Cabading - Lorma 3a

LORMA COLLEGES CON TEMPLATE
NURSING CARE PLAN

RELATED LEARNING EXPERIENCE
NAME: CABADING, TWINKLE MAE M. ROTATION: 3RD AREA: WARD (LORMA 3A)
YEAR LEVEL & SEC.: BSN IV LEWIN DATES: March 7,8,9,14,15,16 CLINICAL INSTRUCTOR: Maria Delilah
Gregoria V. Turzar, RN, MAN
PROBLEM: Acute Pain DIAGNOSIS: t/c Urinary Tract Infection
PRIORITIZATION: 1st DATE: March 8, 2024
Assessment Nursing Planning Implementation Rationale Evaluation

Diagnosis
Subjective: Acute pain related After 8 hours of  Assess vital  To have a GOAL WAS MET.
to infection in the nursing signs. baseline After 8 hours of
“Nahihirapan urinary tract as intervention patient data. nursing intervention
 Ask the client
akong tumayo evidenced by will verbalized  To the patient verbalized
to rate the
dahil masakit likod patient reporting relief of pain and differentiate relief from pain and
pain from the
ko”, as verbalized lower back discomfort. the previous discomfort with a
scale of 1-10
by the patient. discomfort with a and current rating scale of 3/10.
and document
pain scale rating of pain
Pain Scale Rating: the findings.
patterns. .
6/10 6/10.  Monitor and  To make
regulate sure that
Objective: intravenous there are no
Patient looks fluids. obstructions
restless, pale and  Encourage on the IV
uncomfortable. patient to line.
have a bed  To promote
BP: 120/70 rest. calmness
 Encourage and
T: 36.4 comfort.
client to
PR: 60 increase fluid  To help in
intake. flushing
RR: 19 bacteria
 Instruct the
SPO2: 98% client to avoid and toxins.
coffee, tea  To avoid
and soda. irritation to
the urinary
 Encourage
tract.
verbalization
 To provide
of pain and necessary
discomfort. intervention
 Monitor intake s to
and output. decrease
 Observe for pain and
further discomfort.
complaints.  To assess
hydration.
 To attend
needs.
NURSING CARE PLAN
PROBLEM: Activity Intolerance DIAGNOSIS: t/c Urinary Tract Infection
PRIORITIZATION: 2nd DATE: March 8, 2024
Assessment Nursing Planning Implementation Rationale Evaluation

Diagnosis
Subjective: Activity intolerance After 8 hours of  Assess the  To have an GOAL MET. After 8
related to nursing cause of effective hours of nursing
“Naiihi ako, pero generalized intervention patient plan. intervention the
activity
nahihirapan akong weakness and will report an  To have a patient report an
intolerance.
bumangon at inability to stand up increased baseline increased tolerance
 Assess vital
maglakad”, as as manifested by tolerance to data. to perform activities.
signs.
verbalized by the patient’s perform activities.  To
 Teach the
patient. strengthen .
verbalization of patient about
“Naiihi ako, pero muscles
ROM and joints.
nahihirapan akong exercises.
Objective:  To avoid
bumangon at  Encourage prolonged
maglakad”. activity bed rest.
Patient looks weak
and pale. progressively  To
such as sitting decrease
Slow movement. and standing risk of skin
up with breakdown.
Needs support in
assistance.  To avoid
walking.
 Encourage slip.
patient to  To attend
have frequent needs of
position the patient
changes. effectively
 Instructed the and
patient to efficiently.-
wear flat
slippers.
 Instructed the
patient to call
if she needs
assistance.
FDAR
PATIENT NAME: B.N AGE: 73 HOSPITAL NO.:

PHYSICIAN: SEX: ROOM: 308
DATE/TIME FOCUS DATA ACTION RESPONSE NURSE

SIGNATURE
D – Received patient on bed awake and coherent with on-going
03/08/2024 NSS at 650ml at 2:45pm.
2:45pm
A - Assessed the cause of activity intolerance.
A - Assessed vital signs.
A - Taught the patient about ROM exercises.
A - Encouraged activity progressively such as sitting and standing
up with assistance.
A - Encouraged patient to have frequent position changes.
A - Instructed the patient to wear flat slippers.
A - Instructed the patient to call if she needs assistance.
10:00 R - Patient reported an increased tolerance to perform activities.

For continuity of care.
FDAR
PATIENT NAME: B.N AGE: 73 HOSPITAL NO.:

PHYSICIAN: SEX: ROOM: 308
DATE/TIME FOCUS DATA ACTION RESPONSE NURSE

SIGNATURE
D – Received patient on bed awake and coherent with on-going
03/08/2024 NSS at 650ml at 2:45pm.
2:45pm
A - Assessed vital signs.
A - Asked the client to rate the pain from the scale of 1-10 and
document the findings.
A - Monitored and regulated intravenous fluids.
A - Encouraged patient to have a bed rest.
A - Encouraged client to increase fluid intake.
A - Instructed the client to avoid coffee, tea and soda.
A - Encouraged verbalization of pain and discomfort.
A - Monitored intake and output.
A - Observed for further complaints.
10:00 R - Patient verbalized relief from pain and discomfort with a rating
scale of 3/10.
RELATED JOURNAL ANALYSIS
ARTICLE
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6502976/
SUMMARY
The article provides a comprehensive overview of urinary tract infections (UTIs), focusing on epidemiology, burden, and
management strategies. It highlights the prevalence of UTIs, particularly in women, and discusses factors contributing to UTIs in
different age groups, including healthcare-associated UTIs. Additionally, the article emphasizes the personal and societal burden of
recurrent UTIs, discussing their impact on quality of life and healthcare costs. Management strategies, including prophylaxis, are also
explored, with an emphasis on their potential to reduce the burden of UTIs.
DISCUSSIONS
The advantages of the updates presented in the article include a deeper understanding of UTI epidemiology, which can guide
more effective management and prevention strategies. Prophylactic measures highlighted in the article offer opportunities to reduce
the frequency of UTIs and alleviate their personal and societal burdens. However, challenges such as antibiotic resistance and
regional variations in UTI epidemiology pose disadvantages and require tailored approaches to management and prevention. While
the article provides valuable insights into UTI epidemiology and management, its feasibility and adaptability in local settings depend
on factors such as healthcare infrastructure, resource availability, and antibiotic resistance patterns. Local data on UTI prevalence
and causative agents are crucial for informing effective strategies. In my experience, UTIs are indeed common in clinical practice,
especially among certain demographics such as elderly individuals and women. The article resonates with observations regarding
the significant impact of recurrent UTIs on patients' quality of life and healthcare utilization. To manage problems related to UTIs, a
multifaceted approach is necessary, including antibiotic stewardship, education on hygiene practices, and consideration of
nonantimicrobial prophylactic options. Collaborative efforts involving healthcare providers, policymakers, and patients are essential to
address the challenges posed by UTIs effectively. The updates and trends discussed in the article have significant implications for
the nursing profession. Nurses play a crucial role in UTI prevention, diagnosis, and management, as well as patient education
regarding hygiene and prophylactic measures. Additionally, nurses are instrumental in surveillance efforts to monitor UTI trends and
antimicrobial resistance patterns, contributing to evidence-based practice and improved patient outcomes.
RELATED NURSING THEORY:
The article's focus on understanding the burden of UTIs and implementing prophylactic measures aligns with concepts from
the Health Promotion Model (HPM) developed by Nola Pender. The HPM emphasizes the importance of individual characteristics
and experiences, behavior-specific cognitions and affect, and behavioral outcomes in promoting health. By addressing factors
contributing to UTIs and implementing preventive measures, nurses can empower individuals to engage in health-promoting
behaviors, ultimately reducing the incidence and impact of UTIs.

Cabading - Lorma 3a

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Cabading - Lorma 3a

Uploaded by

Copyright:

Available Formats

LORMA COLLEGES CON TEMPLATE

NURSING CARE PLAN

Assessment Nursing Planning Implementation Rationale Evaluation

Assessment Nursing Planning Implementation Rationale Evaluation

PATIENT NAME: B.N AGE: 73 HOSPITAL NO.:

DATE/TIME FOCUS DATA ACTION RESPONSE NURSE

10:00 R - Patient reported an increased tolerance to perform activities.

PATIENT NAME: B.N AGE: 73 HOSPITAL NO.:

DATE/TIME FOCUS DATA ACTION RESPONSE NURSE

You might also like