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    N039-N040 Rejano Nursing Care Plan

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    Bianca Marithè Rejano
    1. The patient presented with suprapubic pain after urination rated 5 out of 10 and dark red vaginal spotting. 2. Assessment findings included a urinary tract infection evidenced by uterine and mild upper abdominal cramping. 3. The nursing diagnosis was inferred to be urinary tract infection as evidenced by signs of uterine and mild upper abdominal cramping.

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    N039-N040 Rejano Nursing Care Plan

    Uploaded by

    Bianca Marithè Rejano
    41 views3 pages
    1. The patient presented with suprapubic pain after urination rated 5 out of 10 and dark red vaginal spotting. 2. Assessment findings included a urinary tract infection evidenced by uterine and mild upper abdominal cramping. 3. The nursing diagnosis was inferred to be urinary tract infection as evidenced by signs of uterine and mild upper abdominal cramping.

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    N039-N040 REJANO NURSING CARE PLAN

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    1. The patient presented with suprapubic pain after urination rated 5 out of 10 and dark red vaginal spotting. 2. Assessment findings included a urinary tract infection evidenced by uterine and mild upper abdominal cramping. 3. The nursing diagnosis was inferred to be urinary tract infection as evidenced by signs of uterine and mild upper abdominal cramping.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    41 views3 pages

    N039-N040 Rejano Nursing Care Plan

    Uploaded by

    Bianca Marithè Rejano
    1. The patient presented with suprapubic pain after urination rated 5 out of 10 and dark red vaginal spotting. 2. Assessment findings included a urinary tract infection evidenced by uterine and mild upper abdominal cramping. 3. The nursing diagnosis was inferred to be urinary tract infection as evidenced by signs of uterine and mild upper abdominal cramping.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    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

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