Assignment 5

Case Study A 20-year-old woman experiences increasing urinary frequency, along with
urgency and dysuria for 2 days. Over the next 12 hours or so, these symptoms persist
and her urine is pink or bloody. She then becomes concerned and goes to the campus
student health clinic for advice. Vital signs are: T = 37.5ºC, P = 105, R = 18, and BP =
105/70 mm Hg. The only abnormal finding on physical examination is a mild tenderness
to deep palpation in the suprapubic area. No genital ulcers are noted. There is no
vaginal discharge. The patient has no previous history of similar complaints. However,
she has recently become sexually active and has been using a diaphragm with
spermicide. Create a sample Nursing Care Plan for this case.

Nursing Care Plan

Assessment Diagnosis Outcomes Intervention Rationale Evaluation

Subjective: - Urge urinary - The patient - Assess - Note - The patient

- experiences incontinence will void causative/ presence of was able to void
increasing and risk for every 3 to 4 contributing conditions every 3 to 4
urinary urge urinary hour in factors often hour in
frequency, incontinence individually - Assess associated with individually
along with that is related appropriate degree of urgent voiding appropriate
urgency and to Urinary amounts interference/ - Record amounts
dysuria for 2 Tract Infection - The patient disability frequency of - The patient
days will report - Assist in voiding during was able to
- patient has no increase in preventing/ a typical 24- report increase
previous history interval managing hour period in interval
of similar between incontinence - To ascertain between urge
complaints urge and - Promote that the client’s and involuntary
- she has involuntary wellness awareness and loss of urine
recently loss of urine (Teaching/ concerns about and was able to
become Discharge developing demonstrate
sexually active Considerations) problem and behaviors or
and has been whether techniques to
using a lifestyle might control or
diaphragm with be affected correct situation
spermicide - Providing
Objective: information to
- her urine is the client or
pink or bloody significant
- T = 37.5ºC others about
- P = 105 potential for
- R = 18 urge
- BP = 105/70 incontinence
mm Hg and lifestyle
- abnormal measure to
finding on prevent or limit
physical incontinence
examination is
a mild
tenderness to
deep palpation
in the
suprapubic area
- No genital
ulcers are noted
and there is no
vaginal
discharge