HOLY NAME UNIVERSITY

College of Health Sciences

Department of Nursing
Tagbilaran City, Bohol

NURSING CARE PLAN

Name of Patient: ________________________________________ Age:.______ Status: ______________________________________
Address: _________________________________________ Date: ________Ward: _________Bed No: __________________
Impression: ________________________________________________________

ASSESSMENT/ DIAGNOSIS PLANNING INTERVENTION

EVALUATION
PROBLEM CUES/NRSG. RATIONALE OF DESIRED OUTCOME(S) BEHAVIORAL NURSING RATIONALE
DX THE PROBLEM OUTCOME(S) INTERVENTIONS
Risk for Infection Pregnant women After 3 days of nursing After 4 hours of nursing Independent Independent Goal met :
related to chronic with gestational intervention, the patient intervention, the patient 1. Assess the 1. Early detection of short term :
conditions secondary diabetes mellitus will: will be able to: client for UTI may prevent After 4 hours of
to Gestational Diabetes are at increased 1. Be free of urinary tract the occurrence of nursing
Mellitus. risk for infections infection 1. Identify infection (UTI) pyelonephritis, intervention,
of the genital tract. 2. Participate and interventions to signs. which can
the patient was able
Subjective Data: Diabetic pregnant adhere to the prevent or reduce contribute to
to:
women are more treatment plan the risk of premature labor.
● Patient 1. Identify
Diabetes mellitus
verbalized “I’m likely to acquire against infection. infection.
has been intervention
always tired genital infections 3. Demonstrate 2. Maintain in
associated with the s to prevent
and extremely because of poor techniques to acquiring normal
reduced response or reduce
thirsty”. metabolic control, prevent the vital signs. of T cells neutrophil the risk of
higher body mass development of 3. Recognize her function, and infection.
Objective Data: index (BMI), and infection. condition and be disorders of 2. Maintain in
● V/S potentially knowledgeable humoral immunity. acquiring
BP-140/90 impaired leukocyte about possible (Alves et al., 2012). normal vital
mmHg function. complications signs.
RR- 25 Moreover, that may occur . 3. Recognize
PR-102bpm pregnancy itself her
 Temp-35 .4 C harbors an condition
● Hyperglycemia: immunocompromi and be
BG >180 mg/dL sed state, leading knowledgea
● Patient shows to an increased ble about
signs of risk of vaginal possible
weakness Candida complicatio
colonization. As 2. Monitor vital 2. Local and ns that may
● Shows signs every 4 systemic signs of
numbness insulin resistance occur .
hours; notify infection may be
around the increases along
of any present and include
mouth with gestational significant fever, chills,
age, the changes. tachycardia ,hypote
● Dry mouth
susceptibility for nsion increased
● Patient shows
infections in respiratory rate,
facial grimace
diabetic pregnant fatigue, and
women may rise metabolic disorders.
with the duration While treated as an
of pregnancy and outpatient, careful
poor glycemic monitoring is Long term :
control. needed, and After 3 days of
infections should be nursing
reassessed in 2-4 intervention ,the
days or immediately patient was able to
if the situation meet the goals :
worsens (Nikoloudi
et al., 2018).
1.with evidence
of the absence of
the signs and
3.If glycosuria is
symptoms related to
present, a client is
3. Determine more likely to infection.
the nature of develop monilial 2. Participate and
any vaginal vulvovaginitis, adhere to the
discharge. caused by Candida treatment plan
albicans and may against infection.
lead to oral thrush 3.Demonstrate
 in the newborn. techniques to
Candida and yeast prevent the
normally reside in development of
the vagina, and infection.
their unchecked
growth is restricted
by lactobacillus.
The common
complaints of
vaginal thrush are
abnormal vaginal
discharge, vaginal
itch, painful
micturition, and
dyspareunia(Sadaq
at et al., 2020).

4.Foot injuries,
sensory
4. Inspect the neuropathy, and
client’s feet, impaired circulation
noting the are associated with
presence of many complications
ulcers, in diabetics,
infected including skin and
ingrown soft tissue
toenails, or infections. The
other initial assessment
problems should evaluate the
requiring foot and the general
interventions situation of the
client. Local signs
of infection are
increased
temperature,
 erythema, pain, lack
of functionality, and
edema (Nikoloudi et
al., 2018).

5. Emphasize
the important 5.It serves as the
of first line of defense
handwashing against infection.
technique

Dependent

1. Provide
catheter and
perineal care
when
indicated.
Dependent
1.Teach the client
to clean from front
to back after
elimination to
minimize the risk of
UTI. Candida
organisms probably
access the vagina
via migration across
the perianal area
 from the rectum.
Nearly 10% of
women in their
reproductive age
have this recurrent
infection, translating
to about 140 million
women being
affected worldwide
2. Maintain (Sadaqat et al.,
aseptic 2020).
technique for
invasive
procedures
such as IV
and catheter
insertion.
2.High glucose in
the blood creates
an excellent
medium for
bacterial growth.
The main
pathogenic
mechanisms are
hyperglycemic
environment
increasing the
virulence of some
pathogens; lower
production of
interleukins in
3. Administer response to
antibiotics as infection;
indicated. glycosuria;
gastrointestinal and
 urinary dysmotility
(Alves et al., 2012).

3.The cornerstone
of any bacterial
infection, including
UTI, is antimicrobial
therapy. Since UTIs
are very common,
especially in
women, controlled
use of antibiotics
must be initiated for
treatment (Abou
Heidar et al., 2019).
Fosfomycin is an
acceptable
antibiotic for
pregnant women
with UTIs. Women
with asymptomatic
bacteriuria should
be treated by the
standard regimen of
antibiotics for seven
days, except for
4. Educate the recurrent infections
client on how where treatment
they can should last for 10-
recognize 14 days (Kalinderi
signs of et al., 2018).
infection.
4.It is important to
seek medical help
early to avoid
further
 complications.
Educate the client
about common
signs of infection
such as fever,
chills, tachycardia,
hypotension
increased
respiratory rate, and
fatigue. Wound
infections in
diabetic clients can
result in gruesome
complications.
Symptoms may
include increased
temperature,
Collaborative : erythema, pain, lack
1. Referral to a of functionality, and
health care edema (Nikoloudi et
professionals . al., 2018).

Collaborative :
1. Ensures more
efficient,and
effective patient
care .