Amanda Feather October 2013 Nursing Care Plan

Amanda Feather October 2013 Nursing Care Plan
HOWARD COMMUNITY COLLEGE NURSE EDUCATION PROGRAM PEDIATRIC NURSING CARE PLAN Student Name: Amanda Lorraine Feat er %&'( Patient Initia)*: EW A+e,SeDate Su!mitted: O"to!er #$ '. /ear o)d ,Fema)e Medi"a) Dia+no*e* PID
Com0)ete u*in+ 0ro1e**iona) re1eren"e* 2"ite re1eren"e* u*ed34 I4 Pat o0 /*io)o+/: II4 Pe)5i" in1)ammator/ di*ea*e a)*o re1erred to a* PID i* a *eriou* in1e"tion o1 t e )o6er 1ema)e re0rodu"ti5e */*tem 6 i" *0read* to t e u00er +enita) !/ t e a*"endin+ *0read o1 or+ani*m* t rou+ t e 5a+ina and "er5i- to t e !od/ o1 t e uteru* and *ometime* t e 1a))o0ian tu!e* and t e o5arie*4 PID i* mo*t o1ten "au*ed !/ "om0)i"ation* o1 " )am/dia or +onorr ea4 II C)ini"a) Mani1e*tation* 2Under)ine Your Patient7* Si+n* 8 S/m0tom*3: Fe5er D/*uria Mi)d,du)) !i)atera) )o6er a!domina) 0ain 9a+ina) di*" ar+e Pain 6it *e-ua) a"ti5it/ Fou) odor di*" ar+e Pro)on+ed or in"rea*ed men*trua) "/")e* Pe)5i" 0ain
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Dia+no*ti" Studie*,La! Ana)/*i* 2Identi1/ and ana)/:e a)) a!norma) data and,or norma) data t at *0e"i1i"a))/ re)ate* to t e ")ient7* dia+no*i*3 See " art on 0a+e Treatment,Nur*in+ Mana+ement T e +oa) o1 treatment i* to redu"e or e)iminate t e !a"teria or mi"roor+ani*m in1e"tin+ t e 0atient$ treat t e */m0tom*$ 0re5ent )on+ term "on*e;uen"e* *u" a* in1erti)it/ and to edu"ate t e 0atient to 0re5ent rein1e"tion4 Parentera) anti!ioti"* 1ir*t %. our* t en PO anti!ioti"* remainin+ '. da/* or a* ordered !/ t e 0 /*i"ian Edu"ate t e 0atient on treatment and im0ortan"e o1 anti!ioti" ad eren"e4 A**i*t 0atient in di*"u**in+ dia+no*i* 6it t e 0arent* or +uardian* Gat er a t orou+ ea)t i*tor/ to determine etio)o+/ o1 PID Pro5ide 0atient AND 0arent edu"ation o1 0re5ention o1 rein1e"tion$ 0o**i!)e "om0)i"ation* and "on*e;uen"e* o1 PID$ *a1e *e-$ STI 0re5ention
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Di*" ar+e P)annin+ Edu"ation on o Im0ortan"e and anti!ioti" "om0)ian"e o Sa1e *e- in order to 0re5ent STI and rein1e"tion o Ta)<in+ to *e-ua) 0artner2*3 a!out STI* t e 0atient "urrent)/ a* o Con*e;uen"e* o1 PID *u" a* in1erti)it/ or e"to0i" 0re+nan"/ o Ho6 to 0re5ent rein1e"tion W en to return to 0rimar/ "are 0 /*i"ian 1or a 1o))o6 u0 5i*it Re1erra) to and O=GYN U0on di*" ar+e 0atient 6i)) e-0erien"e 0ain a* a % or )e** and 6i)) !e a!)e to edu"ate me on 6 at PID i*$ o6 to 0re5ent it and 0o**i!)e "on*e;uen"e*4 C)ient,Fami)/ Tea" in+ Sa1e *e No dou" in+ !e"au*e it remo5e* +ood !a"teria Condom U*e STI 0re5ention Treatment re+iman Side e11e"t* o1 medi"ation* !ein+ di*" ar+ed ome 6it t e 0atient Potentia) "on*e;uen"e* *u" a* e"to0i" 0re+nan"/ and in1erti)it/ Ho6 to redu"e t e ri*< o1 rein1e"tion Pat o0 /*io)o+/ o1 i))ne** and t e im0ortan"e o1 ear)/ dete"tion in PID to 0re5ent *"arrin+ W en to 1o))o6 u0 t e PCP W en to return to t e o*0ita) i4e 6 en */m0tom* 6or*en$ 1e5er 0re*ent a!o5e '&&4. W at to e-0e"t to a00en durin+ o*0ita) *ta/ Im0ortant ;ue*tion* to a*< O=GYN and PCP durin+ 1o))o6 u0
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Li*t in 0riorit/ order all re)e5ant nur*in+ dia+no*e* 1or /our 0atient4 In")ude NANDA dia+no*i*$ etio)o+/$ and *u00ortin+ data4 Identi1/ in order /our to0 1i5e 0riorit/ nur*in+ dia+no*e*4 A"ute 0ain re)ated to +enita) irritation a4e4! 0atient re0ortin+ 0ain a* > out o1 '& u0on admi**ion Ri*< 1or an-iet/ re)ated to 0re*en"e o1 *e-ua))/ tran*mitted in1e"tion a4e4! 0o*iti5e te*t re*u)t* 1or !ot " )am/dia and +onorr ea Ri*< 0rone !e a5ior re)ated to *e-ua) a"ti5it/ at /oun+ a+e a* e5iden"e !/ 0atient *tatin+ * e en+a+ed in un0rote"ted *e-ua) a"ti5it/ 6it mu)ti0)e 0artner* De1i"ient <no6)ed+e r,t "au*e$ tran*mi**ion$ treatment and 0re5ention o1 *e-ua))/ tran*mitted in1e"tion a4e4! 0atient !e)ie5in+ er IUD 6ou)d 0re5ent rein1e"tion Ine11e"ti5e *e)1? ea)t mana+ement re)ated to 0oor re+ard 1or ea)t 0romotion a* e5iden"e mu)ti0)e STI* and t6o a!ortion* !/ t e a+e o1 '. Nur*in+ Note
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EW 6a* admitted to @N 0ediatri" unit 6it a " ie1 "om0)aint o1 a!domina) 0ain ratin+ a* an > out o1 '& on a &?'& 0ain *"a)e$ & !ein+ no 0ain and '& !ein+ t e 6or*t 0ain t e 0atient ad e5er e-0erien"ed4 Her 0rimar/ dia+no*i* i* 0e)5i" in1)ammator/ di*ea*e4 EW a* a *i+ni1i"ant i*tor/ o1 STI "on*i*tin+ o1 t e " )am/dia and +onorr ea$ % a!ortion*$ mu)ti0)e *e- 0artner* 6it out "ondom u*e and re"ent Mirena IUD 0)a"ement4 Prior to di*" ar+e t e 0atient ad *ta!)e 5ita) *i+n* 6it a !)ood 0re**ure o1 '&@,#'$ A>4&BF tem0$ eart rate o1 >. !0m$ re*0iration* o1 'C !reat * 0er minute and re0orted 0ain a* a & on a &?'& 0ain *"a)e$ & !ein+ no 0ain and '& !ein+ t e 6or*t 0ain * e a* e5er e-0erien"ed4 Di*" ar+e in*tru"tion* 6ere +i5en on o6 and 6 en to ta<e medi"ation*$ t e im0ortan"e o1 "om0)ian"e to anti!ioti"*$ *i+n* and */m0tom* o1 PID "om0)i"ation*$ 6 en to 1o))o6 u0 6it PCP$ re1erra) to an O=GYN and o6 to 0re5ent rein1e"tion4 IX. Gro6t : Hei+ t & D at @CE ta)) , Wei+ t @&D at .A4# <+, =MI >A D at %@4@C =MI Head Cir"um1eren"e @C "m De5e)o0ment: A+e* ''?%& Year* Eri<*on7* Sta+e: Ado)e*"en"e Tanner Sta+e: FFFF.4@FF P /*i"a): E-0e"ted: 9ariation in a+e o1 +ro6t *0urt Durin+ +ro6t *0urt +ir)* +ain #?%@ <+ and +ro6 %4@?%& "m4 Ado)e*"ent* e-0erien"e 0u!ert/$ +ro6 *tron+er$ or+an* 1u))/ mature and !od/ 6i)) " an+e ra0id)/ 1or /ear* Menta),Co+niti5e: E-0e"ted: Enter t e *ta+e o1 1orma) o0erationa) t ou+ tG a!)e to rea*on a!*tra"t)/G a!i)it/ to a"t and t in< inde0endent)/ Identit/: E-0e"ted: E-0)orin+ t eir identit/?in")udin+ 0 /*i"a)$ *e-ua)$ re)i+iou*$ et ni"$ *0iritua) et"4 E-0erimentin+ 6it di11erent identitie*$ identi1/ 1ormation 0ro"e** *u" a* *e-ua) identit/$ 1ormin+ a *et o1 5a)ue* and idea)* and a 5o"ationa) dire"tion Per*ona),So"ia): A"tua): Patient a* a 5er/ a"ti5e e-0)oration o1 *e- !ut a* /et to *et or o!tain ea)t / 5a)ue* and idea)* A"tua): Pateint a"t* and t in<* inde0endent)/ !ut doe* not ma<e t e !e*t " oi"e* 1or er 6e)) !ein+ A"tua): .7>E in ei+ t$ .A4#&<+ in 6ei+ t Patient rea" ed menar" e at '% /ear* o1 a+e Cri*i*: Identit/ 5*4 Ro)e Con1u*ion A!domina) Girt %.4#@E Gro6t 8 De5e)o0ment

E-0e"ted: In"rea*in+ "ommuni"ation and time 6it 0eer +rou0G a00)/ a!*tra"t t ou+ t and ana)/*i* in "on5er*ation at ome and *" oo) Se-ua)it/: E-0e"ted: A" ie5e* *e-ua) maturit/G a5e a +ro6in+ intere*t in P*/" o)o+i"a) Hea)t : E-0e"ted: E-0erimentin+ 6it di11erent idea*G 1indin+ t eir re)ation 6it one*e)1$ +rou0*$ o00o*ite *e-G e*ta!)i* t eir o6n 5a)ue*G inde0enden"e4 A"tua): Patient a* a *tron+ intere*t in *e-ua) a"ti5itie* !ut need* more edu"ation on *a1e *e- and er !od/ A"tua): Patient need* to 6or< on *ettin+ er o6n 5a)ue* A"tua): Patient 6a* 5er/ *o"ia) t rou+ out *ta/ and 5er/ a"ti5e 6it 0eer* t rou+ te-t me**a+e
Fami)/ Li1e, Stre**or*: Un*ta!)e ome en5ironment Un*ta!)e )i5in+ en5ironment Im0aired re)ation* i0 6it !io)o+i"a) mot er Pre+nan"ie* Se)1 e*teem
S" oo),Wor<: Patient i* "urrent)/ in *" oo) !ut a* 0oor attendan"e S e re0ort* er 1riend* do not attend er *" oo) and are *e5era) /ear* o)der t an er Fittin+ in 6it ot er* in *" oo) Po0u)arit/ Ho6 0atient attain* 0o0u)arit/ and 1riend*

A**e**ment Data Identify all data that support the priority nursing diagnosis. O? 0atient a* mu)ti0)e STI* O? 0atient a* ad % a!ortion* 0rior to admi**ion S? 0atient *tate* * e a* ad mu)ti0)e *e0artner* S? 0atient *tate* * e doe* not u*e "ondom* 6it er *e-ua) 0artner* S? 0atient a* Nur*in+ Dia+no*i* According to NANDA Nur*in+ A"tion* List in order of priority. Rationa)e State the rationale for each nursing action. Cite reference and page number. E5a)uation Evaluate the patient response to each nursing action providing objective and subjective data. evise nursing actions as necessary.
Ri*< 0rone !e a5ior re)ated to *e-ua) a"ti5it/ at /oun+ a+e a* e5iden"e !/ 0atient *tatin+ * e en+a+ed in un0rote"ted *e-ua) a"ti5it/ 6it mu)ti0)e 0artner*
E-0e"ted Out"ome: S ort Term Goa) 2STG3: Edu"ate t e 0atient on ri*< and "on*e;uen"e* a**o"iated 6it er !e a5ior and 0ro5ide er 6it re*our"e* !/ t e end o1 * i1t Lon+ Term Goa)
'4 E5a)uate ")ient* a!i)it/ to under*tand er i))ne** and a!i)it/ to )oo< at er *ituation rea)i*ti"a))/ %4 Identi1/ ")ient* !arrier* to adHu*tment* (4 En"oura+e ")ient to e-0re** er 1ee)in+ or 5ie6* on er i))ne** and *ituation and a"ti5e)/ )i*ten 6it out Hud+ment and 1o"u* on 0o*iti5e out"ome* .4 Determine a5ai)a!)e re*our"e* and
'4 Pro5ide* a !a*e to de5e)o0 a 0)an o1 a"tion2Her:o+$ S4 A34 %4 Promote* o00ortunit/ to dea) a00ro0riate)/ 6it 0ro!)em* in t e ")ient* *0e"i1i" *ituation2C4 L4 Ha++ert/3 (4 It i* im0ortant to under*tand t e ")ient* 1ee)in+* and 1o"u*in+ on 0o*iti5e out"ome* en"oura+e* t e ")ient to ta<e " ar+e o1 er *ituation and ma<e* " an+e* 6 ere * e "an 2Her:o+$ S4 A34 4. Determinin+ 6 at 0ro+ram* and re*our"e* 6 i" are a00ro0riate 1or t e ")ient 6i)) !e e)01u) in edu"ation and 0re5ention o1 rein1e"tion$
'4 O? C)ient * o6 and "an e-0)ain "on*e;uen"e* o1 er !e a5ior !ut re1u*e* to )oo< at er *ituation and ta<e a"tion S? I don7t 6ant to *tart u*in+ "ondom* %4 O?C)ient a* a )a"< o1 1ami)/ *u00ort at t i* time and a)*o * o6* a )a"< o1 intere*t 1or er o6n 6e)) !ein+ S? ")ient *a/* * e doe*n7t ta)< to er mom mu" (4 O?C)ient 6a* 5er/ 6it dra6n 1rom t e *ituation and 6a* e-treme)/ ;uiet S? ")ient *tate* * e doe*n7t 6ant to ta)< a!out it ri+ t no6 .4 O?C)ient a* *e5era)

not in1ormed er *e-ua) 0artner* o1 er STI O? Patient re1u*e* to ta<e 1urt er a"tion to 0re5ent 1urt er ea)t 0ro!)em* 2LTG3: =/ di*" ar+e to 0atient 6i)) !e a!)e to e-0)ain "on*e;uen"e* and ri*< a**o"iated 6it er *e-ua) 0romi*"uit/ to me4 E5a)uate ea" e-0e"ted out"ome: S ort Term Goa) 2STG3: Re*our"e in1ormation 6a* 0ro5ided to t e ado)e*"ent and t e !io)o+i"a) mot er Lon+ Term Goa) 2LTG3: Patient 6a* a!)e to e-0)ain "on*e;uen"e* and ri*< o1 0romi*"uit/ to me !ut * o6ed )itt)e "are to6ard* " an+in+ er 6a/*4 0ro+ram* @4 A**e** *o"ia) */*tem$ 1ami)/ *u00ort and *tre**or* C4 En"oura+e t e ")ient to *ee< and 0arti"i0ate in *u00ort +rou0* or re1erra) to a t era0i*t #4 Edu"ate ")ient o1 dru+ intera"tion* 6 i" ma/ o""ur 6it medi"ation* a**o"iated 6it er i))ne** >4 Edu"ate t e 0atient on "on*e;uen"e* 6 i" ma/ o""ur 6it er ri*</ !e a5ior HI9$ STI$ STD and *a1er *e- 0ra"ti"e*42 S6eet$ R4 L43 @4 Fami)/ *u00ort i* 5ita) in t e ado)e*"ent a+e and i1 t e " i)d doe* not a5e a *tron+ *u00ort */*tem it "ou)d !e t e "au*ati5e a+ent o1 er *tron+ *e-ua) e-0re**ion at *u" a /oun+ a+e 2C4 L4 Ha++ert/3 6. Su00ort +rou0*, t era0/ 6i)) a))o6 t e ")ient to e-0re** er 1ee)in+ and !e eard 6 i)e a)*o earin+ ot er* *torie*4 T i* ma/ +i5e er t e o00ortunit/ to a5e e11e"ti5e "o0in+4 2Her:o+$ S4 A34 #4 Edu"ation o1 *eriou* "on*e;uen"e* o1 *u" ri*</ !e a5ior ma/ e)0 detour t e ado)e*"ent and 0romote !e a5ior modi1i"ation 2S6eet$ R4 L43 re*our"e* 6 i" a5e !een 0ro5ided to er *u" a* teen *u00ort +rou0*$ O=GYN and ot er "ommunit/ ea)t ")ini"a) @4 S?Patient *eem* to a5e di*tant 1ami)/ re)ation* 6it )imited *u00ort4 C4 O?C)ient 6a* re1erred to a teen *u00ort +rou0 *o * e "an o0e1u))/ meet ne6 1riend* and a5e *omeone to )i*ten to er 6 en * e de"ide* to o0en u0 S?Patient *tate* * e a* )ot* o1 1riend* !ut doe*n7t ta)< 6it er 1ami)/ mu" #4 O?Patient a* !een 0ro5ided )ot* o1 edu"ation on 5ariou* a""ount* o1 *e5ere "on*e;uen"e* 6 i" 1o))o6 STI and PID i*torie* S?")ient di*0)a/* t e ina!i)it/ to )oo< at er *ituation rea)i*ti"a))/ at t e 0re*ent time

A**e**ment Data Identify all data that support the priority nursing diagnosis. Nur*in+ Dia+no*i* According to NANDA Nur*in+ A"tion* List in order of priority. Label aspect of care. Rationa)e State the rationale for each nursing action. Cite reference and page number. E5a)uation Evaluate the patient response to each nursing action providing objective and subjective data. evise nursing actions as necessary. '4 O?C)ient di*0)a/* no "o+niti5e im0airment S?C)ient *tate* * e i* in t e +rade * e i* *u00o*ed to !e in and a* a = a5era+e %4 O?C)ient *eem* 6it dra6n and ;uiet 6 en it "ome* to di*"u**in+ er dia+no*i* S? C)ient *a/* * e doe*n7t 6ant to ta)< a!out it (4 O? Edu"ation 6a* 0ro5ided to 0atient a* 6e)) a* readin+ materia)* S? II +et 6 at I
S? C)ient *tated * e didn7t *ee it ne"e**ar/ to u*e "ondom* on"e er STI 6a* +one "on*iderin+ * e no6 ad an IUD O? C)ient 6a* una!)e to e-0)ain to me t e +enera) "au*e and tran*mi**ion o1 STI and PID O?Patient "urrent)/ a* a rein1e"tion o1 +onorr ea an " )am/dia S? Wont m/ IUD
De1i"ient <no6)ed+e r,t "au*e$ tran*mi**ion$ treatment and 0re5ention o1 *e-ua))/ tran*mitted in1e"tion a4e4! 0atient !e)ie5in+ er IUD 6ou)d 0re5ent rein1e"tion
E-0e"ted Out"ome: S ort Term Goa) 2STG3: =/ end o1 * i1t 0ro5ide t e ")ient and 1ami)/ 6it readin+ materia) and edu"ate on t e 0at o0 /*io)o+/$ treatment and 0re5ention o1 1uture rein1e"tion Lon+ Term Goa) 2LTG3: =/ di*" ar+e t e ")ient and er 1ami)/ 6i)) !e a!)e to e-0)ain t e
'4 A**e** t e ")ient* de5e)o0ment )e5e) and a!i)it/ to )earn and "om0re end in1e"tion 0ro"e** and treatment %4 A**e** t e moti5ation and 6i))in+ne** o1 t e ")ient to !e an a"ti5e mem!er o1 er treatment and rein1e"tion 0re5ention 0)an (4 Re5ie6 t e 0at o)o+/ and anti"i0ated treatment and 0re5ention 0)an* 6it !ot t e ")ient and er 1ami)/ .4 In*tru"t t e ")ient AND t e 1ami)/ a!out t e in1e"tion
'4 Co+niti5e im0airment* need to !e identi1ied *o an a00ro0riate tea" in+ met od "an !e de*i+ned 2C4 L4 Ha++ert/3 %4 Some ")ient* ma/ not !e read/ to )earn more a!out t eir dia+no*i*2C4 L4 Ha++ert/3
3. T i* 6i)) 0ro5ide a
<no6)ed+e !a*e 1or 1ami)/ and ")ient to ma<e in1ormed de"i*ion* a!out treatment "om0)ian"e 2S6eet$ R4 L43 4. In")udin+ t e 1ami)/ in t e tea" in+ ma/ e)0 6it treatment "om0)ian"e e*0e"ia))/ i1 t e 1ami)/ i* ta<in+ an a"ti5e ro)e in 1urt er

0rote"t me 1rom STI "au*e$ tran*mi**ion and 0re5ention o1 rein1e"tion 1rom STI !/ di*" ar+e4 E5a)uate ea" e-0e"ted out"ome: S ort Term Goa) 2STG3: T e ")ient 6a* 0ro5ided 6it man/ re*our"e* and 6ritten materia) on PID$ STI and *e-ua) a"ti5it/ Lon+ Term Goa) 2LTG3: C)ient and 1ami)/ made it ")ear t at t e/ di*0)a/ed +enera) <no6)ed+e o1 STI$ PID and *e-ua) a"ti5it/ t e needed @4 0ro"e**$ 0ro+re**ion and 6 at i* to !e e-0e"ted4 A*< !ot ")ient and 1ami)/ i1 t e/ a5e an/ ;ue*tion* and an*6er a)) ;ue*tion* one*t)/ E-0)ain t e rea*on 1or *e- re*tri"tion unti) t e STI i* treated and ")eared4 Edu"ate t e ")ient and 1ami)/ on t e im0ortan"e o1 anti!ioti" "om0)ian"e Edu"ation t e 0atient on 6 en to ta<e medi"ation*$ *ide e11e"t* o1 medi"ation* * e i* ta<e and 6i)) !e di*" ar+ed ome 6it rein1e"tion 2Her:o+$ S4 A34 An*6erin+ a)) ;ue*tion* one*t)/ e)0* e*ta!)i* a tru*tin+ re)ation* i0 !et6een nur*e$ ")ient and ")ient 1ami)/ 2Her:o+$ S4 A34 Se- re*tri"tion* * ou)d !e im0)emented unti) !ot ")ient and 0artner a5e !een treated and ")eared 1rom an/ STI to 0re5ent re?in1e"tion o1 STI and 0re5ent PID 1rom o""urrin+ 2S6eet$ R4 L43 Edu"atin+ t e 0atient on t e im0ortan"e o1 anti!ioti" "om0)ian"e i* <e/ in 0romotin+ "om0)ian"e 2Her:o+$ S4 A34 Gi5in+ t e ")ient 0ro0er edu"ation on medi"ation* im0ro5e* "om0)ian"e a* t e/ 6i)) not !e *ur0ri*ed 1rom "ertain *ide e11e"t* t at ma/ 0re5ent t e ")ient 1rom 1ini* in+ er "our*e o1 treatment 2Her:o+$ S4 A34 am *u00o*ed to doE O? Edu"ation 6a* 0ro5ided 6 i)e t e 1ami)/ 6a* 0re*ent S? mot er *tated *e5era) time* * e ad ot er 0)a"e* to !e O?C)ient and 1ami)/ did not "ome 1ort 6it an/ ;ue*tion* S? t e/ under*tand treatment re+imen and 6 en to 1o))o6 u0 S? C)ient under*tood t at unti) er and er 0artner 6ere !ot treated and ")eared to STI* t en *e- 6a* re*tri"ted O? C)ient to)d me t e im0ortan"e o1 6 / *ere*tri"tion 6a* needed O?C)ient
5.
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di*0)a/ed ")ear <no6)ed+e t at anti!ioti"* and anti?in1e"ti5e mu*t !e 1ini* ed a* 0re*"ri!ed S? I I <no6 I mu*t "om0)ete m/ medi"ine *o I am treated4E

A**e**ment Data Identify all data that support the priority nursing diagnosis. Nur*in+ Dia+no*i* According to NANDA Nur*in+ A"tion* List in order of priority. Label aspect of care. Rationa)e State the rationale for each nursing action. Cite reference and page number. E5a)uation Evaluate the patient response to each nursing action providing objective and subjective data. evise nursing actions as necessary. '4 O? C)ient did not * are an/ "on"ern* at 0re*ent time %4 O?C)ient *eem* to a""e0t er dia+no*i* and i* read/ 1or 1urt er edu"ation S?I o6 do I 0re5ent 1rom +ettin+ t i* a+ainKE (4 O?C)ient* * o6 under*tandin+ o1 edu"ation 0ro5ided to 0re5ent re? in1e"tion o1 STI or PID S? ISo t e !e*t 6a/ to 0re5ent anot er i* STI i* "ondom u*e e5en
O? 0atient a* % "urrent STI O? 0atient a* ad t6o 0rior medi"a) a!ortion* S? I don7t under*tand 6 / I need to u*e a "ondom
Ine11e"ti5e *e)1? ea)t mana+ement re)ated to 0oor re+ard 1or ea)t 0romotion a* e5iden"e mu)ti0)e STI* and t6o a!ortion* !/ t e a+e o1 '.
E-0e"ted Out"ome: S ort Term Goa) 2STG3: =/ t e end o1 * i1t t e 0atient 6i)) under*tand t e im0ortan"e o1 medi"ation "om0)ian"e Lon+ Term Goa)
'4 Ma<e time to )i*ten to t e ")ient* "on"ern* %4 Ta<e note on t e ")ient* a""e0tan"e *ta+e o1 er dia+no*i* (4 Determine t e ")ient* under*tandin+ o1 treatment re+imen and 0re5ention o1 1uture rein1e"tion .4 A**e** 0er"ei5ed and a"tua) !arrier* to a""e**in+ ea)t "are *er5i"e* and rea*on* 1or 0o**i!)e de5iation* in 0re*"ri!ed 0)an @4 Wor< 6it t e
'4 Li*tenin+ 0romote* 1ee)in+ o1 5a)ue and ma/ identi1/ additiona) 1a"tor* t at ma/ a11e"t t e out"ome or t e ")ient7* treatment 2S6eet$ R4 L43 %4 Jno6in+ t e a""e0tan"e *ta+e a))o6 determination o1 readine** 1or ")ient in5o)5ement in t eir treatment 0)an 2S6eet$ R4 L43 (4 Identi1ie* area o1 "on1u*ion o1 )a"< o1 under*tandin+ *o a 0)an o1 "are 1or 1urt er edu"ation "an !e addre**ed4 2S6eet$ R4 L43 .4 Pro5ide* o00ortunit/

2LTG3: =/ di*" ar+e t e 0atient 6i)) a""e0t 0er*ona) re*0on*i!i)it/ 1or o6n a"tion* and 0arti"i0ate in di*" ar+e in*tru"tion* and treatment re+imen E5a)uate ea" e-0e"ted out"ome: S ort Term Goa) 2STG3: Patient di*0)a/ed ")ear <no6)ed+e o1 im0ortan"e o1 "om0)ian"e o1 medi"ation* Lon+ Term Goa) 2LTG3: U0on di*" ar+e ")ient too< 0art in di*" ar+e in*tru"tion* and treatment 0)an ")ient and do"tor to ne+otiate a treatment 0)an t e ")ient "an "ommit to 6 i)e 6or<in+ 6it routine* o1 *" oo)$ a6a<enin+ et"4 C4 A**i*t ")ient to de5e)o0 rea)i*ti" ea)t +oa)* and in"or0orate 6e))ne** a"ti5itie* to ")ari1/ a"tua) 0ro!)em* and de5e)o0 a)ternati5e a"tion 0)an in "o))a!oration 6it ea)t "are 0ro5ider4 2C4 L4 Ha++ert/3 5. T i* 6i)) e)0 t e ")ient de5e)o0 a *en*e o1 I*a/ *oE in t eir treatment 0)an and a**i*t 6it 0atient "om0)ian"e 2S6eet$ R4 L43 6. Ado)e*"ent* a5e a"ti5e *" edu)e* and a**i*tin+ in maintainin+ rea)i*ti" ea)t and 6e))ne** +oa)* ma/ !e needed 2S6eet$ R4 L43 t ou+ I a5e an IUDKE .4 S?Patient *eem* to t in< er 0artner 6i)) not )i1e a5in+ *e6it er i1 * e 6ant* to *tart u*in+ "ondom* @4 O? 0atient 6a* +i5en a uni;ue treatment 0)an to 0romote "om0)ian"e S? 0atient *tate* * e 6i)) 1ini* a)) 0re*"ri!ed medi"ation* C4 O? Patient 6a* +i5en re*our"e materia)* on a1ter *" oo) 0ro+ram* S? ")ient *a/* * e 6i)) )oo< into ot er e-tra"urri"u)ar a"ti5it/

A**e**ment Data Identify all data that support the priority nursing diagnosis. S? W at i1 m/ 1riend* 1ind out 6 at 6i)) t e/ *a/K O? Patient di*0)a/* a *en*e o1 6orr/ a!out 1riend* and *0ou*e* 6i)) *a/ 6 en t e/ 1ind out a!out er dia+no*i* S?W at i1 m/ !o/1riend )ea5e* me K Nur*in+ Dia+no*i* According to NANDA Nur*in+ A"tion* List in order of priority. Label aspect of care. Rationa)e State the rationale for each nursing action. Cite reference and page number. E5a)uation Evaluate the patient response to each nursing action providing objective and subjective data. evise nursing actions as necessary. '4 O?C)ient * o6* ade;uate <no6)ed+e o1 dia+no*i* %4 S? 0atient *tate* * e doe* not a5e an/ re)i+iou* !e)ie1* O? 0atient doe* not *eem to di*0)a/ an/ et i"a) "on"ern* or a5e an/ e*ta!)i* ed mora)* (4 O? edu"ation 6a* 0ro5ided to 1ami)/ and ")ient on e-0e"ted treatment 0)an .4 O? C)ear +raduated +oa)* 6ere e*ta!)i* ed
Ri*< 1or an-iet/ re)ated to 0re*en"e o1 *e-ua))/ tran*mitted in1e"tion a4e4! 0o*iti5e te*t re*u)t* 1or !ot " )am/dia and +onorr ea
'4 Re5ie6 ")ient* under*tandin+ and <no6)ed+e o1 dia+no*i* %4 Determine an/ et i"a) or re)i+iou* "on"ern* (4 Re5ie6 treatment 0)an 6it ")ient and 1ami)/ .4 E*ta!)i* +raduated +oa)* @4 A""e** a5ai)a!i)it/ and
E-0e"ted Out"ome: S ort Term Goa) 2STG3: =e1ore end o1 * i1t edu"ate t e 0atient on +uided ima+in+ and re)a-ation te" ni;ue* to redu"e t e 0ain and remo5e an/ di*tra"tion* 1rom t e room4 Lon+ Term Goa) 2LTG3: u0on di*" ar+e t e 0atient 6i)) !e a!)e to *)ee0 t rou+ t e ni+ t E5a)uate ea" e-0e"ted out"ome: S ort Term Goa) 2STG3: Patient too<
'4 Pro5ide* o00ortunit/ to ")ari1/ 5ie60oint* or mi*"on"e0tion*4 9eri1ie* 0atient 6i)) a5e a"tua) 1a"tua) in1ormation 2S6eet$ R4 L43 %4 Pro5ide* in*i+ t into t ou+ t* and 1a"tor* re)ated to indi5idua) *ituation 2C4 L4 Ha++ert/3 (4 Pro5ide* o00ortunitie* to e-" an+e a""urate

Patient 6a* edu"ated on re)a-ation te" ni;ue* and 6a* en"oura+ed to turn o11 t e t5 !e1ore !ed and turn o11 er "e)) 0 one Lon+ Term Goa) 2LTG3: U0on di*" ar+e t e 0atient re0orted !ein+ a!)e to *)ee0 t rou+ out t e ni+ t and re0orted a5in+ no 0ain u*e o1 *u00ort */*tem* in1ormation and to ")ari1/ 5ie60oint* or mi*"on"e0tion 2S6eet$ R4 L43 .4 Promote* ")ient in5o)5ement 2C4 L4 Ha++ert/3 @4 Su00ort */*tem* are <e/ in 6it !e a5iora) modi1i"ation* and re*our"e* 6ere 0ro5ided S? C)ient *aid * e 6ou)d "on*ider )oo<in+ into t e 0ro5ided re*our"e* @4 S?C)ient *a/* * e a* a )ot o1 1riend* * e ta)<

A**e**ment Data Identify all data that support the priority nursing diagnosis. Nur*in+ Dia+no*i* According to NANDA Nur*in+ A"tion* List in order of priority. Label aspect of care. Rationa)e State the rationale for each nursing action. Cite reference and page number. E5a)uation Evaluate the patient response to each nursing action providing objective and subjective data. evise nursing actions as necessary. '4 S? Patient *tate* * e ad a *en*e o1 re)ie1 1rom t e 0ain4 Iit num!* t e areaE O? Patient * o6* )e** 1a"ia) +rima"e %4 O? .@ minute* a1ter medi"ation 6a* +i5en 0atient *tate* 0ain a* a . out o1 '&
S? 1a"ia) +rima"in+ S?Patient o)din+ 0e)5i",)o6er a!domen O? Patient *tate* 0ain i* an > on a *"a)e o1 &?'& & !ein+ no 0ain '& !ein+ t e 6or*e 0ain t e 0atient a* e5er e-0erien"ed4
Pain re)ated to +enita) irritation a4e4! 0atient re0ortin+ 0ain a* > out o1 '& u0on admi**ion
'4 Pro5ide "o)d 0a"< 1or t e 0atient to u*e on 0e)5i" re+ion to e)0 redu"e in1)ammation4 %4 Gi5e an/ medi"ation t at i* due or PRN to "ontro) 0ain 0rior to !ed time4 (4 A**i*t 0atient 6it +uided ima+er/ te" ni;ue to e)0 redu"e 0ain
'4 I"e 6i)) e)0 de"rea*e in1)ammation 2 S6eet$ R4 L43
2. Pain medi"ation
6i)) e)0 re)ie5e an/ 0ain re)ated to i))ne** 2 S6eet$ R4 L43 (4 Guided ima+er/ 6i)) e)0 t e 0atient 1o"u* on re)a-ation2C4 L4 Ha++ert/3
E-0e"ted Out"ome: S ort Term Goa) 2STG3: 0atient 6i)) re0ort 0ain a* )e** t an an > on a &?'& 0ain *"a)e 6it in one our o1 medi"ation admini*tration Lon+ Term Goa) 2LTG3: =/ di*" ar+e t e 0atient 6i)) re0ort 0ain a* a % or )e** on a &?'& 0ain *"a)e E5a)uate ea" e-0e"ted out"ome: S ort Term Goa) 2STG3: .@ minute* a1ter

medi"ation admini*tration 0atient re0orted 0ain a* a C Lon+ Term Goa) 2LTG3: U0on di*" ar+e 0atient re0orted 0ain a & on a &?'& 0ain *"a)e

MEDICATION PREPARATION SHEET A))er+ie*: NJDA C i)d7* Wei+ t: .A4# <+ m), our T/0e o1 Rea"tion: FFFFFFN,AFFFFFFFFFFFFFFFFFFFFF Maintenan"e F)uid Re;uirement: >#4%@
Medi"ation Admini*tration Re"ord: A:it rom/"in Ori+ina) P /*i"ian Order: &4&% m+,<+,do*e? one time '&&&m+ one do*e PO STAT Time2*3 Due: Generi",Trade Name: Norma) Do*a+e: PO STAT Lit roma&4&% m+ m+,<+,do*e
Sa1e do*e 1or t i* ")ientK S o6 6or<: &4&%m+ - .A4#<+ M &4AA.m+4 Ye* t i* i* a *a1e do*e C)a**i1i"ation: Ma"ro)ide* A"tion: In i!it* 0rotein */nt e*i* at t e )e5e) o1 t e @&S Indi"ation 1or Patient: anti?in1e"ti5e r,t PID and STI MaHor Side E11e"t*: a!domina) 0ain$ nau*ea$ diarr ea Parameter* C e"<ed: a))er+ie*$ "orre"t do*e$ GI */*tem$ W=C
De5e)o0menta) Con*ideration*: ade;uate nutrition Medi"ation Admini*tration Re"ord: Do-/"/")ine H/date
Ori+ina) P /*i"ian Order: '&&m+ N'%H PO Time2*3 Due: '&&& and %&&& Generi",Trade Name: 9i!ra ta!* Norma) Do*a+e: '&&m+ ;'% 1or # da/*

Sa1e do*e 1or t i* ")ientK S o6 6or<: Ye* t e do"tor ordered t e re"ommended do*e 1or t e +onorr ea in1e"tion 1or t e ")ient* a+e 6 i" i* '&& m+ ;'% PO 1or '% da/ C)a**i1i"ation: A"tion: anti?in1e"ti5e
In i!it* !a"teria) 0rotein */nt e*i* at t e )e5e) o1 %&S !a"teria) ri!o*ome to treat STI, PID diarr ea$ nau*ea$ 5omitin+$ 0 oto*en*iti5it/
Indi"ation 1or Patient: MaHor Side E11e"t*:
Parameter* C e"<ed: a))er+ie*$ De5e)o0menta) Con*ideration*: "a)"ium in 1ood or dair/ 0rodu"t* 6i)) de"rea*e a!*or0tion
Medi"ation Admini*tration Re"ord: Jetoro)a" Tromet amine Ori+ina) P /*i"ian Order: %@m+ NC PRN I9 Time2*3 Due: &&&&,&C&&,'%&&,'>&& PRN Generi",Trade Name: Torado) Norma) Do*a+e: (&m+ NC I9 PRN Sa1e do*e 1or t i* ")ientK S o6 6or<: Mu)ti0)e do*e (& m+ NC not to e-"eed '%& m+ 0er da/ %@m+ - .M '&&m+, %. our*4 Ye* t i* i* a *a1e do*e a* it i* )e** t an '%&m+ 0er da/ C)a**i1i"ation: non?*teroida) anti?in1)ammator/ A"tion: in i!it* 0ro*ta+)andin */nt e*i*$ 0rodu"in+ 0eri0 era))/ medi"ated ana)+e*ia 6it anti0/reti" and anti? in1)ammator/ a+ent*4 Indi"ation 1or Patient: anti?in1)ammator/ and 0ain a* needed

MaHor Side E11e"t*: dro6*ine**$ *tro<e$ m/o"ardia) in1ar"tion$ +i !)eedin+$ e-1o)iati5e dermatiti* Parameter* C e"<ed: Pain )e5e)$ a))er+ie*$ 1i5e ri+ t*$ " e"< 0ain an our a1ter admini*tration De5e)o0menta) Con*ideration*: Patient* under*tandin+ o1 0ain *"a)e4 Wi)) t i* dru+ "au*e de)a/ed +ro6t K Medi"ation Admini*tration Re"ord: Ce1o-itin
Ori+ina) P /*i"ian Order: &4%m+ I9 NC - .> r a1ter ")ini"a) im0ro5ement Time2*3 Due: &.&&$ '&&&$ 'C&&$ and %&&& MEFOOIN
Generi",Trade Name:
Norma) Do*a+e: %+I9 NC - %. P .> our a1ter ")ini"a) im0ro5ement4 Do-/"/")ine '&& m+ N'% our PO,I9 - '. da/* i* a)*o initiated at t e *ame time4 Sa1e do*e 1or t i* ")ientK S o6 6or<: Ma- do*e i* '%+,%. our 1or a)) a+e*4 /e* t i* i* t e indi"ated do*e 1or 0ediatri" PID C)a**i1i"ation: Se"ond +eneration "e0 a)o*0orin$ anti!ioti" A"tion: !ind* to !a"teria) "e)) 6a)) mem!rane "au*in+ "e)) deat Indi"ation 1or Patient: anti?in1e"ti5e
MaHor Side E11e"t*: *ei:ure*$ 0*eudomem!ranou* "o)iti*$ a))er+i" rea"tion$ ana0 /)a-i*$ diarr ea Parameter* C e"<ed: U*e 6it "aution in 0eni"i))in?a))er+i" 0atient* or in rena) im0airment4 Contraindi"ated 6it /0er*en*iti5it/ to "e0 a)o*0orin De5e)o0menta) Con*ideration*: Wei+ t$ a+e$ a!i)it/ to under*tand t e im0ortan"e o1 medi"ation "om0)ian"e ti)) t e end o1 t e 0re*"ri0tion
Wor<* Cited
C4 L4 Ha++ert/ and R4 =4 Ne**$ QDia+no*i* and treatment o1 0e)5i" in1)ammator/ di*ea*e$Q WomenR* Hea)t $ 5o)4 .$ no4 .$ 004 (>(?(A#$ %&&>4 M4 Y4 Sutton$ M4 Stern!er+$ A4 Laidi$ M4 E4 S4 Loui*$ and L4 E4 Mar<o6it:$ QTrend* in 0e)5i" in1)ammator/ di*ea*e o*0ita) di*" ar+e* and am!u)ator/ 5i*it*$ United State*$ 'A>@?%&&'$Q Se-ua))/ Tran*mitted Di*ea*e*$ 5o)4 (%$ no4 '%$ 004 ##>?#>.$ %&&@ 94 L4 S ort$ P4 A4 Totten$ R4 =4 Ne**$ S4 G4 A*tete$ S4 F4 Je)*e/$ and C4 L4 Ha++ert/$ QC)ini"a) 0re*entation o1 M/"o0)a*ma +enita)ium in1e"tion 5er*u* Nei**eria +onorr oeae in1e"tion amon+ 6omen 6it 0e)5i" in1)ammator/ di*ea*e$Q C)ini"a) In1e"tiou* Di*ea*e*$ 5o)4 .>$ no4 '$ 004 .'?.#$ %&&A4 R4 L4 S6eet and R4 S4 Gi!!*$ QPe)5i" in1)ammator/ di*ea*e$Q in In1e"tiou* Di*ea*e* o1 t e Fema)e Genita) Tra"t$ 004 %%&?%..$ Li00in"ott Wi))iam* 8 Wi)<in*$ P i)ade)0 ia$ Pa$ USA$ %&&A4 E4 Sern!er+$ A4 Mo+ addam$ and H4 Moi$ QA:it rom/"in and mo-i1)o-a"in 1or mi"ro!io)o+i"a) "ure o1 M/"o0)a*ma +enita)ium in1e"tion: an o0en *tud/$Q Internationa) Sourna) o1 STD and AIDS$ 5o)4 'A$ no4 '&$ 004 C#C?C#A$ %&&> S6eet$ R4 L4 2%&''34 Treatment o1 a"ute 0e)5i" in1)ammator/ di*ea*e4 Infectious Diseases in !bstetrics and "ynecology4 Retrie5ed 1rom tt0:,,+o4+a)e+rou04"om,0*,i4doKidMGALE D#CA%>&>@@>>C85M%4'8uM"o)uA''.A8itMr80MPPNU8*6M68a*idMC%d#@CaC">%"(((e"&#!@C"@(.'CdA1d Her:o+$ S4 A4$ A)t au*$ C4 L4$ HeiHne$ S4 C4$ Oa<e* ott$ P4$ Jerr/$ S4$ Ha/$ P4$ 8 Lo6$ N4 2%&'%34 Timin+ o1 0ro+re**ion 1rom C )am/dia tra" omati* in1e"tion to 0e)5i" in1)ammator/ di*ea*e: a mat emati"a) mode))in+ *tud/4 #$C Infectious Diseases$ %&$ '>#4 Retrie5ed 1rom tt0:,,+o4+a)e+rou04"om,0*,i4doKidMGALE D#CA(&A#A.%%.85M%4'8uM"o)uA''.A8itMr80MPPNU8*6M68a*idMC>(1!!%.>"e##""C!aA(ea@#1e'e".(#
Te*t N4 +onorr oeae DNA 0ro!e CMP, =MP
Date A,%%,%&' ( A,%%,%&' (
C)ient Re*u)t* Po*iti5e
Norma) Parameter Ne+ati5e
Rea*on Pre*en"e o1 +onorr oeae !a"teria C e"< 1or meta!o)i" " an+e*
Nur*in+ A"tion Edu"ate 0atient on STI treatment and re? in1e"tion 0re5ention E-0)ain to " i)d t i* re;uire* a !)ood dra6 and i1 I9 i* 0re*ent 6e are +oin+ to a5e to u*e a need)e and it 6i)) urt tem0orari)/ Pro0er 0ro"edure 1or +i5in+ a urine *am0)e ")ean "at" 4
?Car!on Dio-ide '>4> 2L3 ?Anion Ga0 '> 2H3 ?=UN @ 2L3 ?Creatinine '4& 2H3 ? C rea"ti5e Protein %#4# 2H3 =i)iru!in %2H3 Leu<o"/te e*tera*e (T 2H3 W=C '&?%& 2H3 =a"teria 0re*ent H+! '&4A 2L3 H"t (%4& 2L3 Neutro0 i)* #( 2H3 A!*o)ute neutro0 i) >'>& 2H3
Urina)/*i*
A,%%,%&' (
Co%: %#?.' Anion: >?'C =UN: #?%& m+,d) Creatinine: &4C? &4> C rea"ti5e &4C>? >4% =i)iru!in? U' Leu<o"/te? ne+ W=C? ne+ =a"teria? none H+! '&4%? '(4. H"t ('4#? (A4> Neutro0 i) (.4(? C%D A!*o)ute
C=C
A,%%,%&' (
A00endi- US
A,%%,%&' (
Norma)
No in1)ammation
Determine* 6 et er or not t ere i* 0re*en"e o1 !a"teria and in1e"tion in t e urinar/ tra"t Determine* t e 0re*en"e o1 e)e5ated 6!" "ount to determine in1e"tion and " e"< "on"entration o1 R=C A00endi"iti* ru)e out
E-0)ain to " i)d t i* re;uire* a !)ood dra6 and i1 I9 i* 0re*ent 6e are +oin+ to a5e to u*e a need)e and it 6i)) urt tem0orari)/ E-0)ain to " i)d t i* re;uire* a !)ood dra6 and i1 I9 i* 0re*ent 6e are +oin+ to a5e to u*e a need)e and it 6i)) urt tem0orari)/

A!domen,Pe)5i " CT A,%%,%&' ( In1)ammation o1 t e uteru* No in1)ammation or in1e"tion 0re*ent In1)ammation r,t +enita) irritation Edu"ate 0atient on t e CT 0ro"e** and edu"ation PID 0re5ention a1ter do"tor* *0ea< 6it t e ")ient and 1ami)/ a!out dia+no*i* Edu"ate t e 0atient on
9a+ina) U)tra*ound
A,%%,%&' (
In1)ammation o1 t e 5a+ina) "ana)
Norma) ea)t / ti**ue 6it no *i+n* o1 in1e"tion or in1)ammation
In1)ammation r,t 0re*en"e

Amanda Feather October 2013 Nursing Care Plan

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Amanda Feather October 2013 Nursing Care Plan