Assessment Diagnosis Planning Nursing Intervention Rationale Evaluation

Dolores Wellbeing, a 16 y/o student, comes in for consultation with her mother and is having an unintended pregnancy.
The mother stated that lately, her daughter is experiencing severe nausea and vomited 3 – 4 times almost every day
accompanied by lightheadedness, cramping of legs and a feeling of irregular heartbeat. The mother also informed the
nurse that her daughter is having dysuria for a week, flank pain, spotting and loss of appetite. During interview, the
mother additionally stated that her daughter has been emotionally upset since the boy who got her pregnant disclaims the
baby but still has the conviction to take care of herself and her present condition. On assessment of the client, she is
coherent, states her pain is 7 on a scale of 1 – 10, and minimal blood on her vaginal pad. Her Temperature is 38 oC, Pulse
115 bpm, Respiration 20 cpm, BP 140/100. LMP is March 1, 2019, height 4’11” and weights 40 kgs. Laboratory results
are as follows:
Hgb – 9 gm/dl (12 – 15.5 gm/dl)
Hct – 51.4% (36% – 48%)
WBC in U/A – 12,000 mcL (4,500 – 11,000 mcL)
Na – 114 mmol/L (135 – 145)
K – 2.5 mmol/L (3.5 – 5.0)
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION
INTERVENTION
Subjective: Acute Pain related to Short Term: Independent: 2 hours after
The mother inflammation of the After 2 hrs of - Perform an Pain associated the nursing
informed the nurse urinary tract as nursing extensive with UTI is intervention,
that her daughter is evidence by High intervention the Assessment described as the patient was
having dysuria for a WBC in UA patient will report of the burning on able to
week and flank pain =12,000 mcL, pain satisfactory pain client’s urination, flank verbalize that
scale of 7/10 dysuria control at a level description of pain, lower her pain
Objective: and flank pain of 2/10 from the pain, such as abdominal or decreases to
- Pain scale of pain scale. quality, suprapubic pain. 2/10.
7/10 nature, and In comparison,
- High WBC in severity of some clients with The Goal is
UA =12,000 Long Term: pain. recurrent met.
mcL After completing infections are
- light fever of 38 the nursing asymptomatic.
celcius intervention the This information
patient will report will help in
absence of pain. determining the
choice of
intervention.
- Assess for UTI symptoms

signs and include dysuria
symptoms of (painful, burning,
urinary tract or difficult
infection. urination),
urinary frequency
and urgency, and
nocturia (voiding
two or more
times at bedtime).
- Monitor the Increased WBC

WBC count. count is a
systemic
response to
infection.
- If the patient Heat applied to

is having pain the perineum can
Estrada, Aaron Charles
on her help relieve pain
suprapubic and spasms.
area or lower
back Apply a
heating pad
- Encourage Increasing fluid

the patient to intake to 2 to 3
increased oral liters per day aids
fluid intake in urine
unless production,
contraindicat dilutes urine,
ed. soothes an
inflamed bladder,
promotes renal
blood flow, and
flushes bacteria
from the urinary
tract.
Dependent:
- Administer analgesic
analgesics medications can
(e.g., help relieve
acetaminophe bladder
n) as irritability,
indicated by spasm, and pain.
the physician.
- Administer Antibiotics such

antibacterial as trimethoprim
agents as (TMP) or
indicated by cephalexin are
the physician. usually the first
choices but they
are only for
prescription.
Short-course
therapy with a
single antibiotic
or a three-day
course lowers
treatment costs,
improves
adherence, and
has a lower rate
of side effects.
Collaborative:
- collaborate Since the patient
with an ob- is pregnant we
gyne for the should also take
pain into consideration
medications the medications
that are safe that may affect
for pregnant the babies growth
women. and and by further

further assessing the
assess the patient it can
patient to provide the
Identify opportunity to
specific modify the pain
signs/sympto management and
ms and allows a timely
changes in intervention to
pain prevent
characteristic developing of
s requiring complications.
medical
follow-up and
a different
intervention
ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

INTERVENTION
Subjective: Imbalanced Nutrition: Short Term: Independent: 8 hours after the
The mother Less Than Body After 8 hrs of Set appropriate Patients may lose nursing
informed the Requirements related nursing intervention short-term and interest in intervention the
nurse that her to insufficient dietary the patient will be long-term goals addressing this patient displays
daughter is intake as evidence by able to display dilemma if realistic normalization of
below ideal weight, normalization of short-term goals her laboratory
having a loss of
low potassium and laboratory values are not established. values such as
appetite
sodium levels and and be free of signs the NA and K
loss of appetite. of malnutrition as Provide a pleasant A pleasant and demonstrate
reflected in the environment. environment willingness to
Objective:
defining reduces stress and eat.
- Low Hgb – 9
characteristics. encourages eating,
gm/dl (12 – 15.5
which is especially Goal is met.
gm/dl)
important for
- low Na – 114
pregnant women.
mmol/L (135 –
145)
Long Term: Promote Elevating the head
- low K – 2.5
After 4 months of proper positioning. of the bed by 30
mmol/L (3.5 –
nursing intervention degrees improves
5.0)
the patient will swallowing and
- height 4’11” and
demonstrate reduces the risk of
weights 40 kgs
progressive weight aspiration while
(malnutrition)
gain toward a goal eating.
of 115 lbs.
Provide It is critical to pay

companionship attention to the
during mealtime. social perspectives
of eating in both
hospital and home
settings, especially
given the state of
condition of
pregnant women.
Determine time of We should feed

day when the them the most
patient’s appetite is nutritious foods
at peak. Offer possible, especially
highest calorie meal when their
at that time. appetites are at
their peak.
Dependent:
Administer IV If the patient
therapy as per cannot tolerate
doctors order solid foods IV
therapy will the
one to provide
hydration,
vitamins, and
nutrients that will
support a healthy
pregnancy.
Collaborative:
Ascertain healthy Nitrogen balance
body weight for age can be determined
and height. Refer to by experts such as
a dietitian for a dietician as a
complete nutrition measure of the
assessment and patient's nutritional
methods for status. Protein
nutritional support. malnutrition may
result from a
negative nitrogen
balance. The
dietician can also
determine the
patient's daily
nutrient
requirements in
order to promote
satisfactory
nutritional intake
and a healthy
pregnancy.
EDITED as of 11/12/21 after the presentation of NCP from Ma’am Sherryl
1. Compute for the AOG (date of consultation – April 24, 2019)
2. Compute for the EDC –(December 8, 2019)
3. Compute for the BMI – 17.8 (underweight)

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Dolores Wellbeing, a 16 y/o student, comes in for consultation with her mother and is having an unintended pregnancy.

- Assess for UTI symptoms

- Monitor the Increased WBC

- If the patient Heat applied to

- Encourage Increasing fluid

- Administer Antibiotics such

Estrada, Aaron Charles

ASSESSMENT DIAGNOSIS PLANNING NURSING RATIONALE EVALUATION

Provide It is critical to pay

Determine time of We should feed

Estrada, Aaron Charles

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