Torre, May Crystal

Tumangday, Princess
Villamor, Grismeh
BSN 2-F

Case Scenario:
 NURSING CARE PLAN
Assessment Nursing Expected Nursing Rationale Evaluation Discharge
Diagnosis Outcomes Interventions Planning

Subjective Risk for Short-term Independent: Independent: Short-term Medication/s:

data/s: chlamydia goal/s: a)Monitor vital a) Monitoring the goal/s: Administer
None infection related After 3-4 hours of signs of the patient. vital signs can serve After 3-4 hours of Azithromycin and
to slight pain, nursing as a baseline data nursing Doxycycline for
Objective burning when intervention: b)Encourage the and to help assess intervention: one dose of 1g,
data/s: urinating, and patient to drink the effectiveness of followed by 500
-Slight pain abnormal a)The patient will plenty of fluids. interventions and MET mg OD for 2 days
-Burning when vaginal report relief from detect changes in a)The patient as ordered.
urinating discharge. pain and c)Provide status. reports relief from
-Abnormal discomfort during information about pain and burning Environment:
vaginal urination. chlamydia infection, b)To promote sensation during Provide a
discharge its modes of urinary flushing and urination. stress-free, clean,
- Unprotected b)The patient will transmission, ways alleviate pain and and quiet
sexual demonstrate to prevent it, discomfort during MET environment for
intercourse understanding of potential urination. b)The patient the patient to
chlamydia infection complications if left demonstrates promote
prevention untreated, and c)To impart understanding of relaxation.
measures. emphasize the knowledge about chlamydia
importance of her signs and infection Treatment:
Long-term practicing safe sex symptoms as well prevention Continue
goal/s: through counseling. as the risk factors of measures. medications as
After 1 week of reproductive ordered by the
nursing Dependent: infection basing on Long-term physician.
intervention: a)Administer her past history and goal/s:
antibiotics such as her risky sexual After 1 week of Health
a)The patient will azithromycin and habits. nursing Teaching:
have a normal doxycycline as intervention: Educate the
vaginal discharge. ordered by the Dependent: patient on
physician. a)To treat and lower MET preventive
the risk of bacterial a)The patient has measures,
infections such as a normal vaginal including
chlamydia. discharge. consistent and
correct use of
condoms, regular
screenings for
STIs, and
reducing the
number of sexual
partners.

Out-patient:
Ensure that the
patient has a
follow up
appointment with
her primary
healthcare
provider.

Diet:
Instruct the
patient to
consume a
variety of fruits,
vegetables, whole
grains, and lean
protein. Avoid
processed foods
and added
sugars.

Support
System:
Encourage
 significant other
to provide
emotional support
and guidance for
the patient.

Spirituality:
Advice the patient
to strengthen her
faith to the Lord.

References:
Doxycycline: antibiotic to treat bacterial infections - NHS (www.nhs.uk)
Nursing Care Plan | NCP Chlamydial Infection | Nurse Care Plan
Chlamydia Case Study | A Pathophysiology Case Study (osu.edu)