URDANETA CITY UNIVERSITY
San Vicente West, Urdaneta City, Pangasinan 2428
Name of Student: JORGIE H. CASTRO___________________________________
Affiliating Agency/Area: ___________________________________________
________________________
Name of patient: Patient A__________________
Assessment Nursing Diagnosis
Subjective: Problem, Etiology, Signs
(P.E.S.) format
“ Nurse, masakit po You must also state
pag-ihi ko.” As here a nursing dx (Pain
verbalize of patient in urination as
with a pain scale of manifested by
5 out of 10 suprapubic pain and
characterized as bacteria in urine)
moderately strong Problem - Urinary tract
pain - did not infection (UTI) caused by
localize elsewhere bacterial infection within
and lasted for just a the urinary tract.
few minutes.
Etiology - Most commonly
due to infection with
Escherichia coli species
(80-90% of cases). Other
causes include Klebsiella,
Enterococcus, Proteus
mirabilis and
Staphylococcus
saprophyticus. Periurethral
colonization by the
invading pathogen appears
to be the initiating step in
a cascade of events
leading to a UTI.
COLLEGE OF HEALTH SCIENCES
Bachelor of Science in Nursing
NURSING CARE PLAN (NCP)
Year Level and Group: BSN 2 BLK.10_______________
Month/Year of Exposure:
Age: 24 years old_______________________ Gender: Female___________________
Planning Intervention Rationale Evaluation
(at least 10)
Short Term Goal: Independent: Short Term Goal Evaluation
S.M.A.R.T. + Evidence ⮚ Assessment
● Monitor vital signs. ● Alterations from normal After 6 – 8 hours of
After 6 – 8 hours of may be signs of infection. appropriate nursing
appropriate nursing intervention, the patient was
intervention, the ● Perform a comprehensive ● Indicates need for/ able to:
patient will be able to: assessment. Assess effectiveness of
location, characteristics, intervention sand may ● Report pain is relieved or
● Report pain is controlled, with the pain
onset, duration, signal
relieved or scale of 3 out of 10 from
frequency, quality and development/resolution of
controlled, 5 out of 10.
severity of pain. complications.
with the pain
scale of 3 out ● Verbalize understanding
● Observe for nonverbal ● Some patients may deny of condition.
of 10 from 5 indicators of pain:
the existence of pain.
out of 10. moaning, guarding,
These behaviors can help
crying, facial grimace. with proper evaluation of
● Verbalize
pain.
understanding ⮚ Therapeutic
of condition. ● Limit the use of indwelling ● Catheter use increases
bladder catheters to the risk for UTI.
manage incontinence. Alternative measures
such as regular toileting
can prevent infection.
● Provide clean, quiet, and
● To make the patient
good environment.
comfortable.
 Signs & symptoms –
dysuria, frequent and
urgent urination,
hematuria, suprapubic
tenderness, chills and
sweats, flank pain.
Objective: INFERENCE
(at least 5) Scientific Explanation
(Diagram Form)
Vital signs:
BP – 120/80mmHg A urinary tract infection is
CR – 95 bpm caused by micro-
RR – 20 cpm organisms in the urinary
T – 36.5C tract. Most of these
bacterial organisms are
● Facial from the gastrointestinal
grimace tract. Common causes of
● Restlessness UTIs are E.Coli (about
● Urinalysis 85% or more), Klebsiella
revealed 30 species and
to 40 WBCs Staphylococcus
saprophyticus. Lower UTIs
per high-
affect the bladder (cystitis)
powered
and urethra. Upper UTIs
field, 20 to
(pyelonephritis) affect the
30 RBCs, renal pelvis and kidneys. If
moderate it is not possible to
bacteria, differentiate between a
moderate lower or upper UTI, then it
epithelial is considered an
cells, and undifferentiated UTI
some casts.
(diagram in different
sheet)
Source:
TeachMePediatrics.com
● Use non pharmacological
pain relief methods
(relaxation exercises,
breathing exercises,
music therapy).
Long Term Goal:
⮚ Educative
S.M.A.R.T.+ Evidence
● Encourage the client to
void often every 2 to 3
After 72 hours of
hours a day and
appropriate nursing
interventions, the completely empty the
patient will be able to: bladder.
● Free from urinary ● Encourage increased fluid
tract infection as intake.
evidenced by the
absence of chills,
flank pain, and
suprapubic ● Encourage the client to
complete the whole
tenderness; clear
duration of the antibiotic.
non-foul smelling
urine and normal
WBC count.
● Encourage the use of a
sitz bath.
Dependent:
● Provide antibacterial
medications as ordered
by physician.
Interdependent/Collaborative
In the collaboration with the
medical technologist
● Monitor urinalysis test.
● Monitor WBC count
● Works by increasing the
release of endorphins,
boosting the therapeutic
effects of pain relief
medications.
Long term Goal Evaluation
● To prevent bladder
distention, facilitate
After 72 hours of appropriate
flushing of the bacteria
nursing interventions, the
and avoid reinfection. patient was able to:
● Free of urinary tract
● To facilitates urine infection as evidenced by
production and flushes the absence of chills,
bacteria from the urinary flank pain, and
tract. suprapubic tenderness;
clear non-foul smelling
● Patient should finish the urine and normal WBC
prescribed duration of the count.
antibiotics, even if the
symptoms disappear,
because not finishing a
course of antibiotics may
result to reinfection.
● Sitz baths may reduce
perineal pain and
promotes muscle
relaxation.
● Reduces bacteria present
in urinary tract.
● Increased WBC count is a
systemic response to
infection.
● The presence of RBCs and
WBCs in the urine is
associated with the
 inflammation process
during an infection.

Checked by: _________________________________ Date: ____________________

Clinical Instructor’s Name and Signature