trials and observational studies have investigated various
pharmacological agents as potential treatment for Coronavirus Disease 2019 (COVID-19), but the
results are heterogeneous and sometimes even contradictory to one another, making it difficult for
clinicians to determine which treatments are truly effective. Results from these studies are
heterogeneous and sometimes even contradictory to one another, making it difficult for clinicians
to determine which treatments are truly effective. Level of evidence behind these drugs are diverse
and must be classified into categories to effectively inform policy and practice.

Conclusions: In this NMA, we found that anti-inflammatory agents (corticosteroids, tocilizumab,

anakinra, and IVIG), convalescent plasma, and remdesivir were associated with improved
outcomes of hospitalized COVID-19 patients. Hydroxychloroquine did not provide clinical
benefits while posing cardiac safety risks when combined with azithromycin, especially in the
vulnerable population. Only 29% of current evidence on pharmacological management of COVID-
19 is supported by moderate or high certainty and can be translated to practice and policy; the
remaining 71% are of low or very low certainty and warrant further studies to establish firm
conclusions.

What did the researchers do and find?

• In randomized controlled trials (RCTs), remdesivir and corticosteroid were shown to
reduce COVID-19 aggravation and mortality rates.
• In the whole dataset, including data from RCTs and observational studies, antiinflammatory
agents (corticosteroid, tocilizumab, anakinra, and IVIG), convalescent
plasma, and remdesivir were associated with improved clinical outcomes of
COVID-19.
• Hydroxychloroquine provides no benefit in mitigating COVID-19 disease course while
posing safety risks, especially to vulnerable populations.
What do these findings mean?
• These findings could help prioritize further research on drugs of possible benefit.
• Only 29% of current evidence on pharmacological management of COVID-19 is based
on moderate/high evidence certainty and can be reflected in practice and policy;
remaining 71% are of low or very low evidence certainty and warrant further studies to
establish firm conclusions.

Prioritization and Justification

1. Ineffective Breathing Pattern The client is experiencing a problem regarding

related to hyperventilation as evidenced by her breathing pattern. An ineffective breathing
respiratory rate of 24 cpm. pattern is inspiration and/or expiration that
does not provide adequate ventilation. Hence,
it could compromise proper ventilation. I
prioritized this because it involves a concern
with oxygen. If the breathing pattern is not
effective, proper oxygenation does not take
place. According to Maslow’s Hierarchy of
needs, oxygen is one of the physiological needs
of an individual. She or she needs to meet it
first before his other needs in order to survive.
In addition, oxygen is being diffused in the
blood to provide the needed nutrients by the
different organs. Hence, the problem
regarding ineffective breathing patterns must
be prioritized.

2. Hyperthermia related to increase in Hyperthermia is defined as a core body

metabolic rate as evidenced by the temperature temperature above the normal diurnal range
of 38.1degrees centigrade. due to failure of thermoregulation. According
to Khan et. al, prolonged hyperthermia could
induce cell death in the brain. And according to
Maslow’s Hierarchy of needs, Temperature is
one of the physiological needs of an individual
in order to survive. With these being said, the
problem concerning hypothermia is the second
priority. This is less prioritized than
oxygenation because it does not predispose the
 individual immediately to experience an
impairment of her vital organs.

3. Activity Intolerance exhaustion related Activity intolerance is the Insufficient

to excessive coughing, and dyspnea physiological or psychological energy to
endure or complete required or desired daily
activities. This is one of the problems of the
client due to excessive coughing for the past
day and the occurrence of dyspnea due to the
episodes of desaturation and the abnormal
respiratory rate level. According to Maslow’s
hierarchy of needs, “Activity” is also a part of
an individual’s physiological needs. Hence,
this must be prioritized too. However, it is not
as urgent as problem number 1 and 2.
Insufficient activity will not predispose the
vital organs to fail, but ineffective oxygenation
and persistent hyperthermia does. And,
resolution of the ineffective breathing pattern
and the problem with hyperthermia will cause
the client to gain enough physiological and
psychological energy to accomplish her daily
activities.

4. Risk for imbalanced Nutrition: Less The Risk for imbalanced Nutrition: Less than
than Body Requirements increased metabolic Body Requirements means that there is a risk
needs secondary to fever and infectious for insufficient intake of nutrients to meet
process metabolic needs. The client is predisposed to
this problem because excessive coughing and
difficulty of breathing for how many days
could have interrupted him in eating properly.
This is the last priority because the problem is
still a risk and it could still be prevented.
 NCP Proper

Ineffective Breathing Pattern related to hyperventilation as evidenced by respiratory rate of 24 cpm.

Assessment Explanation of Goals and Interventions Rationale Evaluation Criteria

the Problem Objectives

S An ineffective LTO Dx LTO is FULLY

>The patient breathing After 4 days of >Assess the rate and >Tachypnea, shallow MET if after 4 days of
verbalized that pattern is a nursing depth of respirations for respirations, and nursing interventions,
she was condition of interventions, 1 full minute asymmetric chest the patient will:
already able to inadequate the patient will: movement are >Establish a normal,
breathe ventilation due >Establish a frequently present effective respiratory
properly to an normal, because of discomfort pattern as evidenced
yesterday, but impairment in effective of moving chest wall by
complains that the mechanism respiratory or fluid in lung. When a.) Absence of
she is once of inspiration pattern as pneumonia is severe, tachypnea
more having and expiration. evidenced the client may require b.) the presence of
trouble Prolonged by endotracheal arterial blood gasses
breathing at inadequate a.) Absence of intubation and (ABGs) particularly
the moment. ventilation may tachypnea mechanical the PaO2 of 80-100
The client also lead to b.) the presence ventilation to keep mmHg.
mentioned that compromised of arterial blood airways clear.
she is already respiratory gasses (ABGs) LTO is
able to function particularly the >Decreased airflow PARTIALLY MET
expectorate performance, PaO2 of 80-100 >Auscultate lung fields, occurs in areas if after 4 days of
phlegm such as mmHg. noting areas of consolidated with nursing interventions,
effectively providing decreased or absent fluid. Bronchial
compared oxygen for the airflow and breath sounds the patient will
yesterday. tissues, and adventitious breath (normal over manifest:
removing waste sounds, such as bronchus) can also a.) Absence of
O products. crackles occur in consolidated tachypnea
>RR: 24 areas. Crackles, b.) the presence of
CPM, irregular rhonchi, and wheezes arterial blood gasses
and shallow are heard on (ABGs) particularly
>Use of inspiration and the PaO2 at 126
accessory expiration in response mmHg.
muscles to to fluid accumulation,
breathe thick secretions, and LTO is NOT MET if
(hypothetical airway spasm or after 4 days of nursing
data) obstruction. interventions, the
>Nasal flaring patient will manifest:
(hypothetical >Cough that is a.) Tachypnea (RR
data) persistent and >20 CPM)
>Crackles >Assess the presence constant can interfere b.) the presence of
were and character of cough with breathing (such arterial blood gasses
auscultated on as can occur with (ABGs) particularly
the left lobe of asthma, acute the PaO2 at 126
the lungs bronchitis, cystic mmHg.
(hypothetical fibrosis, croup,
data) whooping cough). STO is FULLY MET
>The STO if after 8 hours of
expectorated After 8 hours of nursing interventions,
secretions are nursing the patient will:
yellowish in interventions,
the patient will:
color and thick >Manifest a >Assess the client's > Awareness and >Manifest a
in consistency. respiratory rate awareness and cognition affects an respiratory rate of 20-
(hypothetical of 20-22 cpm cognition. individual’s ability to 22 cpm
data) >Demonstrate a manage own airway >Demonstrate a
>ABG result: decrease in and cooperate with decrease in crackles
pO2= 126 crackles upon interventions upon auscultation
mmHg auscultation such as controlling >Expectorate phlegm
>Expectorate breathing and effectively
phlegm managing secretions. >Verbalize awareness
effectively of 3 causative factors
>Verbalize regarding COVID-19
awareness of 3 >Note the color of skin >If pallor, duskiness, or Pneumonia.
causative factors and mucous and/or cyanosis are >Demonstrate 3
regarding membranes. present, supplemental appropriate coping
COVID-19 or oxygen and/or other behaviors after being
Pneumonia. interventions may be infected from
>Demonstrate 3 require COVID-19.
appropriate
coping >Review laboratory >ABG determines STO is
behaviors after data, such as ABGs degree PARTIALLY MET
being infected of oxygenation and if after 8 hours of
from COVID- carbon dioxide or nursing interventions,
19. even CO 2 retention. the patient will:
These factors cause >Manifest a
an impairment in an respiratory rate of 22-
individual’s breathing 24 cpm
pattern. >Demonstrate a
minimal decrease in
Tx crackles upon
Independent auscultation
>Elevated head of bed; >This is done to >Expectorate minimal
change position promote phlegm
frequently physiological and >Verbalize awareness
psychological ease of of 1-2 causative
maximal inspiration. factors regarding
Keeping the head COVID-19 or
elevated lowers Pneumonia.
diaphragm, >Demonstrate 1-2
promoting chest appropriate coping
expansion, aeration of behaviors after being
lung segments, and infected from
mobilization and COVID-19.
expectoration of
secretions to keep the STO is NOT MET if
airway clear. after 8 hours of
nursing interventions,
>Assisted client with >Deep breathing the patient will:
frequent deep- facilitates maximum >Manifest a
breathing exercises. expansion of the respiratory rate of 24
lungs and smaller cpm
airways >Demonstrate
>Offered 500 mL of crackles in both lobes
warm fluids >Fluids, especially of the lungs upon
warm liquids, aid in auscultation
mobilization and >Expectorate phlegm
ineffectively
 expectoration of >Verbalize 0
secretions. causative factors
>Provide/encourage regarding COVID-19
use of adjuncts, such as >This is done to or Pneumonia.
incentive spirometer facilitate deeper >Demonstrate 0
respiratory effort. appropriate coping
>Suction airway, as behaviors after being
needed >This is done to clear infected from
secretions. COVID-19.
Dependent
>Utilize pulse oximetry
to check oxygen and >Pulse Oximetry is a
pulse rate helpful tool to detect
alteration in oxygen
initially but for CO2
levels, end-tidal CO2
monitoring or arterial
blood gases would
require obtaining
>Ambulate patient as
tolerated with doctors >Ambulation can
order three times daily further break up and
move secretions that
block the airway
>Administer oxygen as
ordered. >Oxygen
administration
corrects hypoxemia
>Administer
respiratory medication >Scheduled and PRN
as ordered. medications help
during episodes and
reduce exacerbation.
Educative
>Encourage pursed-lip
breathing and >This is done to clear
diaphragmatic or secretions.
abdominal breathing
exercise

>Encourage small
frequent meals >These breathing
techniques can be
used during activities
to reduce the amount
of air trapping in the
lungs.
>Teach about the
indication, dosage, >This prevents
frequency, and possible crowning of the
side effects of diaphragm.
prescribed education.

>Teach the family and

caregiver signs and
symptoms of >Knowing side
respiratory distress. effects and proper
usage of medication
ensures the best
>Encourage possible treatment.
ambulation/exercise, as
individually indicated >In case of an
by the physician emergency, the
family needs to have
the skills to provide
initial care and call
for help to prevent
care delays and
ensure the best
possible patient
>Demonstrate to the outcome.
client the proper
manner of splinting the >This is done to
chest. prevent onset or
reduce severity of
respiratory
complications and to
improve respiratory
>Instruct the client on muscle strength.
how to do effective
coughing while in an >Splinting reduces
upright position. chest discomfort, and
an upright position
>Emphasize to the favors deeper, more
client and to the forceful cough effort.
significant other the
importance of adhering >Coughing is a
to standard natural self-cleaning
precautionary measures mechanism, assisting
like wearing masks the cilia to maintain
properly and frequent patent airways.
handwashing

>Inform the client and

the significant other/s
in a simple manner on
how can an individual >This is to protect the
be infected by COVID- client from
19 experiencing
worsening of her
current infection with
COVID-19. This is
also to protect the
family members from
being infected by the
virus. By being aware
of the ways on how
someone can become
infected, they will be
able to practice
 effectively and adhere
to the precautionary
measures like
wearing masks and
frequent
handwashing.

References:

Edemekong PF, Huang B. Epidemiology Of Prevention Of Communicable Diseases. [Updated 2021 Jul 23]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: [Link]

Kim, M. S., An, M. H., Kim, W. J., & Hwang, T.-H. (2020). Comparative efficacy and safety of pharmacological interventions for the
treatment of COVID-19: A systematic review and network meta-analysis. PLoS Medicine, 17(12), e1003501.
[Link]

Doenges, M. E., Moorhouse, M., & Murr, A. C. (2010). Nursing care plans: guidelines for individualizing client care across the
lifespan. Philadelphia: F.A. Davis Company.

Doenges, M. E., Moorhouse, M., & Murr, A. C. (2019). Nurse's pocket guide diagnoses, prioritized interventions and rationales.
Philadelphia: F.A. Davis Company.

LeMone, P., Burke, K., & Bauldoff, G. (2008). Medical-surgical nursing critical thinking in patient care. New Jersey: Pearson.

Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H. (2010).Brunner & suddarth's textbook of medical surgical nursing.
Philadelphia: Wolters Kluwer.