NURSING CARE PROCESS

Name of Patient:​ Suzanna ​ Age: ​29 ​Sex​: F ​ Civil Status:​ N/A ​ Room/Bed No.: ​N/A
Medical/Surgical Diagnosis :​Asymptomatic Bacteriuria​ ​Assessment date:​ Oct. 6, 2020 ​ Intervention date: ​N/A
Prepared by: ​Rayos, Raine Andrea V. ​Section/Grp No.: ​ ​ CI/Supervisor:
Cues Nursing Analysis Goals and Implementation Rationale Evaluation
Diagnosis Objective

Subjective Stem #1: SCIENTIFIC Long -term Goal​:

cues: Risk for ANALYSIS After 5 hours of nursing
N/A Maternal/Fetal intervention, the patient
Infection Urinary tract will remain free of
Objective infections (UTIs) infection, as evidenced
Cues: As evidenced are frequently by achieving normal
by: laboratory results.
encountered in
Lab results: Decrease in
- Leucocyte – hemoglobin and pregnant women.
25 u/l increase in Pyelonephritis is Short-term Goal: After 30 days of nursing
- Hemoglobin leucocyte the most common After 30 minutes of intervention the client will
: 11.6 g/dL serious medical nurse-patient discussion, be able to:
condition seen in the patient will be able
pregnancy. Thus, it to:
is crucial for
Objectives: 1. Independent 1. Untreated 1. MET.
providers of 1. Cognitive: Developmental: asymptomatic The client has
obstetric care to be Verbalize Health teaching about bacteriuria is a understood and
knowledgeable understanding of what risks can be risk factor for verbalized the risk
about normal individual risk associated with acute cystitis factors that can be
findings of the factors in 5 minutes. untreated asymptomatic (40%) and associated with
urinary tract, bacteriuria pyelonephritis untreated
(25-30%) in Asymptomatic
evaluation of pregnancy to Bacteriuria
abnormalities, and both the fetus
treatment of and the
disease. mother.
Fortunately, UTIs Pyelonephritis,
in pregnancy are preterm birth,
low birth
most often easily
weight, and
treated with
excellent outcomes. increased
Rarely, pregnancies perinatal
complicated by mortality​ are
also
pyelonephritis will
associated​.
lead to significant Reference:
maternal and fetal Urinary Tract
morbidity Infections in
Pregnancy:
(Hakakha, 2015). Practice
Essentials,
Pathophysiology,
Etiology. (2020).
SITUATIONAL Retrieved 4
ANALYSIS October 2020,
Patient Suzanna is from
https://emedicine.
29 years old medscape.com/arti
gravida 4 para 2+1 cle/452604-overvi
ew#:~:text=Untrea
admitted at 32 ted%20asymptom
weeks of gestation atic%20bacteriuria
%20is%20a,parity
for expectant %2C%20and%20l
management for ow%20socioecono
twin pregnancy mic%20status​.

with asymptomatic
placenta previa type
II posterior. She has
a history of
secondary
subfertility for 7
years, failed
intrauterine
insemination and
intrauterine death
of 2007.
2. Psychomotor 2. Independent 2. Fluid intake 2. MET
Encouraged to Developmental: facilitates The client drinks
increase oral fluid Monitoring the amount urine about at most 3
intake (2 to 3 liters a of water intake a day production and liters of water a
day). and avoiding colored flushes day to cut down
drinks. Namely cola, bacteria from the risk of any
tea, juices, and the like. the urinary further infections
tract.
Reference:
6 Urinary Tract
Infection Nursing
Care Plans.
(2017). Retrieved
4 October 2020,
from
https://nurseslabs.
com/urinary-tract-
infection-nursing-
care-plans/2/