Patient’s name: B.

M Chief Complaint: After Pains

Room/Bed #: Diagnosis: G1P1 PU delivered cephalic to a live baby boy
Age: 17 years old Attending Physician: Dr. XX
General Objectives: To promote optimal activity, rest and sleep

Assessment Nursing Rationale Specific Nursing Intervention Rationale Evaluation

Diagnosis Objectives

Subjective Cues: Infection Causative Agent Within 8 Independent: Within 8 hours of duty
“Gasakit akon related to hours of duty - Facilitates urine the patients WBC
pus-on ga dula- bacterial patients - Increase oral fluid intake production and subside.
dula man lang. invasion in Reservoir WBC will - monitor laboratory test flushes bacteria from
the lining of turn back to - Encourage the client to void urinary track.
Objective Cues: the uterus normal. often every 2-3 hours a day. - To know if the WBC
secondary to Portal of exit - Encourage the client to and puss cells
 HCT- .35 UTI complete the whole duration of increase.
 HGB – antibiotic - Prevent bladder
115 Mode of - Palpate the clients bladder distension, facilitate
 RBC- 3.58 transmission every 4 hours flushing of the
 WBC- - Instruct client to perform bacteria and prevent
19.2 proper perineal care and hand reinfection.
Portal of entry washing. - To prevent
reinfection
Dependent: - To determine the
Susceptible host Give medication according to the presence of urinary
physicians order. retention
Lippincott - Cefuroxime 500 mg 1 - Helps minimizing
Williams and tab(BID) risk of contamination
Wilkins, Collarbotive: and reinfection.
Professional Laboratory results; Urinalysis
guide to
pathophysiology,
third edition.