URDANETA CITY UNIVERSITY

San Vicente West, Urdaneta City, Pangasinan 2428

COLLEGE OF HEALTH SCIENCES

Bachelor of Science in Nursing

NURSING CARE PLAN (NCP)

Name of Student: REJANO, BIANCA MARITHE C. Year Level and Group: BSN-2 GROUP B

Affiliating Agency/Area: ___________________________________________ Month/Year of Exposure: ________________________

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

(at least 10)

Subjective: Problem, Etiology, Short Term Goal: Independent: Short Term Goal
The patient Signs S.M.A.R.T. +  Assessment Evaluation
complained of (P.E.S.) format Evidence
suprapubic pain  Assessed the patient This information will help  Goal met, within 3 hrs
after urination, Urinary Tract After 3 hours of description of pain such in determining the choice of nursing intervention
rated 5 out of Infection as nursing intervention as quality and severity of of intervention. the clients report
10. evidenced by uterine, the patient’s upper pain. satisfactory pain
and mild upper abdominal cramping  Assessed for risk factors To avoid having kidney control less than 2 on
She presented abdominal cramping. when urinating of UTI. stones. a scale of 0-10.
with painless, decreased.
dark red vaginal
spotting.  Therapeutic

 Establish rapport To provide an effective

nurse-patient relationship.
 Instruct the patient to To prevent perineal
wash her perineal area infection.
after urinating.
 Educate the patient by
Objective: INFERENCE Long Term Goal: wearing looser pants and Long term Goal Evaluation
(at least 5) Scientific Explanation S.M.A.R.T.+ Evidence cotton underwear, and To reduce risk of certain
(Diagram Form) sleeping without vaginal infection.  After 3 days of nursing
underwear. intervention, the
Hemoglobin was Ureteral dilation After 3 days of  Educate the patient to patient’s upper
12.4 is seen due to nursing intervention drink enough fluids, abdominal cramps
compression of the patient’s upper especially water. Drinking enough water is when urinating has
Urinalysis: the ureters from abdominal cramps one of the easiest ways to totally disappeared.
WBC: 30 to 40 the gravid when urinating has Dependent: help prevent and treat
per high- disappeared.  Assessment UTIs.
uterus.
 powered field
RBC: 20 to 30  Check drug dosage, and
moderate expiration date before
Hormonal
bacteria, intake. To ensure the patient is
effects of
moderate receiving the correct
Pregnancy
progesterone
epithelial cells, medication for the correct
causes
also may cause
and some casts. reason and avoid dosage
numerous
smooth muscle  Therapeutic errors.
changes
relaxation in the
Ultrasound
woman’s
revealedbody
leading a to  Maintain medication on
that
dilation increase
and
strong fetal time.
theheartbeat
urinarylikelihood
stasis, Too achieve the maximum
of urinary
and ranging tract
from effectivity of the
140 to 150
infections
vesicoureteral  Educative medication.
beats per
(UTIs).
reflux
minute (bpm).
increases.  Instruct the patient to
avoid foods that can
trigger UTI. To avoid further
 Explain to the patient the complications.
use of drug, indication
dosage, route and why do To provide information to
she needs it. the patient before
administering it.

Interdependent/Collaborativ
e
 Assessment

 Set collaborations with

other professionals such To achieve effective
as (medical technologist) nursing intervention to
assisting medical the patient.
technologies when the
patient is urinating.

 Therapeutic

 Ensure the patient safety.

To develop safety
 Educative compliance plan.

 Explain the procedure to

the patient. To provide information to
 the client and understand
the procedure.

Checked by: Mac Gregory Yusaoen Date: October 23, 2021

Clinical Instructor’s Name and Signature