Chapter 2

Nursing Care Plan

Identity : can impact to other people, man and women have ratio 1:1

The main complaint: in patients who have a virus MERS usually complained about chest pain
and often undergo pain, pneumonia, coughing and sneezing

Disease history now : the main complaint MRS, factors its originator, long complaints, the
complaints, factors that heavier.

The acts of disease of former times : your allergy history, smoking habit ,coffee, medicines,
alcohol

The acts of the health : identification various kinds of diseases children, aver got a virus were
before that.

The acts of environmental health : is the client stay in an dirty

Physical examination

B1 :respiratory increased , shortness of breath , breath the nostrils , the use of the tools breath ,
breath sound ronchi , cough.

B2 :pale, dam the jugulars vein , abnormality the sound of the heart (gallop, mur murs, cyanosis,
clubbing finger, CRT>3

B3 : fever , chills , pain in their the body

B4 : nothing problem

B5 : nothing problem

B6 : fatigue
Data analysis

NO DATA ETOLOGY PROBLEM

1 Ds : pt said cough Mers-CoV Ineffectiveness of
Do : airway clearance
Cough ineffective The buildup of fibrin,
Ronchi exudate, ritrosites and
RR increased leukocytes
Have a secret
Stacking secret on the
bronchi

Coughing, tightness
breath, dysnea

Ineffectiveness of airway
clearance
2 Ds : pt said out of breath Mers-CoV Gas exchange
Do : disruption
Cyanosis Capillary thickening
CRT > 3 increases
The breath of the nostrils
Tachycardia Transfer of exudate
Hypoxia plasma to intertisiel

Edema of the alveoli

capillary space

Decrease in diffusion
oxygen
 Gas exchange disruption

3 Ds : pt said the body is hot Mers-CoV Hyperthermia

Do :
Fever Pyogen release
T > 37,5 C endogenous (cytokines)
Acral heat
Tachycardia Interleukin 1 &
Shivering interleukin 6

Stimulates the vagus

nerve

The signal reaches the

central nervous system

The formation of brain

prostaglandins

Stimulates the
hypothalamus

Increase the temperature

Grind, improve Basal

temperature
 Hyperthermia

Nursing Diagnoses

1. Ineffectiveness of airway clearance related with secretion buidup is characterized by pt

said cough, Cough ineffective, Ronchi, RR increased, Have a secret.
2. Gas exchange disruption related with decrease in O2 in inspiratory air is characterized by
pt said out of breath, Cyanosis, CRT > 3, The breath of the nostrils, Tachycardia,
Hypoxia.
3. Hyperthermia related with changes in temperature regulation is characterized by pt said
the body is hot, Fever, T > 37,5 C, Acral heat, Tachycardia, Shivering
 INTERVENSION

No Diagnose Goal and yield criteria Intervention Rational

1 Ineffectiveness of After doing nursing action 1. Instruct the patient to rest and breath 1. to meet the needs of
airway clearance related in expecting the cleanliness deeply oxygenation
2. Position the patient to maximize 2. position the patient with
with secretion buildup is of airway can be overcome
ventilation semi-fowler position to
characterized by pt said with result criteria: no
3. Do chest physiotherapy if necessary
reduce shortness
cough, Cough cyanosis and dyspnea 4. Remove the secret with cough or
3. to prevent secret buildup
ineffective, Ronchi, RR 1. oxygen saturation suction 4. to clear the secret of the
5. auscultation of breath sounds and note
increased, Have a secret within normal limits bronchus
2. Thorak photos additional sounds 5. to determine the next
6. collaboration of antibiotics
within normal limits action
7. Maintain adequate hydration to resolve
3. no extra breath 6. to keep the airway clean
the secret
sounds again effective
8. TTV monitor
4. vital signs within 7. so that secret can be
normal limits removed easily
8. to know the general
condition of the patient
2. Gas exchange disruption After the act of nursing for 1. Position the patient to maximize 1. position the patient with
related with decrease in 3x24 hours in expected gas ventilation semi-fowler position to
2. Install the mayo if necessary
O2 in inspiratory air is exchange disruption can be reduce shortness
3. Do chest physiotherapy if necessary
2. to free the airway
characterized by pt said overcome with the criteria 4. Set the intake to optimize the balance
3. to improve alveoli
out of breath, Cyanosis, of results: liquid
ventilation
5. Monitor respiration and oxygen status
CRT > 3, The breath of 1. Arterial blood ph value 4. to optimize the balance
6. Monitor breath sounds like snoring
5. to know the general
the nostrils, Tachycardia, in normal range 7. Monitor respiratory pattern: bradycipes,
 Hypoxia. 2. normal breathing takipenia, kusmaul, hyperventilation. condition of the patient
8. Auscultation of heart sound, number,
3. bga within normal limits and to take further action
rhythm, and heart rate 6. to know the existence of
4. No cyanosis
9. Monitor TTV
blockage
5. Normal skin color
7. to provide adequate
ventilation
8. to determine the
adequacy of gas exchange
9. to know the general
condition of the patient
3 Hyperthermia related After the act of nursing for 1. Identify the triggering factors. 1. Determination and
with changes in 3x24 hours in expected gas 2. Monitor the patient’s HR, BP, and management of the
temperature regulation is exchange disruption can be especially the tympanic or rectal underlying cause are
characterized by pt said overcome with the criteria temperature. necessary to recovery.
the body is hot, Fever, T of results: 3. Monitor fluid intake and urine output. 2. progresses. Tympanic
> 37,5 C, Acral heat, 1. temperature range If the patient is unconscious, central or rectal temperature
Tachycardia, Shivering 36,5-37,5o C venous pressure or pulmonary artery gives a more accurate
2. skin not redness pressure should be measured to monitor indication of core
3. vital sign in the fluid status. temperature.
normal range 4. Review serum electrolytes, especially 3. Fluid resuscitation may
serum sodium. be required to correct
5. Adjust and monitor environmental dehydration. The
factors like room temperature and bed patient who is
linens as indicated. significantly
6. Give antipyretic medications as dehydrated is no longer
prescribed. able to sweat, which is
necessary for
evaporative cooling.
4. Sodium losses occur
with profuse sweating
and accidental
hyperthermia.
5. Room temperature may
be accustomed to near
normal body
temperature and
blankets and linens
may be adjusted as
indicated to regulate
temperature of the
patient.
6. Antipyretic
medications lower
body temperature by
blocking the synthesis
of prostaglandins that
act in the
hypothalamus.