Assessment Nursing Planning Interventions Rationale Evaluation

Diagnosis
SUBJECTIVE: Acute pain Short Term: INDEPENDENT GOALS ARE
- Patient narrates the pain related to - After 30-45 1. Establish 1. To gain patient’s FULLY MET
as sharp, steady, and bacterial minutes of rapport and trust and
radiating across her lower infection and nursing instruct client not cooperation. To Short Term:
abdomen bilaterally. inflammation intervention, to share personal prevent the - After 30-45
of urinary the patient’s care items transmission of minutes of
- Last night the patient tract as pain will be infection by sharing nursing
developed new nausea evidenced by reduced and personal items. intervention,
and vomiting. sharp, steady, will the patient’s
and radiating verbalized 2. Encouraged 2. Sitz baths can pain shall
- She also stated that she pain across relief. the use of sitz help to relieve have been
has not been able to lower bath. perineal pain and reduced or
keep down any food or abdomen Long Term: relax muscles. no pain felt
drink this morning. bilaterally. - After 8 and shall
hours of 3. Perform pain 3. To evaluate the verbalized
- The patient had a nursing assessment (0-10 pain of the patient. relief.
normal bowel movement intervention, scale), noting
yesterday. the client will pain’s location, Long Term:
have a and - After 8
- She also verbalized that normal characteristics. hours of
she felt cold and temperature nursing
shivering this morning, as evidenced 4. Identify 4. To fully intervention
followed by feeling by the precipitating and understand the patient
warm. absence of relieving factors. patient’s pain. shall have
fever and been able to
- The patient denies chills. 5. Observe non- 5. Observation may have a
vaginal bleeding. verbal cues like not be congruent normal
- After 8 guarding behavior with verbal report temperature
OBJECTIVE: hours of or facial grimaces. or some indicator as evidenced
• The client is 18 weeks nursing maybe present by the
pregnant intervention, when the client is absence of
• V/S taken as follows: the client will unable to verbalize. fever and
T: 38.8°C obtain a chills.
P: 120 bpm normal white 6. Assess skin 6. Skin color is
R: 20 bpm blood cell color and skin usually altered in - After 8
BR: 110/70 (WBC) count. turgor. patient with acute hours of
pain, skin turgor nursing
• Ultrasound of KUB CVC - After 24-36 can help the nurse intervention,
abdominal X-ray Done. hours of to know if the the client
nursing patient is shall have
• Urinalysis Result: intervention, dehydrated. obtained a
Leukocyte Esterase - the client will normal white
Positive be free of 7. Encourage 7. To promote blood cell
Blood - Positive urinary tract patient to sip renal blood flow (WBC) count
Ketones – Positive infection and small amounts of and to flush
Bacteria - Positive will now be water until she bacteria from the - After 24-36
WBCs - 30 -50 per high able to can tolerate urinary tract and to hours of
power field demonstrate liberal amounts of prevent nursing
Nitrites - Positive ways on how fluid dehydration. intervention,
Protein - Negative to prevent Forcing the patient the client
STD panel - Urine urinary tract to drink large shall have
Gonorrhea/ infections. amount of fluid will been free of
chlamydia/trichomoniasis lead to more urinary tract
- Negative vomiting. infection and
shall have
been able to
8. Encourage the 8. Patient should demonstrate
client to complete finish prescribed ways on how
the duration of duration of the to prevent
the antibiotic antibiotics, even if urinary tract
therapy as the symptoms infections.
prescribed disappear, because
not finishing a
course of antibiotics
may result to
reinfection

9. Note urine 9. Urinary

flow and retention and
characteristics increased pressure
in the urinary tract
may cause reduced
flow.

10. Obtain a urine 10. To ensure that

sample to be used the nursing
in urinalysis after interventions are
giving antibiotics. accurate in treating
the patient’s
concern

11. Encouraged 11. To prevent

the client to void bladder distention,
often every 2 to 3 to facilitate flushing
hours a day and of the bacteria and
completely empty to avoid
the bladder. reinfection.

12. Encourage 12. Cranberry juice

drinking of has been shown to
cranberry juice reduce adherence
(four to six 8 of bacteria to the
ounces glasses uroepithelial cells in
per day). the urinary tract.

13. Educate the 13. To help the

patient about patient to avoid
proper hygiene having an infection
and upon and other bacterial
discharging. Also infections. In
instruct family in educating the
complications and patient upon
importance of discharging, a nurse
maintaining must state the
medical regimen, following: proper
including when to storage and use of
call physician. medication, what to
do if a dose is
missed, potential
side effects and
whom to call if
infection arose. It is
critical for the
family to be aware
of the risk in order
to avoid further
complications.

14. Encourage 14. Adequate sleep

sleep and rest is an essential
modulator of
immune responses.
A lack of sleep can
weaken immunity
and increased
susceptibility to
infection.
DEPENDENT:
1. Administer 1. To maintain
pain reliever such acceptable level of
as acetaminophen pain. Notify
and ibuprofen or attending physician
as prescribed by if regimen is
the attending inadequate to meet
physician. pain control goal.

2. IV 2. For fluid
administration of replacement of the
0.9% saline 500 fluid loss due to
mL bolus vomiting

3. Administer 3. Antibiotics can

antibiotic therapy help in clearing up
as prescribed the infection
• Ceftriaxone 1 • Ceftriaxone is
gm IV a day used for the
• Cephalexin treatment of
urinary tract
infection.
• Cephalexin is also
said to be a safe
antibiotic
medication for
pregnant women in
treating UTI.

4. Refer to 4. An obstetrician -
 Obstetrician - gynecologist, or OB
Gynecologist as -GYN, is a
ordered healthcare
professional that
specializes in
female
reproductive
health. People
trained as OB –
GYNs specialize in
both obstetrics and
gynecology:
obstetrics involves
working with
pregnant women,
including delivering
babies.

Identified Nursing Diagnosis

 Acute pain related to bacterial infection and inflammation of urinary tract as evidenced by sharp, steady, and
radiating pain across lower abdomen bilaterally.

SCENARIO:

A 26-year-old woman comes to the clinic because of a 3-day history of lower abdominal pain. She is 18 weeks
pregnant by dates. The patient describes the pain as sharp, steady, and radiating across her lower abdomen bilaterally.
Last night she developed new nausea and vomiting. She has not been able to keep down any food or drink this morning.
She had a normal bowel movement yesterday. She says she felt cold and shivering this morning, followed by feeling
warm; however, she did not check her temperature. She denies vaginal bleeding.

Vital Signs – Temp. 38.8 ®C, P- 120 bpm, R-20bpm, BP- 110/70, Ultrasound of KUB, CVC abdominal X - ray done.
Urinalysis Result: Leukocyte esterase – Positive, Blood- Positive, Ketones – Positive, Bacteria-Positive, WBCs- 30-50 per
high power field, Nitrites-Positive, Protein-Negative, STD panel - Urine gonorrhea/chlamydia/trichomoniasis negative.

NURSING CARE PLAN

Group Members

Marie Jien Kia Mendoza Cherry May Tan Allianna Salonga

Jeia Marjolyn Ponce Benedict Santos Von Karl Sunga

Dayne Santiago Megumi Kylle Roque Justin Conrad Llena

Kristel Paule Trisha Nava

Lorie Anne Sangalang Justine Mae Manlulu