NURSING CARE PLAN

28- year -old f emale presents to t he clinic with a 2 day history o f frequency, burning a nd pain upon urination; in creased lower abdominal pain a nd vaginal discharge over the past w eek.

HPI Complains o f urinary s ymptoms s imilar to those o f previous u rinary tract infections ( UTIs) which started approximately 2 d ays ago; also experiencing s evere lower abdominal p ain and noted brown f ouls smelling d ischarge after h aving unprotected in tercourse with her former boyfriend.

PMH Recurrent U TIs (3 this year); g onorrhea X 2, chlamydia X 1 ; Gravida I V Para I II Past Surgical Hi story Tubal ligation 2 y ears ago.

Family/Social Hi story Family: S ingle; history o f multiple m ale sexual p artners; currently lives w ith new boyfriend and 3 children.

Social: Denies smoking, alcohol and drug use.

Medication History None Trimethop rim (TOM)/ Sulfamethoxazole (SMX) -Rash ROS Last pap 6 months ago, Denies breast discharge. Positive for Urine looking dark.

Physical exam BP 100/80, HR 80, RR 16, T 99.7 F, Wt 120, Ht 5’ 0” Gen: Female in moderate distress. HEENT: WNL. Cardio: Regular rate and rhythm normal S1 and S2. Chest: WNL. Abd: soft , tender, increased suprapubic tenderness. GU: Cervical motion tenderness, adnexal tenderness, foul smelling vaginal drainage.

Rectal: WNL. Pag e 2 of 3 Advanced Nursing Practice I ©20 16 South University 3 Week 4: Genitourinary Clinical Case EXT: WNL. NEURO: WNL.

Laboratory and Diagnostic Testing Lkc differential: Neutraphils 68%, Bands 7%, Lymphs 13%, Monos 8%, EOS 2% UA: Starw colore d. Sp gr 1 .015, Ph 8.0, Protein neg, Glucose neg, Ketones neg, Bacteria – many, Lkcs 10 - 15, RBC 0 -1 Urine gram stain – Gram negative rods Vaginal discharge culture: Gram negative diplococci, Neisseria gonorrhoeae, sensitivities pending Positive monoclonal AB for Chl amydia, KOH preparation, Wet preparation and VDRL negative Page 3 of 3 Advanced Nursing Practice I ©20 16 South University