GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
Bulaong Subdivision, Barangay West, General Santos City 9500
Tel No.: (083) 302-3507, Telefax No.: (083) 552-979
Patient: Patient C Attending Physician: Dr. Juele
Age and sex: 38 years old/Female Diagnosis: Acute Pyelonephritis, severe anemia S/P blood transfusion probably
due to abdominal uterine bleeding
Year and Section: BSN4-B Chief complaint: Cough, fever, dysuria Group: Group 1
NURSING CARE PLAN
ASSESSMENT DIAGNOSIS and INFERENCE OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
Subjective cues: Nsg dx: General: Independent: After 4 hours of
Client verbalized“ Readiness for enhanced To facilitate progress 1. Establish rapport. ➢ To build trust and nursing
ma’am,unsa ang mga therapeutic management towards achievement effective intervention, the
pagkaon nga akoang related to disease management and goals. communication client
likayan” ➢ Verbalized
Inference/Background 2. Monitor and record vital ➢ All vital sign are knowledge of
“Unsa pud akong knowledge: Specific: signs important to monitor. causes and
buhaton para dili nani Within 4 hours of Changes of vital signs treatment of
mo balik og mga A pattern of regulating and nursing interventions, are documented to UTI, controls
buhatunon para kani integrating into daily living a the client will be able detect alteration risk factors
akong malikayan.” programs for treatment of to:
She also added. illness and its sequelae that is ➢ Verbalize 3. Verify client’s level of ➢ Provides an ➢ Enhanced
sufficient for meeting health- knowledge of understanding of opportunity to assure therapeutic
related goals and can be causes and therapeutic regimen- note accuracy and management
Objective cues: strengthened. treatment of UTI, specific health goals completeness of as evidenced
- Willingness to controls risk knowledge base for by verbalizing
go back home factors future learning the need to
and manage Reference: comply with
the disease at Hinkle, J. L. (2018). Brunner’s ➢ Enhance 4. Explain to the client about ➢ Frequent recurrences the home
home & Suddarth’s Medical-Surgical therapeutic UTI risk factors, of UTI may indicate medication
- The patient Nursing 14th edition vol2, 2011. management as prevention and treatment that the client has and antibiotic
shows Wolters Kluwer. evidenced by difficulty understanding therapy
positivity verbalizing the the disease and
towards the need to comply complying with Goal met.
treatment. with the home prescribed therapeutic
medication and management
VS: antibiotic therapy
➢ T: 36.3 C
(normothermia)
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
Bulaong Subdivision, Barangay West, General Santos City 9500
Tel No.: (083) 302-3507, Telefax No.: (083) 552-979
➢ PR: 100 bpm
(regular rhythm)
➢ RR: 20 cpm
(normal rhythm)
➢ Blood Pressure: Health teaching:
130/80mmHg 1. Teach the client about ➢ To resolve the current
(normotensive) the measures to infection and prevent a
prevent urinary tract recurrence
infections. Interventions
may include;
✓ Encourage not ➢ This can result in the
to ignore the stasis of urine
need to void
✓ Perineal ➢ This will help in
hygiene after a preventing the
bowel migration of the
movement pathogen in the
urethral opening and,
in women, the vaginal
opening.
✓ Frequent ➢ Completely emptying
bladder the bladder prevents
emptying bladder distention and
compromised blood
supply to the bladder
wall. These predispose
the client to UTI
✓ Avoid wearing ➢ Such fabrics can
tight-fitting or accumulate moisture
constricting and can provide an
undergarments environmental for
made of non- bacterial growth.
breathing Cotton fabric and
materials loose fitting clothing
are more encouraged.
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
Bulaong Subdivision, Barangay West, General Santos City 9500
Tel No.: (083) 302-3507, Telefax No.: (083) 552-979
2. Instruct the client to ➢ These foods are
avoid spices, sodas, considered urinary
junk foods and tract irritants and may
minimize any salty irritate the urinary
foods system.
3. Encourage the client to ➢ Increasing fluid
increased fluid (water) intake(2 to 3 liters per
intake unless day) helps facilitate
contraindicated urine production,
dilutes urine, reduces
irritation of the
inflamed bladder, and
flushes bacteria from
the urinary tract
4. Instruct the importance ➢ Even if the symptoms
of completing the disappear, the client
antibiotic therapy or any should finish the
home medication prescribed duration of
the antibiotic therapy
or any home meds.
Unable to do so may
result in reinfection.
Collaboration:
1. Consider referring the ➢ To provide specialized
client to the nutrition and nutrition management
dietetics team for the client
References:
Doenges, et al., (2019). Nurse’s Pocket Guide 15th Edition pp.611-614 F.A. DAVIS COMPANY.
Gonzalo, A. (2023, January 12). Faye Abdellah: 21 Nursing Problems Theory. Nurseslabs. Retrieved January 30, 2023, from
[Link]
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
Bulaong Subdivision, Barangay West, General Santos City 9500
Tel No.: (083) 302-3507, Telefax No.: (083) 552-979
EVALUATION TOOL FOR NURSING CARE PLANS (HOSPITAL)
NAME ________________________________________ AREA ________________________________ DATE ________________
AREAS EXCELLENT GOOD FAIR POOR
4 3 2 1
Lists at least 5 subjective or objective data List 3 -4 subjective or objective data List 1 - 2 subjective or objective Unable to list subjective or objective data that
DATA COLLECTION that should be collected when the that should be collected when the data that should be collected should be collected when the diagnosis is present.
diagnosis is present. Background of the diagnosis is present. Background of when the diagnosis is present. Background of the problem was not stated.
problem was clearly and correctly stated. the problem was not well stated. Background of the problem was
incorrectly stated.
NURSING DIAGNOSIS Diagnoses written correctly per NANDA Written incorrectly without sufficient data to
format with proper etiology &sufficient support diagnosis
data to support diagnosis
Goal is measurable, realistic, related to Goal is not measureable, not realistic, not
the problem; related to the problem;
PLANNING/GOALS& Data supports if goal is met, not met with Data does not support if goal is met, not met
EVALUATION appropriate revisions with
inappropriate revisions
Identified dependent, independent, Identified most dependent, Identifies dependent, Interventions were inappropriate and are not
IMPLEMENTATION & collaborative interventions appropriately; independent, collaborative independent, collaborative categorized as dependent, independent or
RATIONALE Scientific rationale is supported textbook interventions appropriately; interventions with teaching; collaborative.
citation Scientific rationale is somewhat Scientific rationale is not relevant
[Evidence Base Information] relevant & supported with citation ¬ supported from textbook
[Evidence Base Information]
[Evidence Base Information]
Writing is totally free of grammar and There are occasional grammar and Grammar and spelling errors are frequent.
WRITING SKILLS spelling errors. spelling errors.
Hard to follow the ideas.
Clear and concise presentation of ideas. Clear presentation of ideas.
All references used are important and Most of the references cited and No references cited
REFERENCES current; are of good/scholarly quality. listed are not important and/or
References are correctly cited not of good/scholarly quality.
References are not correctly cited
and listed.
NOTE: If the Nursing Diagnosis is incorrect, then only data collection & writing skills will be graded accordingly. Other criteria will be automatically garnering a grade of zero.
COMMENTS: ________________________________________________________________________________________________________________________________________________
CI’S NAME & SIGNATURE ____________________________
GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.
Bulaong Subdivision, Barangay West, General Santos City 9500
Tel No.: (083) 302-3507, Telefax No.: (083) 552-979