Appendix B NURSING CARE PLAN

Name : Laurel, Cleo M. Date of Admission : January 30, 2018 ()

Room Number : Gyne 3
Age : 38 years old
Hospital Number : 000000000040740
Attending Physician :
Impression : Student Nurse’s Name : Darnley Lovielyn C. Latoja
Signature :
Diagnosis :
Assessment: In the case of Laurel, Cleo M., 38 years old, woman, Chief Complaint: Heavy vaginal bleeding
lying flat on bed, awake, and afebrile, had heavy vaginal
bleeding. History of Present Illness:

On the night of January 29, 2018, patient had her menstruation

then on the dawn of January 30, 2018, the patient notice that she
Significant Findings has already heavy vaginal bleeding and recognized it as fresh
blood. She felt cold on her extremities then lost her
consciousness. She was admitted at Eversley Childs Sanitarium (
Hematology Section: Urinalysis: )

Hemoglobin 6.29 g/dL Protein (+) Past Health History Relevant to Present Illness:

Hematocrit 26.9 % RBC (numerous) G3 T3 P0 A1 L2

V/S During Admission:

BP: 80/50 mmHg T: 34.2°C P: 82 bpm R: 19cpm

Diagnosis Procedure Done:

 Urinalysis and CBC

 Urinalysis
Macroscopic Result Microscopic Result
Color Yellow RBC numerous
Appearance Cloudy WBC 3–5
PH 5.0 Epithelial cells Few
Specific Gravity 1.020 Amorphous material Few
Protein Trace
Glucose Neg ( - ) Bacteria moderate

 Blood Typing
Blood Type “B+”
RH Pos ( + )

Remarks:
HgSAg non-reactive
 Cues/ Nursing Scientific Basis Outcome Nursing Rationale Evaluation
Evidences Diagnosis Criteria Intervention
Subjective Deficient After 6-8 hours - Assess vital - These changes in After 6-hours of
“Kusog kaayo fluid of nursing signs, noting low vital signs are nursing
ang akong volume r/t intervention, the blood pressure – associated with intervention, the
pagdugo nya active fluid patient will be severe fluid volume loss patient is able to:
mura na syag loss as able to: hypotension, and/ or
fresh blood, di evidenced rapid heartbeat, hypovolemia. - Patient
pareha anang by excessive - Maintain fluid and thready established the
sa normal vaginal volume at peripheral pulses. following vital
menstruation,” bleeding functional level signs:
as verbalized as evidenced by - Note changes in - These signsT
by the patient. stable vital usual mentation, indicate sufficient P
signs. behaviour, and dehydration toR
Objective: functional cause poor cerebral BP
Vital Signs - Verbalize abilities such as perfusion or can
T understanding confusion, falling, reflect the effect of - Verbalize
P of causative and dizziness. electrolyte understanding of
R factors and imbalance. causative factors
BP purpose of and purpose of
individual - Note complaints - These signs individual
therapeutic and physical signs indicate sufficient therapeutic
interventions associated with dehydration. interventions and
and dehydration such medications.
medications. as lack of
sweating, GOAL
dizziness, and PARTIALLY
confusion. MET

- Review - To evaluate the

laboratory data body’s response to
such as bleeding or other
hemoglobin fluid loss to
[Hb]/Hct, determine
prothrombin time, replacement needs.
activate partial
thromboplastin
time [aPPT];
glucose; blood
urea nitrogen
[BUN], and
creatinine [Cr].

- Keep fluids - To promote

within client’s hydration.
reach and
encourage
frequent intake,
as appropriate.

- Monitor vital - To assess sudden

signs. changes in vital
signs.

- Discuss signs or - This promotes

symptoms timely
indicating need intervention.
for emergent or
further evaluation
and follow-up.
 Cues/ Nursing Scientific Basis Outcome Nursing Rationale Evaluation
Evidences Diagnosis Criteria Intervention
Subjective Anxiety r/t After 6-8 hours - Monitor vital - To identify After 6-8 hours
“Naguol ko sudden of nursing signs. physical responses of nursing
kay nikalit Blood intervention, the associated with intervention, the
lang ug taas Pressure patient will be both medical and patient is able
akong BP elevation able to: emotional to:
paghuman ug conditions.
Blood - Appear - Appear relaxed
Transfusion,” relaxed and - Review coping - To determine and verbalized,
as verbalized report that skills used in the those that might be “Di na ko ni
by the patient. anxiety is past. helpful in current hunahuna-on pa
reduced to a circumstances. kay salig ko na
Objective manageable ma okay rako.”
Vital Signs level. - Establish a - To establish
T therapeutic rapport with the - Demonstrated
P - Demonstrate relationship, patient. problem solving
R problem solving conveying skills such as
BP skills. empathy and talking with
unconditional others, which is
Crying - Use resources/ positive regard. her way of
support systems coping with
effectively. - Be available to - To let the patient anxiety,
the client for express her according to her.
listening and feelings with
talking. regards to her - Talk with her
current situation. SO regarding her
current condition
- Encourage client - To let the patient and expressed
to acknowledge express her reduction of
and to express feelings with anxiety.
feelings such as regards to her
crying. current situation. GOAL MET.

- Accept the - The client may

client as is. need to be where
he or she is at this
point in time.

- Educate the SO - The SO is the

to be with the client’s support
patient at all system.
times.
 Cues/ Nursing Scientific Basis Outcome Nursing Rationale Evaluation
Evidences Diagnosis Criteria Intervention
Subjective Risk for After 6-8 hours - Note the client’s - These affect the After 6-8 hours
“Malipong ko injury of nursing age, gender, client’s ability to of nursing
usahay tungod intervention, the developmental protect self and/or intervention, the
atong kusog patient will be stage, decision- others, and patient is able
na pagdugo,” able to: making ability, influence choice of to:
as verbalized and level of interventions and
by the patient. - Verbalize cognition/ teaching. - Verbalize
understanding competence. understanding of
Objective of individual individual
Vital Signs factors that - Assess client’s - To identify risk factors that
T contribute to muscle strength for falls. contribute to
P possible injury. and gross and fine possible injury
R motor such as dizziness
BP - Demonstrate coordination. or weakness.
behaviours,
lifestyle - Instruct the - To avoid - Demonstrate
changes to client/ SO to potential injury. behaviours,
reduce risk request lifestyle changes
factors and assistance, as to reduce risk
protect self needed. factors and
from injury. protect self from
- Raise the side - To provide safety injury such as
- Modify rails when patient and security. use of
environment as is in bed. wheelchairs and
indicated to support system.
enhance safety. - Place assistive - To provide client
devices such as means of safety - Modify
wheelchairs. transportation. environment as
indicated to
- Provide - To provide enhance safety.
information information to the
regarding client or SO.
conditions that
may result in
increased risk of
injury such as
weakness and
dizziness.
 UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUE
COLLEGE OF NURSING

DRUG STUDY

Patient: C. M. L. Age: 38 years old Hospital No.: 000000000040740 Room No.: Gyne 3

Impression/ Diagnosis: Dysfunctional Uterine Bleeding

Allergy to: None

Generic/ Brand Dose, Indication/

Adverse/ Side Effects Nursing
Name & Strength & Mechanisms of Drug Rationale Client Teaching
Drug Interaction Responsibilities
Classification Formulation Action

Generic: Ordered: Indication: CNS: dizziness, - Discontinue oral - To avoid - Encourage

Ferrous sulfate Treatment and headache, syncope iron preparations drug-drug patient to
prevention of iron prior to parenteral implications. comply with
Timing: deficiency anemia. GI: nausea, administration. medication
Brand: constipation, dark regimen.
Hemarate Mechanism of Action: stools, epigastric - Let patient take - Absorption is
Duration: An essential mineral pain, GI bleeding, drug 1 hour before most effective - Advise patient
found in hemoglobin, vomiting or 2 hours after in an empty that stools may
Classification: myoglobin, and many meal. stomach. become dark
Antianemics, Other Forms: enzymes. Enters the Misc.: temporary green or black.
iron bloodstream and is staining of teeth - Avoid using - This ceases
supplements transported to the (liquid preparations) antacids, coffee, the absorption - Instruct
organs of the tea, dairy products, of the drug. patient to
reticuloendothelial eggs, or whole- follow a diet
system. grain breads. high in iron.
 UNIVERSITY OF CEBU LAPU-LAPU AND MANDAUE
COLLEGE OF NURSING

DRUG STUDY

Patient: C. M. L. Age: 38 years old Hospital No.: 000000000040740 Room No.: Gyne 3

Impression/ Diagnosis: Dysfunctional Uterine Bleeding

Allergy to: None

Generic/ Brand Dose, Indication/

Adverse/ Side Effects Nursing
Name & Strength & Mechanisms of Drug Rationale Client Teaching
Drug Interaction Responsibilities
Classification Formulation Action

Generic: Ordered: Indication: CNS: dizziness, - Assess BP and - To be able to - Emphasize the
Losartan Alone or with other fatigue, headache, pulse frequently determine if importance of
agents in the insomnia, weakness during initial dose there are continuing to
Timing: management of adjustment and changes in take as directed,
Brand: hypertension. CV: chest pain, periodically during patient’s BP. even if feeling
Cozaar edema, hypotension therapy. well.
Duration: Mechanism of Action:
Blocks the EENT: nasal - Monitor - To determine - Take missed
vasoconstrictor and congestion frequency of compliance. doses as soon as
Classification: Other Forms: aldosterone- secreting refills. remembered if
Anti- effects of a angiotensin Endo: not almost time
hypertensive, II at various receptor hypoglycaemia, for next dose;
angiotensin II sites, including weight gain do not double
receptor vascular smooth dose.
antagonist muscle and the adrenal GI: diarrhea,
glands. abdominal pain, - Caution
dyspepsia, nausea patient to avoid
salt substitutes
GU: impaired renal containing
function potassium or
foods
F and E:hyperkalemia containing high
levels of
MS: back pain, potassium or
myalgia sodium unless
directed by
Misc.: angioedema, health care
fever professional.

- Warn patient
that drug may
cause dizziness.

- Instruct
patient to notify
health care
professional if
swelling of
face, eyes, lips,
or tongue or if
difficulty
swallowing or
breathing occur.

- Emphasize the
importance of
follow-up
exams to
evaluate
effectiveness of
medication.
Appendix E (IVF Study)

Type of How to Dosage and Nursing

Classification Components Indication Contraindication
Solution Supply Frequency Responsibility
 GENOGRAM

MATERNAL PATERNAL

C.B. S.B. A.M. B.M.

F.B. C.B. C.B. L.B. A.M. A.M L.C. A.M.

..

LEGENDS
MALE
B.M. C.A. A.M.
FEMALE C.M.L.

PATIENT

DECEASED

ASTHMATIC

HYPERTENSIVE

LIVER
CANCER