TABLE OF CONTENTS

INTRODUCTION ----------------------------------------------------------------------------------------------------- 1 OBJECTIVES ----------------------------------------------------------------------------------------------------------- 2 General Specific Knowledge Skills Attitude BIOGRAPHICAL DATA ---------------------------------------------------------------------------------------------- 3 PRESENT HISTORY--------------------------------------------------------------------------------------------------- 4 PAST HISTORY-------------------------------------------------------------------------------------------------------- 4 FAMILY HISTORY----------------------------------------------------------------------------------------------------- 4 SOCIAL HISTORY------------------------------------------------------------------------------------------------------4 LABORATORY HISTORY Hematology--------------------------------------------------------------------------------------------------5 Cross Matching----------------------------------------------------------------------------------------------6 Blood Typing Rh---------------------------------------------------------------------------------------------7 GROWTH AND DEVELOPMENT----------------------------------------------------------------------------------- 8-9 IMMUNIZATION CHART-------------------------------------------------------------------------------------------- 10 24-HOUR DIETARY RECALL---------------------------------------------------------------------------------------- 11 PHYSICAL ASSESSMENT-------------------------------------------------------------------------------------------- 12-14 ANATOMY AND PHYSIOLOGY ------------------------------------------------------------------------------------15 PATHOPHYSIOLOGY OF THE DISEASE--------------------------------------------------------------------------- 16 NURSING CARE PLAN----------------------------------------------------------------------------------------------- 17-22 DRUG STUDY --------------------------------------------------------------------------------------------------------- 23-29 HEALTH TEACHING-------------------------------------------------------------------------------------------------- 30-31 PROGNOSIS------------------------------------------------------------------------------------------------------------ 32 CONCLUSION---------------------------------------------------------------------------------------------------------- 33 REFERENCE

INTRODUCTION
Pain, is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain motivates us to withdraw from potentially damaging situations, protect a damaged body part while it heals, and avoid those situations in the future. Most pain resolves promptly once the painful stimulus is removed and the body has healed, but sometimes pain persists despite removal of the stimulus and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or disease. It is a major symptom in many medical conditions, and can significantly interfere with a person's quality of life and general functioning. Nursing intervention would be applied upon conducting assessment to know the strengths and weaknesses in order to plan and implementing the right interventions to be given to the client health care needs.

For this shifting we the BSN III-B nursing students of Saint Gabriel College, Monday group assigned at Saint Gabriel Hospital 3rd floor wing-A part of our requirements in RLE is to have case presentation. Out of four ( 4 ) clients we choose the post operative mother ( cs ) related to our concept pain and surgery gather pertinent information about her demographic data, family history, past and present history, health history and social history and also her health practice to be able to gain understanding on how mentioned factors can affect the wellness of the post-op patient and her family. Moreover this activity helped us to develop our skills in pain assessment to determine what the cause of pain is and how it is therapeutically being handled and manage. It also trained us to become critical and creative thinker in creating our nursing care plan and health teaching that is appropriate to our patient. Lastly pain assessment and management is a very complex concept that involves comprehensive assessment.

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GENERAL OBJECTIVE

At the end of the presentation, the BSN 3 students are expected to acquire knowledge, enhance skills and develop the desired attitude in the care of clients in pain.

SPECIFIC OBJECTIVES
Specifically, this presentation aims to achieve the following specific objectives;

KNOWLEDGE (Cognitive)
1) Define pain. 2) Obtain knowledge about Pain assessment. 3) Gather pertinent information about the client biographical data, past, present, health history and social history. 4) Develop our critical thinking in making individualized nursing care plan. 5) Formulate health teaching that is appropriate to the health care needs of our patient.

SKILLS
1) Develop good therapeutic communication skills within the patient and her family. 2) Improve verbal and written communication. 3) Enhance our skills in vital signs taking and admission of patient. 4) Improve charting and carrying out doctors order.

ATTITUDE
1) Established rapport and trust with the patient& family and gain their cooperation. 2) Establish good interpersonal relationship among hospital personnel. 3) Promote teamwork and camaraderie among group mates and related others.

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BIOGRAPHICAL DATA
Name: Mrs. L.R Age: 40 years old Address: Cerudo Banga,Aklan Status: Married Birthday: January 25, 1971 Birth place: Cerudo Banga, Aklan Chief Complaint: Term pregnancy Diagnoses: Caesarian Section Attending Physician: Dr. G.V Date of Admission: June 25, 2011 at 1:00 pm

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PRESENT HISTORY

Mrs. L.R is admitted on June 24, 2011 @ around 1:00 pm due for repeat caesarian section that is scheduled June 25, 2011. Accompanied by her sister.

PAST HISTORY
1st pregnancy of Mrs. L.R was right tubal ectopic pregnancy last August 2, 2004.The 2nd pregnancy was miscarriage due to strenuous activity, it was on January 7, 2005.3rd pregnancy was caesarian section last December 4, 2006 due to umbilical cord coil and her 4th pregnancy was an elective caesarian section scheduled on June 25, 2011.

FAMILY HISTORY
Mrs. L.R has no familial history like hypertension, diabetes, allergy and CA.

SOCIAL HISTORY
Mrs. L.R goes to church every Sunday with her family. She goes every week end to the mall for relaxation and they attend to their family affairs.

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LABORATORY HISTORY
HEMATOLOGY
Name: L.R Ward: 307 Physician: Dr. G. V Diagnosis: CS Age: 40 Sex: F C.S: M Date: 6/25/11 Lab. No: Exam. Dessired: Hgb/Hct

Hemoglobin Mass Cons: 125 g/L Erythrocyte Vol. Fraction: 0.37 L/L Thrombocyte No. Cons adequate x 10 8/L

Normal Value F: 120-160 M: 135-180 F: 0.37-0.45 M: 0.40-0.54 150-450

M.A.C.B Registered Medical Technologist E.A.S, MD, DPSP Pathologist

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CROSSMATCHING FORM
Name: L.R Ward: 307 Requested by: Dr. G.V Age: 40 Sex: F Status: M Date: 6/25/11

Patients Blood Type: A(+) Donors Blood Type: A(+), whole blood

Blood Bank: PNRC PNRC Date Expired 7-29-11 7-29-11

Serial No. 162 495 162 456 Remarks Compatible Compatible

Volume 450 cc 450 cc

Date Extracted 6-24-11 6-24-11

E.A.S, MD, DPSP Pathologist

M.M.F, RMT. RN RMT

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BLOOD TYPING & Rh TYPING

Name: L.R Ward: 307 Requested by: Dr. G.V

Age: 40 Sex: F Status: M

Date: 6/25/11

Blood Type: A Rh (D): Positive

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GROWTH AND DEVELOPMENT

A. INFANCY ( birth 1 y.o )

On this stage, according to Mrs. L.R she was breastfeed by her mother. She started to crawl at age of 6months. Her first word spoken was ma at the 9 months old. She started to walk at age of 1 year.

B. TODDLERS ( 1-3 y.o )

According to her she was hospitalized when she was 2 years old due to infection of punctured wound in her sole of right foot. She was very talkative and playful. She even fond of climbing on their table. Shes hyperactive child.

C. PRESCHOOLER ( 4-6 y.o )

At this stage she started to play with other children at their neighbourhood. She chooses her dress and dress up by herself. She started to wash her hand alone.

D. SCHOOL AGE ( 6-12 )

She started schooling at 6 years old, as grade one pupil. At first her parents and her sisters helped her doing her assignments and eventually she does it on her own. She added that she enjoyed making coconut candies during weekends. She participated in different school activities. E. ADOLESCENT (12-18 )

At 13 y/o her first menstrual period started. According to her, she was nervous when she saw blood flowing on her legs and her mother laughed at her, and told her that she is already a lady. She had her first boyfriend at age of 18. She continued being active at school activities engaging in folk dancing, declaiming and very active member of various school organizations until she finished her course (Bachelor of Science in education major in elementary education at North Western Visayan Colleges. And passed her teachers board exam a year after she graduated). -8-

F. YOUNG ADULT (20-40 )

> According to her, after she passed the board exam she started to apply as elementary teacher and lucky given the chance to teach at Daja Elementary School. She got married at age of 33 y/o. and got pregnant few months after she got married. She was devastated when her Ob-gyne told her that she had the right tubal ectopic pregnancy. A year after, she got pregnant again but at 8 weeks she had miscarriage because of travelling and strenuous activities. The following year after, she got with her third pregnancy were her first born is a baby girl, delivered through classical caesarean section due to umbilical cord coil. Six (6) years after, she got pregnant for the fourth time and delivered her new born baby boy through repeat classical caesarean section. For her, doctor told her that she is a high risk, because of her age and her past medical history.

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Immunization Chart
Patients Name BCG Mrs. L.R DPT 1,2,3 OPV 1,2,3 HEPA-B 1,2,3 & BOOSTER Measles Others 1 dose of TT

According to Mrs. L.R, she is fully immunized but she lost her immunization record.

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24 Hour Dietary Recall

Breakfast Lunch Dinner Breakfast

1 cup of porridge 1 glass of water

1 cup of porridge 1 glass of water 1 slice of loaf bread

1 cup of Quaker Oats 1 can of pineapple juice

2 slices of bread cup of coffee

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PHYSICAL ASSESSMENT 1st Interview(June 28, 2011) Linear Measurement Height- 51 Weight- 54 kgs 2nd Interview(June 29, 2011) Vital Signs: T- 36.5c/ax P- 77 bpm R- 33 bpm Bp- 120/90 mmHg CR- 81

Vital Signs: T- 36.5c/ax P- 86 bpm R- 29 bpm

BP- 130/70 mmHg CR- 77 bpm

General Appearance: During our physical assessment, Mrs. L.R. was wearing a blue shirt and also a blue pajama. Mrs. L.R. was watching a show on the T.V. Shes curious about what were doing to her and she keeps on asking questions. She is very cooperative when we assessed her.

SKIN >Brown in color >Warm to touch >No lesion >Good skin turgor >No scar noted NAILS >Trimmed with clean finger nails >Capillary refill of 2 sec. >Convex curvature angle between nails >Texture of the nails in the hand and foot are slightly smooth HAIR >Equally distributed, dark, short, and thick >No lice infestation -12-

HEAD >Circumference of 54 cm. >No nodules or masses noted at her head >Proportionate to body size

FACE >Coordinated facial movement, no involuntary facial muscle movement >Oval in shape EYES >black pupils >eyebrows are evenly distributed >eyelashes are evenly distributed >both eye movements are coordinated >21 involuntary blinks/min >PERRLA >Eyeballs are symmetrical EARS >Auricles have same colors in facial skin >Pinna recoils after it is folded >With minimal amount of cerumen in both ears

NOSE >Symmetrically formed nostrils >Uniform in color and no discharge upon inspection >Can distinguish different odors MOUTH >Lips are symmetrical, dry and pinkish in color >Pinkish gums >8 false teeth >Tongue move freely and no lesion

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NECK >No nodules, masses or swelling noted >Exhibit complete voluntary control; could easily turns her head from left to right >Can flex and extend his neck BREAST >The client refused to be examined but verbalize that no lesion is noted CHEST >Normal rise and fall is noted during inhalation >No lesion is noted as verbalized by the patient AXILLAE >No lesion is noted >Armpit hair is present ABDOMEN >With tympanic sound >4 inches of incision noted >12 stitches noted (classical c-section)

GENITALS & ANUS >The client refused to be examined but she verbalize that no lesion is noted

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Anatomy and Physiology of the Female Reproductive System

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction, called the ova or oocytes. The system is designed to transport the ova to the site of fertilization. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle. During menopause the female reproductive system gradually stops making the female hormones necessary for the reproductive cycle to work. When the body no longer produces these hormones a woman is considered to be menopausal. The external structures of the female reproductive system include: Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair. Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body). Bartholins glands: These glands are located next to the vaginal opening and produce a fluid (mucus) secretion. Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs include: Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal. Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit. Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones. Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants to the uterine wall.

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PATHOPHYSIOLOGY

Predisposing Factor Age 40 y/o Sex Female

Predisposing Factor 1st pregnancy tubal ectopic pregnancy 2nd pregnancy 8 wks. miscarriage due to strenuous activities (Jan. 7, 2005) 3rd pregnancy 41 wks. Classical Caesarean section due to umbilical cord coil (Dec. 4, 2006)

CLASSICAL CEASARIAN SECTION

INDUCTION OF SPINAL ANESTHESIA

INCISION BELOW THE UMBILICUS

BABY WAS BORN/DELIVERED

SUTURING OF THE INCISION

OUT OF THE OPERATING ROOM THEN BROUGHT TO RECOVERY ROOM FOR VITAL SIGNS STABILIZATION

BROUGHT TO WARD

ANESTHESIA DURATION EXPIRED POST OP PAIN

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G. V CUES: Subjected Data: putoe-putoe ang tueog ag ga sinakit ang tinahian as verbalized by the patient. NURSING DIAGNOSIS: Sleep-rest pattern disturbance related to acute pain secondary to interruption in skin/tissue layers of mechanical closure/sutures. OBJECTIVES:

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011

NURSING INTERVENTION: Independent: -Monitor v/s

RATIONALE:

EVALUATION: Goals were partially met as evidenced by: -pain was reduced as claimed. -BP decreased from 130/70mmHg to 120/80mmHg -patient reported that she had good sleep and had rested.

General Objectives: To promote optimal activity exercise, rest and sleep.

-this will serve as initial baseline data. -possible underlying condition on certain organs that need treatment. -to determine the need of care or treatment.

Objective Data: Temp.= 36.5c/ax Pulse= 86bpm RR= 29bpm CR-77bpm BP=130/70mmHg -incision of 4 inches in length with 12 stitches. -guarding the incision site when moving. -yawning.

Specific Objectives: After 4 hours of nursing intervention, the patient will report: -relief from pain -BP will normalize from 130/70mmHg to 120/80mmHg -have plenty of sleep and rest. -report interrupted sleep.

-assess for pain particularly on the affected area.

-scale level of pain from 0-10.

-advise patient to -enough rest have adequate rest and sleep would and sleep be of great help for energy restoration. -place the patient in a comfortable position(supine). -render massage -to promote comfort.

-to provide soothe and comfort. -milk contains Ltrypthopan that aids in sleep.

-encourage milk before bedtime.

Dependent: -give pain relievers w/n necessary

-relieves pain and gain cooperation.

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V
CUES: Subjected Data: Gasakit akong operation as verbalized by the patient. -pain scale of 6 out of 10. Objected Data: -weak -pale -grimacing of face when moving. -perform activities with assistance. NURSING DIAGNOSIS : Activity intolerance related to pain. OBJECTIVES: General Objectives: To promote optimal activity, exercise, rest and sleep.

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011

NURSING INTERVENTION: Independent: -closely monitor v/s particularly BP, CR, and RR. -note presence of factors contributing to fatigue and pain. RATIONALE: EVALUATION: Goals were partially met as evidenced by: -patient claimed that pain reduced from 4-2 -identified negative factors affecting activity tolerance or reduces their effects. -had verbalized her feelings. -claimed to have improved quality of rest and sleep.

-these serve as baseline data.

Specific Objectives: After 2-4hours of nursing interventions the patient will be able : -claim to have the pain reduced from 6-3. -Identify negative factors affecting activity tolerance and eliminate or reduced their effects w/n possible. -report measurable increase in activity tolerance. -verbalized feelings. -claim to have good quality of rest and sleep.

-pain affects a clients actual and perceived ability to participate in plan of care. -to promote comfort.

-keep the client in a comfortable position. -evaluate client actual and perceived limitation of deficit in light of usual activities.

-provides comparative baseline and information about needed education regarding quality of life. -symptoms maybe result of/ or contributing to intolerance of activity. -to protect the client from injury.

-note client reports weakness, fatigue, pain, difficulty of accomplishing task or insomnia. -assist with activities and provide assistance with ambulation. -provide quite environment while acknowledging difficulty of situation for the client.

-helps minimize frustration and rechanneled energy.

Dependent: -administer mefenamic acid/ celoxib as ordered. Collaborative: -provide referrals to other disciplines such as to nutritionist regarding the diet of patient.

-to relieve pain.

-for the client to have knowledge of the foods that could boost her health and what not to eat.

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V CUES: NURSING DIAGNOSIS: -Incision site. RISK for infection related to insufficient knowledge to avoid exposure to pathogens.

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 OBJECTIVES: General Objectives: To promote safety through prevention of accidents, injury, or other trauma and through the prevention of the spread of infection. Specific Objectives: After 1 hour of nursing intervention the patient will: -verbalize understanding of individual causative, risk factors. -indentify interventions to prevent risk of infection. -achieve timely wound healing, be free of purulent drainage pr erythema, and be afebrile. NURSING INTERVENTION: Independent: -note risk factors for occurrence of infection. -observed for localized signs of infection, insertion lines, surgical incisions/wounds. -note signs and symptoms of sepsis, fever, chills, diaphoresis, altered LOC. -uses proper hygiene by all care givers between therapies/clients. RATIONALE: EVALUATION: Goals were partially met as evidenced by: -client verbalized understanding of individual risk factors. -identified intervention to reduce risk of infection. -demonstrated techniques, lifestyle changes, to promote safe environment. -achieve timely wound healing, be free of purulent drainage or erythema, be a febrile.

-to assess causative factors. -to assess contributing factors.

-these are signs of infection.

-a first line defense against health care associated with infection. -to prevent the spread of infections.

-maintain sterile techniques for all invasive procedures. -recommend routine body shower/scrubs when indicated. -change surgical/other wound dressing, as indicated, using proper technique for changing/disposing of contaminated materials.

-to reduce bacterial colonization.

-to maintain medical aseptic technique and reduce contamination.

-lower perineal/ pelvic region dressings when using bedpan. -encourage early ambulation and position changes. -provide regular perineal care.

-to prevent contamination.

-to promote faster recovery.

-reduces risk of ascending urinary track infection. -to promote wellness.

-review individual nutritional needs, appropriate excersise program and need for rest. -instruct the client in techniques to protect the integrity of skin. -include information in preoperative teaching about ways to reduce potential for post operative infection. Dependent: -emphasize necessity of taking antivirals/antibiotics as directed.

-to prevent the spread of infection.

-to promote wellness.

-premature discontinuation of treatment when client begins to feel well may result in return of infection and potentiate resistant straine.

-discuss importance of not taking anti biotics/using left over drug unless specifically instructed by health care provider.

-in appropriate use can lead to development of drug resistant straines/ secondary infection.

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V DRUG NAME: CLASSIFICATION/ ACTION: Generic Name: Tramadol/ Classification: Hydrochloride -analgesic Brand name: -Tramal

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 DOSAGE/ROUTE FREQUENCY/TIMING: Dosage: -50mg INDICATIONS/ CONTRAINDICATIONS: Indications: -for the mngt. Of moderate-moderately severe pain in adult. Contraindication: -should not be administered to patients who have previously demonstrated hypersensitivity to tramadol, any other components of this products or opiods. -contraindicated in any situation where opiods are contraindicated, including acute intoxication with any of the ff: alcohol, hypnotics, narcotics centrally acting analgesics, opiods or psychotropic drugs. -tramadol may worsen CNS and respiratory depressions in these patients. SIDE EFFECTS/ ADVERSED REACTIONS: Side effects: dizzeness/vertigo, Nausea, constipation, headache, somnolence, vomiting, pruritus, sweating, dyspepsia, dry mouth, asthemia. Adversed reactions: -CNS stimulation A composite of nervousness, anxiety, agitation, tremor, spacticity, euphoria, emotional lability and hallucinations. NURSING RESPONSIBILITIES: -observed 10 rights in giving medications. -monitor v/s. -evaluate pain by using pain scale. -assess for any history of drug addiction, allergies or seizures.

Action: -a centrally acting analgesic not related chemically to opiates. Management of moderate to moderately severe pain.

Route: -IV

Frequency: -every 8hours

Timing: 8am,4pm,12mn,8am

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V DRUG NAME: CLASSIFICATION/ ACTION: Generic name: -Metoclopramide Classification: -gastrointestinal Brand name: -hepatobiliary drugs -Plasil -antiemetic Actions: Inhibits gastric smooth muscle relaxation produced by dopamine, therefore increasing cholinergic response of the gastro intestinal smooth muscle. It accelerates intestinal cransit and gastric emptying by preventing relaxation of gastric body increasing the phasic activity of antrum.

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 DOSAGE/ROUTE/ FREQUENCY/TIMI NG: INDICATION/ CONTRAINDICATION: Indication: -for treatment of gastroesophageal reflux dse. Contraindications: -should not be used whenever stimulation of gastrointestinal motility might be dangerous. -contraindicated in patients with phlochromocyloma because the drug may cause a hypertensive crisis. -should not be used in epileptic patients receiving other drugs which are likely to cause extrapyramidal reactions, since the frequency and severity of seizures or extrapyramidal reactions may be increased. -contraindicated in pt. with known sensitivity or intolerance to the drug. SIDE EFFECTS/ ADVERSED REACTIONS: Side effects: -extrapyramidal reactions, drowsiness, fatigue and lassitude anxiety. Less frequently, insomnia, headache, dizzeness, nausea, galactorrhea, gynecomastia, bowel disturbances. Adversed reactions: -restlessness, sedation, lassitude, fatigue,diarrhea, insomnia, dystonic reactions, and bowel upsets. -somnolence, Parkinson, nervousness and menstrual disorder. NURSING RESPONSIBILITIES: -observed 10 rights in giving medications. -frequently monitor BP of pt. In taking IV form of drug. -assess pt. GI complaints, nausea, vomiting, anorexia, constipation, abdominal distention before and after administration. -check for rashes or allergies.

Dosage: -10mg

Route: -IV

Frequency: -every 8 hours

Timing: -8am, 4pm, 12mn, 8am

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V DRUG NAME: CLASSIFICATION/ DOSAGE/ ACTION: ROUTE/ Generic name: FREQUENCY/ -Azithromycin Classification: TIMING: -Macrolide Dosage: Antibiotic -500mg/tab Brand name: -Zithromax Action: Route: -Bacteriostatic -Oral or bactericidal in susceptible Frequency: bacteria. -O.D Timing: -8am

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 INDICATION/ CONTRAINDICATION: Indication: -treatment of lower respiratory infection. Acute bacterial exarcebations COPD due to haemophilus influenza , moraxella catarrbalis, streptococcus pneumoniae due to s-pnumoniae, himfluenzae. SIDE EFFECTS/ ADVERSE REACTIONS: Side effects -stomach cramping discomfort diahrrea, fatigue, headache. Adverse reaction CNS: -dizziness, headache, vertigo, somnolence, fatigue. GI: -diarrhea, abdominal pain, nausea, dyspepsia, flatulence, vomiting, melena, pseudomembranus, colitis. Others: -supper infections, angioedema, rash, photosensitivity,vaginitis. NURSING RESPONSIBILITIES: -monitor vital signs regularly. -assess for hypersensitivity reaction to take this drug. -take this medication with full stomach to prevent nausea and vomiting. -do not take this with antacids.

Contraindication; -contraindicvated with hypersensitivity to azithromycine or any macrolide antibiotics.

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V DRUG NAME: CLASSIFICATION/ DOSAGE/ ROUTE/ ACTION FREQUENCY/TIMING: Generic name: Ranitidine Classification: Dosage: -Histamine H2 50mg receptor antagonist Brand name: -antiulcerative Zantac Route: -IV Action: -inhibits histamine action at H2 Frequency: receptors of -every 8 hours parietal cells. Inhibiting basal and nocturnal gastric Timing: acid secretion. -8am, 4pm, 12mn, 8am

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 INDICATION/ CONTRAINDICATION For active duodenal ulcer, pathologic hypersecretory conditions, benign gastric ulcer, erosive esophagitis, H pyloric duodenal ulcer. Contraindication: -No significant Adversed reactions: -reversible hepatitis, blood dyscrasias occur rarely. SIDEEFFECTS/ ADVERSED REACTIONS: Side effects: -occasional 2% diarrhea -rare 1% constipation -headache(may be severe) NURSING RESPONSIBILITIES: -Observe 10 rights in giving medications. -Take drug of meals at bedtime. -Have medical regular check-up to evaluate your responses -You may experience these side effects: Constipation/diarrhea (request aid from the health care provider) -Nausea and Vomiting (take drug with meal) -Enlargement of the breast, impotence, or decrease libido(reversible ) - Headache (adjust lights and temperature and avoid noise)

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Name: L.R Age: 40 y.o Address: Cerrudo, Banga, Aklan Attending Physician: Dr. G.V DRUG NAME: CLASSIFICATION: DOSAGE/ ROUTE/ FREQUENCY/TIMING: Generic name: Classification: -Cefuroxime -Antibiotic Dosage: -Cephalosporin -750mg nd (2 gen) Brand name: -Zinacef Action: Bactericidal; inhibits synthesis of bacterial cell wall causing cell death. Route: -IVTT

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 INDICATION/ CONTRAINDICATION: Indication: -pharynitis, tonsillitis caused by streptococcus pyogenes. -Otitis media caused by pneumonia,s. pyogenes,haemophilus influenzae. -Lower respiratory infection caused by s. pneumonae,haemophilos, para influenza. -UTI -Skin and skin structure infection. Contraindication: -With allergy to cephalosporin or penicillins. SIDE EFFECTS/ ADVERSED REACTION: Adversed reactions: GI-nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence, pseudo membraneous colitis. Hyper sensitivity: Ranging from rash to fever to anaphylaxis local, pain, phlebitis. NURSING RESPONSIBILITIES: -Monitor v/s every hour -assest for any side effects will occur: stomach upset or diarrhea. -Report severe diarrhea with blood pus, mucus, rash, difficulty of of breathing, unusual tiredness, fatigue, unusual bleeding or bruishing, unusual itching, irritation.

Frequency: -every 8 hours

Timing: -8am, 4pm, 12mn, 8am

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Name: L.R Age: 40 y.o Address:Cerrudo, Banga, Aklan Attending Physician: Dr. G.V DRUG NAME: CLASSIFICATION/ ACTION: Generic name: Parecoxib Classification: Parecoxib Na Brand name: Dynastat

Diagnosis: CS Cc: Term pregnancy Date: June 24, 2011 DOSAGE/ROUTE/ FREQUENCY/ TIMING: Dosage: -40mg INDICATION/ CONTRAINDICATION: Indication: -Dynastat is used to help relieve any pain or swelling you may experience as the result of an operation. SIDE EFFECTS/ ADVERSED REACTION: Side effects: -Peptic ulcer (ie stomach or duodenal ulcer), a recent history of one, or have had peptic ulcers before. -changes in blood pressure -dizziness or lightheadedness due to low blood pressure -back pain -a reduced sense of touch -stomach upset including nausea (feeling sick), vomiting, heartburn, indigestion, cramps -constipation, diarrhoea, pain in the stomach, wind -sleeplessness -irritability -sore throat -inflammation and pain after a tooth extraction -skin rash, including hives, raised red, itchy spots Adversed reaction: Rash, ulcerations or any other signs of an allergic reaction; GI disturbances and bleeding; NURSING RESPONSIBILITIES: -observe the 10 rights of medication administration. - assess the patient if she has allergies from aspirin or other NSAID medicines including coxib medicine. - ask the patient to eat full stomach before giving the medication. - ask the patient if she is breast feeding, if she is, advise the patient to discontinue breast feeding during the treatment. -teach the patient the side effects and adverse effects of the medication. - advise the patient to report immediately if there is any side effects or adverse effect that is observed.

Action: Parecoxib is the prodrug of valdecoxib. It has a very high selectivity for inhibiting cyclooxygenase-2 (COX-2) mediated prostaglandin synthesis to reduce mediators of pain and inflammation. The selective inhibition of COX-2 is coupled with reduced GI toxicity, but associated increased risk for thrombotic events and renal impairment have been noted.

Route: -IV

Frequency: -every 8 hours

Timing: -8am, 4pm,12mn, 8am

Contraindication: -Aspirin or NSAID hypersensitivity; allergy to sulphonamides; inflammatory bowel disease; moderate to severe heart failure; ischaemic heart disease, peripheral arterial disease, or cerebrovascular disease; following CABG; active peptic ulceration; severe hepatic impairment (Child-Pugh score 10); pregnancy (3rd trimester) and lactation.

hypotension; hypertension; back pain; edema; numbness; agitation or sleeping difficulties; anaemia; sore throat or difficulty breathing; pruritus; decreased urine output; jaundice, abnormal liver function; low platelet count; skin swelling, blistering or peeling; kidney failure; heart failure, heart attack, bradycardia, arrhythmia.

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HEALTH TEACHINGS FOR THE MOTHER

TEACHINGS Teach the mother to avoid strenuous activity and have adequate rest and sleep. Teach the mother to take her medicines that are prescribed by her doctor. RATIONALE To regain her strength.

For effective and therapeutic medication management and to facilitate wound healing. To ensure that her health is in good condition. To prevent infection and fast wound healing. To prevent dehiscence of the wound again.

Teach the mother to have follow-up to her ob-gyne doctor after one week. Teach the mother to reinforce in aseptic technique of wound care. Teach the mother to apply gentle pressure of the incision site by using pillow or binder when coughing or sneezing. Teach the mother to pursed lip deep breathing techniques.

To promote relaxation of the muscles and for non-pharmacologic way of pain management. Fruits that rich in vitamin C can help fast healing of the wound. It helps the wound dry fast and healing of the wound.

Advise the mother to eat fruits that rich in vitamin C. Advise the mother to use fresh guava leaves, boiled, and when it is warm she may use it for washing the wound.

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HEALTH TEACHINGS FOR THE BABY

TEACHINGS Care of the umbilical cord of the baby. RATIONALE To prevent infection of the umbilical cord of the baby. For the sake of the baby not to suck the dirt from the nipple of her mother. For the babys benefit to suck milk well and comfortable. To avoid aspiration for the baby.

Teach the mother to clean her nipple and areola before breast feed. Teach her mother to let her baby suck her nipple and areola when breast feeding. Teach the mother to let her baby to burp after breast feeding. Teach her mother to bring her baby in the rural health center every time the babys due time/month for immunization. Teach the mother to expose her baby to sunlight at around 7-9 in the morning.

For the baby to complete his/her immunization. Morning sunlight helps the absorption of calcium comes from the milk that he/she sucks in his/her mothers breast.

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PROGNOSIS
Mrs. L.R our client was admitted last June 24, 2011 at SGH 3rd Floor Wing A Room 307 due to her scheduled Caesarean Section (Elective) that was scheduled by her OB-gyne Doctor Dr. G. Villaruel last June 25, 2011 a day after her admission. She had been hospitalized for 6 days and was able to recover fast. After her C-section and Bilateral Tubal Ligation, she was able to respond well on her day to day treatment and cooperate in the intervention that was rendered to her most especially with regards on the pain management and incision/ wound care management. She was discharged on June 30, 2011 at 2:30 in the afternoon. Her prognosis was very good, since this is her second C-section and her family has the knowledge on how she will be taken cared when she goes home. We made sure that there will be a continuity of care when she goes home by reinforcing her knowledge through health teachings for her and her new born in order to prevent unwanted post-op complications like infection, sepsis, and tetanus.

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CONCLUSION
We the BSN-III B assigned at SGC 3 Wing A concluded that we are able to obtain knowledge about pain assessment whereas assessing pain we consider the vital signs literacy pain experience, emotion, spiritual, social discomfort, socio-cultural belief, age, presence of others, pain expectancy, pain acceptance and pain apprehension. Using nursing process and therapeutic communication we are able to establish rapport and trust with patient and her family and gain their cooperation. Furthermore we are able to improve our verbal and written communication and enhance our skills in vital signs taking, admission of patient, carrying our doctors order and taking care of our patient as a whole. As a group each as exerted effort to know and adjust to other that promotes teamwork and camaraderie. We work hand and hand, cooperate and help each other. In spite of being busy completing our requirement such as; doing drug study, nursing care plan, readings and lecture. Aside from handling and monitoring our patient that are assigned in our care this experience helps as realize our passion in taking good care of our patient. To sum up with it was very good and satisfying experience for us as a novice student in exposure in hospital setting. As a student nurse we develop our eagerness to learn more knowledge, skills and right attitude concerning patient centered care that we could make use and apply that would mold as to be a competent nurses someday.

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REFERENCE
Family R. N103 PAIN AND SURGERY Prepared by Mr. Elizalde M. Baldueza RN, MAN Handbook of nursing diagnosis 12th edition by. Lynda Juall Carpenito Moyet, RN, MSN, CRNP (LIPPINCOTTS) Nursing drug guide 2010 by Amy M. Karch MIMS 126-K edition 2010 MEDICAL SURICAL NURSING concepts and clinical application second edition 2009 by: Josie Quiambao Udan, RN, MAN

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SAINT GABRIEL COLLEGE

OLD BUSWANG KALIBO, AKLAN

In Partial Fulfillment of Requirements In Related Learning Experience NCM 103 CONCEPT: PAIN AND SURGERY

Presented by:

Nino Isberto John Patrick Indulo Ricah Rianna Iquia Janssen Importado Dranreb Alexis Inac Hanna May Martin Frederick Inolino Mary Rose Enejosa (BSN III-B Group 6)

Mrs. Necita A. Ebesate __________________________ Clinical Instructor 1st Shifting SGH 3rd Floor Wing-A (7-3 Shift)

June 20 July 16, 2011 _________________ (Date of exposure)

NURSING CARE PLAN

DRUG STUDY