GMC Hospital BSN 1B: Nursing Care Plan for Risk of Infection

This nursing assignment presents a comprehensive nursing care plan for a 26-year-old female patient admitted to GMC Hospital with complaints of brown vaginal discharge and a history of unprotected sex. The care plan, developed by a BSN 1B student, addresses the patient's risk for infection, stemming from unprotected sexual intercourse. The plan includes a thorough assessment utilizing Gordon's Functional Health Patterns, identifying the patient's health perception, nutrition, elimination, activity, sleep, cognitive, self-perception, role, sexuality, and coping mechanisms. The nursing diagnosis focuses on the risk of infection related to unprotected sexual intercourse, supported by subjective and objective cues. The plan outlines desired outcomes, interventions (both independent and dependent), and evaluations, along with background knowledge about risk of infection. The interventions emphasize patient education on safe sex practices, feminine hygiene, and medication administration. The plan also references diagnostic examinations, though specifics are not detailed in this assignment. The document aims to provide a practical guide for nursing students and professionals.

Nursing Related Learning Experience Manual
Name of Student Daniel James Z. Fernandez Yr & Sec BSN 1B
Clinical Instructor Ma’am Judith Barcelona Area -
Date of Exposure 07/18/2020 Hospital GMC
GORDON’S FUNCTIONAL HEALTH PATTERN
Functional Health
Pattern
Cue Cluster Inference Diagnostic
Statement
Priority Rationale
1. Health Perception &
Management
 When interviewed,
she states that her last
pelvic examination
was 6 months ago.
She denies any
history of cancer or
abnormal Pap smear
results.
 She has never been
tested for HIV.
 A Norplant birth
control device was
placed in her left arm
1 year ago.
Ineffective health
management
Ineffective health
management r/t pattern of
health care as manifested
by the statement that she
has never been tested for
HIV
High 2 Patient may be at risk for
HIV or more serious
complications in line of her
reproductive organ
2. Nutrition /
Metabolism
Does not follow any
special diet
Insufficient cues Insufficient cues Insufficient cues Insufficient cues
3. Elimination Pattern N/A
4. Activity / Exercise Does not follow any
exercise pattern
Insufficient cues Insufficient cues Insufficient cues Insufficient cues
5. Sleep / Rest N/A
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6. Cognitive /
Perceptual
N/A
7. Self – Perception /
Self - Concept
Subjective:
 She explains that she
is not comfortable
discussing this
problem with her new
boyfriend- “I am afraid
he might leave me.”
 She comes to the
clinic appearing
anxious.
Anxiety Anxiety r/t intimate
relationship as manifested
by the statement, “I am
afraid he might leave me.”
Medium 1 Patient needs time in order
for her to tell her boyfriend
in a short span of time so
that possible cross
infection may be
prevented.
8. Role / Relationship Subjective:
 A single mother of two
and has a boyfriend
Not a problem No diagnostic statement N/A N/A
9. Sexuality /
Reproductive
Subjective:
 She states she is
experiencing a brown
vaginal discharge that
started 2 days ago.
 Her last menstrual
period was normal
and ended 1 week
ago today.
 She admits to
unprotected sex 3
weeks ago with her
boyfriend.
Objective:
 physical assessment
reveals normal hair
distribution and no
Risk for infection Risk for infection r/t
unprotected sexual
intercourse as evidenced
by the client’s unprotected
sex 3 weeks ago with her
boyfriend
High 1 Brown discharges from the
vagina of the patient
indicates serious problems
in her reproductive organ
and may lead to more
serious complications
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Nursing Related Learning Experience Manual
lesions, masses, or
swelling.
 The labia majora and
labia minora are pink,
moist and free of
lesions, excoriation,
and swelling.
 A small amount of
malodorous brown
discharge is noted at the
vaginal orifice.
 There is no bulging at
the vaginal orifice. The
perineum is intact with a
healed episiotomy scar.
 No discharge is
observed on urethral
palpation. Internal
examination reveals cervix
to be slightly anterior and
pink, with a slit-like os, and
free of lesions.
 A brown discharge
is noted on the cervix.
 The vaginal walls are
pink and moist with
streaks of brown
discharge.
 Bimanual examination
reveals a mobile, firm, but
tender cervix. The fundus
is palpated at the level of
symphysis pubis.
 The ovaries are
palpated bilaterally without
lesions and are
approximately 3 cm. the
right ovary is very tender
on palpation.
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 A routine Pap smear
is performed and culture
specimens are taken.
 A smooth, firm,
mobile, nontender
posterior uterine wall and
a smooth, firm, thin,
movable rectovaginal
septum are palpated
during rectovaginal
palpation.
10. Coping – Stress
Tolerance
N/A
11. Value Belief N/A
PROBLEM IDENTIFICATION
Problem (PES) Date Identified Time Date Resolved
Risk for infection r/t unprotected sexual
intercourse as evidenced by the client’s
unprotected sex 3 weeks ago with her
boyfriend
07/18/2020 1:55 PM 07/18/2020
Ineffective health management r/t pattern
of health care as manifested by the
statement that she has never been tested
for HIV
07/18/2020 1:55 PM 07/18/2020
Anxiety r/t intimate relationship as
manifested by the statement, “I am afraid
he might leave me.”
07/18/2020 1:55 PM 07/18/2020
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Nursing Related Learning Experience Manual
PRIORITIZATION OF PROBLEMS
Nursing Diagnosis Prioritization Rationale
Risk for infection r/t unprotected sexual intercourse as
evidenced by the client’s unprotected sex 3 weeks ago
with her boyfriend
High 1 Brown discharges from the vagina of the patient
indicates serious problems in her reproductive organ
and may lead to more serious complications
Ineffective health management r/t pattern of health care
as manifested by the statement that she has never been
tested for HIV
High 2 Patient may be at risk for HIV or more serious
complications in line of her reproductive organ
Anxiety r/t intimate relationship as manifested by the
statement, “I am afraid he might leave me.”
Medium 1 Patient needs time in order for her to tell her boyfriend in
a short span of time so that possible cross infection may
be prevented.
NURSING CARE PLAN
Name of
Patient
T.P. Rm/Bed No. 11 Ag
e
26 Chief
Complaints
Experiencing a brown vaginal discharge
Address US Admission
Date
07/18/2020 Sex F Diagnosis Risk for infection
ASSESSMENT HEALTH
PATTERN
NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
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Subjective Cues:
 She states she
is experiencing
a brown
vaginal
discharge that
started 2 days
ago.
 She admits to
unprotected
sex 3 weeks
ago with her
boyfriend.
Objective:
 A small amount
of malodorous
brown discharge is
noted at the vaginal
orifice.
 A brown
discharge is noted
on the cervix.
 The vaginal
walls are pink and
moist with streaks
of brown discharge.
Sexuality/
reproducitve
Note: Use P-E-S format
Risk for infection r/t
unprotected sexual
intercourse as evidenced
by the client’s unprotected
sex 3 weeks ago with her
boyfriend
General:
After 3 weeks:
 Patient will be free
of infection, as
evidenced by
absence of signs
and symptoms of
infection.
Specific:
 Patient will be
educated about
safety measures
when engaging
sex.
 Patient will intake
medical
prescriptions
Independent:
 Provide a clean, well-ventilated
environment. Screen visitors and staff
for signs of infection and maintain
isolation precautions as indicated.
Rationale: Reduces number of
pathogens presented to the immune
system and reduces possibility of patient
contracting a nosocomial infection.
 Monitor vital signs, including
temperature.
Rationale: Provides information for
baseline data; frequent temperature
elevations and onset of new fever
indicates that the body is responding to a
new infectious process or that
medications are not effectively controlling
incurable infections.
 Monitor the patient for any signs of
swelling, purulent discharge or
presence of pain.
Rationale: These are the classic signs of
infection.
 Educate patient about safe sex;
utilization of protection such as
condoms.
Rationale: This will decrease the risk of
having sexually transmitted infections.
 Encourage adequate rest.
Rationale: It can reduce stress and boost
the immune system.
 Educate patient about safe sex;
utilization of protection such as
Background Knowledge
Risk for Infection is
defined as at increased
risk for being invaded by
pathogenic organisms.
Use this nursing diagnosis
guide to create your Risk
for Infection Care Plan.
Infections occur when the
natural defense
mechanisms of an
individual are inadequate
to protect them.
Organisms such as
bacterium, virus, fungus,
and other parasites invade
susceptible hosts through
inevitable injuries and
exposures. People have
dedicated cells or tissues
that deal with the threat of
infection. These are
known as the immune
system.
The human immune
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system is crucial for
survival in a world full of
potentially deadly and
harmful microbes, and
serious impairment of this
system can predispose to
severe, even life-
threatening, infections.
Organs and tissues
involved in the immune
system include the
thymus, bone marrow,
lymph nodes, spleen,
appendix, tonsils, and
Peyer’s patches (in the
small intestine). If the
patient’s immune system
cannot battle the invading
microorganism sufficiently,
an infection occurs.
Breaks in the integument,
mucous membranes, soft
tissues, or even organs
such as the kidneys
and lungs can be sites for
infections after trauma,
invasive procedures, or
invasion of pathogens
through the bloodstream
or lymphatic system. And
a common means for
infectious diseases to
spread is through the
direct transfer of bacteria,
viruses or other germs
from one person to
another. This can
condoms.
Rationale: This will decrease the risk of
having sexually transmitted infections.
 Educate/Instruct client about a good
feminine hygiene
Rationale:It is important to clean genitalia
to prevent risk of possible infection. It's
a good idea to avoid perfumed soaps,
gels and antiseptics as these can affect
the healthy balance of bacteria and pH
levels in the vagina and cause irritation.
Use plain, unperfumed soaps to wash the
area around the vagina (the vulva) gently
every day.
Dependent:
 Administer medications as prescribed
and monitor the patient’s responses
to those medications
Rationale: Monitoring ensures
therapeutic effectiveness
Collaborative:
 Refer patient to gynecologist.
Rationale: This is to further examine the
patient on her discharge in order to know
patient’s condition as this can also reduce
the anxiety of patient.
Objective Cues
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transpire via contact,
airborne, sexual contact,
or sharing of IV drug
paraphernalia. Also,
having inadequate
resources, lack of
knowledge, and being
malnourished place an
individual at high risk of
developing an infection.
Source:
https://nurseslabs.com
/risk
/for/infection/
ASSESSMENT HEALTH
PATTERN
NURSING DIAGNOSIS DESIRED OUTCOME INTERVENTION EVALUATION REMARKS
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Nursing Related Learning Experience Manual
Name of Student Yr & Sec
Clinical Instructor Area
Date of Exposure Hospital
DIAGNOSTIC EXAMINATIONS
Name of Patient Rm/Bed No. Age Chief Complaints
Address Admission Date Sex Diagnosis
Date Ordered Diagnostic
Examination
Normal
Values Result Significance
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Nursing Related Learning Experience Manual
College of Health Sciences Department of Nursing NOTRE DAME OF DADIANGAS UNIVERSITY