Ron Miguel L.

Capulong

Nr23- Group 1

GABMMC- OB Ward

Assignment no. 1 OB High Risk

CASE # 4 Sexually-Transmitted Disease (Gonorrhea)

PRIORITY PROBLEM

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Subjective: Acute Pain Neisseria After 8 hours of Independent: To increase the After 8 hours of
related to the gonorrhoeae nursing • Examine in a accuracy of the nursing
Patient reaction of I comprehensive diagnosis of the intervention the
intervention the
verbalized infection Adhesion to pain include disease client reported:
client will:
“mahapdi kapag urethra or other location,
umiihi ako at mucosal surface • Identify the characteristics, • Identified the
I and onset, cause of pain
masakit yung cause of the
Incubation is 3-5 duration,
itlog ko” pain
days frequency, • Used the
Objective: I • Use the quality, intensity methods of
For men, the To prevent prevention of
methods of
-Facial Grimace disease start as • Control of irritation of the non-analgesic to
prevention of environmental client and to relieve pain
-Fever an acute
-Green pus urethritis with a non-analgesic to factors that can ease the pain
discharge discharge relieve pain affect the through comfort
-Pain scale 6/10 containing client's response • Used
gonococci in • Use analgesics to discomfort analgesics as
large numbers as needed To alleviate the needed
• Increase clients
Vital Signs • Report pain enough sleep or weariness due • Reported pain
Temp – 38.6 was controlled rest to pain and to was controlled
RR – 22 enhance the
BP – 130/90 recovery of the
PR – 100 client
• Teach the
client proper To focus the
breathing client on
exercise breathing/to
distract the
client from the
pain
Dependent:
•Give analgesics
as ordered To minimize the
pain

ASSOCIATED PROBLEM

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

Neisseria After 8 hours of Monitor vital To immediately After 8 hours of

Subjective: Hyperthermia gonorrhoeae nursing signs recognize if the nursing
related to I intervention the client’s intervention the
Patient Adhesion to client will condition is client
inflammatory
verbalized urethra or other experience: getting better or experienced:
reactions
“mahapdi kapag mucosal surface worsening
umiihi ako at I • The • The
masakit yung Incubation is 3-5 temperature in temperature is
itlog ko” days the normal To prevent in the normal
I Increase fluid dehydration and range
range
Objective: For men, the intake and weakening
disease start as • Pulse and nutrition
-Facial Grimace an acute respiration
-Fever urethritis with a Give antipyretics
-Green pus within the
discharge as needed. To decrease the • Pulse and
discharge normal range
containing temperature of respiration is
-Pain scale 6/10 gonococci in the client within the
large numbers normal range
Vital Signs
Temp – 38.6
RR – 22
BP – 130/90
PR – 100