Liceo de Cagyaan University

R.N. Pealez Blvd., Kauswagan Cagayan de Oro City College of Nursing

DR CARE STUDY
In Partial Fulfillment of the course Requirements In NCM501203: Related Learning Experience Submitted by: Baran, Jayzel G. Emong, Reyner Wayne Galanza, Lorelyn T. Piquero, Maria Seiko O. Taganas, Jessah V. Group D2 sub group 2

Submitted to: Mr. Raul D. Valenzuela, RN Clinical Instructor

Introduction Pregnancy is defined as a gestational process of growth and development of a new individual within a woman. It begins with a process called fertilization. By which out of millions of sperm cells ejaculated by a man only one has the chance to fertilize a females egg cell. Pregnancy is an integral component of human reproduction. For approximately 40 weeks, the still developing human being survives the fragile environment of the uterus. The growth of the fetus requires utmost care on the part of the mother. Any physical and emotional disturbance that affects the mother can have a great impact in intrauterine development. Intrauterine development, therefore, is a dependent process. Anything that affects the mother may adversely affect the development of the fetus. In a country where fertility rate is higher compared to developed countries, it is expected that the government cannot afford to deliver quality health services to majority of its people who cannot pay for private health care. This is reflected in the policies of state-run health care institutions. Mothers expected to deliver NSVD are confined to birthing homes and those with complications are encouraged to deliver in the hospitals. This strategy aims to manage the use of resources and to curb down mortality rates. People are left with few options to choose from. With this problem in mind, it is the duty of the nurse to be flexible at all times. In order to suit clients needs, the nurse has to master the concepts of maternal and child health care so that by the hive problems arise, the best solution is always chosen. As future nurses, it is the responsibility of the proponents to acquaint themselves in this field of nursing practice in order to function competently. In order to suit clients needs, the nurse has to master the concepts of maternal and child health care so that by the hive problems arise, the best solution is always chosen. This study includes the patients profile, an overview of the three periods, Nursing Care Management, Health Teaching, and Referrals. Although this study cannot be considered comprehensive, it is still a reflection of the clients health focused on reproductive wellness.

II. Patients Profile

Name Address Sex Age Birthday Religion Height Weight Civil Status Admitting Diagnosis Initial Assessment: Gravida 2, Para 2, Term 2, Premature 0, Abortion 0, Living 2 Temperature Pulse Rate Respiratory Rate Blood Pressure Fetal Heart Beat Last Menstrual Period Estimated Date of Confinement : : : : : : : 36.8rC 91 bpm 19 cpm 120/80mmHg 135 bpm April 5, 2010 January 12, 2011 : Mrs. B : Malaybalay City Bukidnon : Female : 25 years old : June 13, 1974 : Roman Catholic : 53 : 51kgs : Single : PUFT on Labor Pains, G2P2

III. Stages of Labor/Physiology of Labor

Labor is a series of events by which uterine contractions and abdominal pressure expel a fetus and placenta from a pregnant woman. During pregnancy, the uterus consists of a large number of greatly hypertrophied smooth cells. Each cell is activated by a series of chemical reaction to begin regular contractions in a highly coordinated manner and with such force that the cervix is dilated and the expulsion of the baby and placenta occur. Several mechanisms are involved in initiating and maintaining the labor. However the precise trigger of labor is unknown.

1. First Stage (Dilatation stage) From the onset of first contraction through labor contractions to full cervical dilatation. This stage averages about thirteen hours for a primipara and about eight hours for multipara. It composed of 3 Phases: Latent Phase , Active Phase and Transition Phase. 2. Second Stage (Delivery stage) The period from fully dilated cervix to the delivery or expulsion of the baby 3. Third Stage (Placental stage) Begins in the delivery of the placenta 3 signs of placental expulsion: 1. Calkins sign 2. Sudden gush of the blood 3. Lengthening of the cord 4. Fourth Stage (Recovery stage) The First 1 to 4 hours after birth of the placenta.

A. THEORIES OF LABOR

1. Low Progesterone Theory / Progesterone Deprivation

When progesterone (uterine muscle relaxant) decrease in late pregnancy with corresponding increase in estrogen (uterine muscle stimulant), labor starts. 2. Oxytocin Theory The pressure of the fetal head on the cervix in late pregnancy stimulates the posterior pituitary gland to secrete oxytocin which causes uterine contractions. 3. Estrogenic, Fetal Hormone and Prostaglandin Theory All these have stimulating effect on uterine musculature causing uterine motility. 4. Theory of the Aging Placenta As the pressure matures, more and more pressure is exerted on the fundal portion, the usual placental site and the most contractile portion of the uterus. It is believed that the resultant diminished blood supply to the area causes contraction. 5. Uterine Stretch Theory The most acceptable theory. As the uterine muscles get stretched with fetal growth and increasing amniotic fluid, irritability and contraction to empty the contents of the uterus are likely results. B. Components of Labor 1. Passageway refers to the adequacy of the womans pelvis and birth canal in allowing fetal descent. 2. Passenger refers to the fetus and its ability to move through the passageway. 3. Powers refers to frequency, duration and strength of uterine contractions to cause complete cervical effacement and dilatation. 4. Person refers to the pregnant womens general behavior and influences upon her influences labor progress.

Mechanisms of Labor 1. Engagement Refers to the setting of the presenting part of the fetus far enough into the pelvis to be at the level of the ischial spine, a midpoint of the pelvis. 2. Descent Is the downward movement of the biparietal diameter of the fetal head to within the pelvic inlet. Full descent occurs when the fetal head extrude beyond the dilated cervix and touches the posterior vaginal floor. The pressure of the fetus on the sacral nerves causes the mother to experience a pushing sensation. Descent occurs because of the pressure on the fetus by the uterine fundus. 3. Flexion As descent occurs, pressure form the pelvic floor causes the fetal head to bend forward onto the chest. The smaller anteropostreior diameter (the suboccipitobregmatic diameter) is the one presented to the birth canal in this flexed position. Flexion is aided by abdominal muscle contraction during pushing. 4. Internal Rotation During descent, the head enters the pelvis with the fetal anteroposterior head diameter in a diagonal or transverse position the head flexes as it touches the pelvic floor, and the occiput rotates until it is superior, or just below the symphysis pubis, bringing the head into the best diameter for the outlet of the pelvis. 5. Extension As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a pivot for the rest of the head. The head thus extend, and the foremost parts of the head, the face, and the chin, are born. 6. External Rotation In external rotation, almost immediately after the head of the infant is born, the head rotates back to the diagonal or transverse position of the early part of labor. The

after coming shoulders are thus brought into anteroposterior position, which is best for entering the outlet. The anterior shoulder is born first, assisted perhaps by downward flexion of infants head. 7. Expulsion Once the shoulders are born, the rest of the baby is born easily and smoothly because of its smaller size. This is expulsion and is the end of the pelvic division of labor. True Labor versus False Labor

False Contractions 1. Began and remain irregular 2. First abdominally and remain confined to the abdomen and groin 3. Often disappear with ambulation and sleep 4. Do not increase in duration, frequency or intensity 5. Do not achieve cervical dilatation

True Contractions 1. Begin irregularly but become regular and predictable 2. Felt first in lower back and sweep around to the abdomen in a wave 3.Continue no matter what woman s level of activity 4. Increase in duration, frequency and intensity 5. Achieve cervical dilatation

IV. Ideal Nursing Care Plan for the mother Name of patient: Irish Balacuit

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective: ``Sakit akong

Acute kaayo related

pain At the end of 30 1. Reposition as indicated 1. May relieve pain and After to minutes of nursing e.g., semi-fowlers. interventions, to patients pain will 2. Provide additional be lessened from a comfort measures, e.g., pain scale of 8 to 6. back rub heat/cold applications. 2. Improves enhance circulation. minutes nursing

30 of

tahi,``

as episiotomy

verbalized by the secondary patient. childbirth

circulation, interventions, tension patients pain

reduces and

muscle

anxiety

associated was

lessened

Objective: Facial grimace Pain of 8/10 Presence of episiotomy scale

with pain. Enhances sense from 8 to 6. of well being.

3. Encourage use of relaxation techniques e.g., deep breathing exercises, guided imagery.

3. Relieves muscle and emotional tension;

enhances sense of control and may improve coping abilities.

4. Respond immediately to complaints of pain.

4. In the midst of painful experiences, patients may

perception of time

become distorted. Prompt responses to decreased patient. complaints anxiety in

Dependent: 1. Administer Mefenamic acid 500mg 1 cap PRN as ordered by the physician. 1. It has an anti-

inflammatory and analgesic effect that could relieve pain and decrease of the nervous

stimulation sympathetic system.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective:

Risk

for At the end of 1 hour 1. Monitor vital sign nursing especially Temperature. 2. Encourage intake of

1. To indicate present of After 1 hour of infection nursing

daghan-daghan infection related of pa akong sa dugo, to

postpartum interventions,

2. This maintain optimal intervention, nutritional status patient was

gikan

pag wound. as

patient will be able protein and calorie rich to prevent from foods 3.Wash hands and teach other care giver to wash hands, before contact

panganak

able to prevent 3. To remove getting from the infection. an

verbalized by the patient.

getting an infection.

microorganism hands.

Objective:  Postpart um wound  weak

with patient and between procedures with the patient 4. Maintain or teach asepsis for dressing 4. Use of aseptic

technique decreases the

changes and wound care. chances of transmitting or spreading pathogens to the patient Dependent: 1. Administer Co1. A combination of a

amoxiclav 500mg 1 tab BID as ordered by the physician.

penicillin and a substance called clavulanic acid. It kills bacteria by interfering their ability to form cell walls. The bacteria

therefore breakdown and die.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective:

Activity

At the end of 1 hour 1. Assess patient's ability nursing to interventions, to perform normal tasks/ADLs, noting

1.

Influences

choice

of After 1 hour of nursing intervention, was able to

``Dili pa nako kaya intolerance maglihok-lihok kay related sakit akung tahi,`` generalized as verbalized by weakness the patient. secondary postpartum Objective: -Weakness -Body malaise wound

interventions/needed assistance.

patient will be able reports of weakness, to ambulate and fatigue and difficulty accomplishing tasks.

regain strength and ambulate.

to regain strength.

2. Assist patient to prioritize ADLs/desired activities. Alternate rest

2. Promotes adequate rest, maintains energy level, and alleviates strain on the

-Inability ambulate

to

periods with activity periods. Write out schedule for patient to refer to.

cardiac systems

and

respiratory

3. Recommend quiet atmosphere; bed rest if indicated.

3. Enhances rest to lower body's oxygen

requirements, and reduces strain on the heart and lungs.

4.Provide/recommend assistance with activities/ambulation as necessary, allowing patient to do as much as possible. 5. Note changes in balance/gait disturbance, muscle weakness.

4. Although help may be necessary, self esteem is enhanced when patient

does something for self.

5.

May

indicate changes with vitamin affecting

neurological associated b12

deficiency,

patient safety/risk of injury.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective:

Risk for imbalance At the end of 1 1. Provide oral

1. Prevents discomfort of After dry mouth and help to

hour

of

`` Wala koy gana nutrition: less than hour, the patient will hygiene on regular, mukaon kay luya body requirements be able to eat and frequent basis, pa akong lawas `` related to changes regain strength. as verbalized by in digestive including petroleum jelly for lips. 2. Encourage the patient to eat food with high calories and increase adequate fluid intake. 3. Explain the

nursing the

have desired in ingesting interventions, foods.

patient was able to eat and regain

the patient.

process/absorption of nutrients to

2. To provide nutrients strength. and give strength to

Objective: - restless -weak appearance in

secondary fatigue

patient.

3. This is to let the

importance of having patient realize that her a good nutrition. nutrition will have a great influence in taking care of her baby. 4. Encourage the patient to eat foods 4. This will make the patient eat since it is her

of her choice. 5. Provide a quiet environment, limit visitors as needed foods.

favorite 5. It promotes rest and relaxation, thus, will allow the patient to regain strength.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective:

Sleep

pattern At the end of 1 1. Encouraged the hour, the patient will patient to limit the

1. This will promote comfort at the same time rest and relaxation.

After

hour

of

`` lisod kog tulog disturbance kay palibot saba ``

nursing interventions, the

ang related to ambient be able to have visitors. as noise comfort and

patient was able to 2. To have comfort and help to promote sleep. eat

verbalized by the patient.

manage to rest and 2. Encourage to fall asleep. drink warm milk before bedtime.

Objective: - fatigue -weakness -noisy and crowded 3. Instruct to limit or provide linens to have comfort and promote sleep. 3. This is to let the patient realize that her nutrition will have a great influence in taking care of her baby.

4. Provide comfort such as back rubbing.

4.

This

will

enhance

relaxation thus, makes the patient fall asleep.

5. Instruct to limit fluid intake in evening.

5. To reduce the need for nighttime elimination.

Ideal Nursing Care Plan for the newborn Name: Baby boy Balacuit

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective: not applicable

Risk

for At the end of 1 hour 1. Monitor vital sign nursing especially Temperature. 2. Wash hands before

1. To indicate present of After 1 hour of infection nursing interventions, 2. To prevent transmission patient of microorganism. was

infection related of to

exposed interventions,

umbilical cord Objective:

patient will be able and after contact to the to prevent from patient. 3. Assess immunization status.

able to protect from getting an

getting an infection. fresh umbilical cord cut

3. Young age is prone in infection. getting an infection, thus, the baby is at higher risk.

4. Instruct mother to maintain asepsis for dressing changes and wound care. 5. Limit visitors.

4. Use of aseptic technique decreases the chances of transmitting or spreading pathogens to the patient. 5. To reduce number of microorganism in the

patient that is present in the environment.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

At the end of 1. To avoid aspiration 30 nursing intervention, 2. To avoid discomfort and aspiration 3. To mobilize secretions 4. It prevents secretions from obstructing airway patient able experience aspiration evidence was to no as by minutes

Subjective: not applicable

Risk aspiration related presence

for At the end of 30 minutes of nursing to interventions, of patient will be able to experience no as by

Objective: Abnormal breath sounds crackles

secretions

aspiration evidence noiseless respiration

1. Elevate head of bed at 30 degrees and infant propped on right side after feeding. 2. Breastfeed baby from time to time 3. Assist postural drainage 4. Suction secretions 5. Maintain proper position

5. To facilitate drainage of noiseless secretions respiration

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective: not applicable

Hypothermia

At the end of 30 1. Note underlying cause

1.

To

assess After minutes nursing

30 of

related to cold minutes of nursing (e.g., cold environment). environment interventions, the

causative/contributing factors 2. To prevent in

baby will be able to 2. Remove wet clothing. Objective: cool skin prevent from having Wrap in warm blankets, hypothermia. extra clothing, as appropriate. 3. Place knit cap on infants head.

further interventions, body baby was able to display core temperature

decrease temperature.

3. Prevent further decrease within in body temperature. range.

normal

4. Avoid use of heat lamps or hot water bottles.

4. Surface rewarming can result in rewarming shock due to surface vasodilation.

5. Measure core temperature.

5. To evaluate effects of hypothermia.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective: not applicable

Risk for Injury At the end of 1 hour 1. Maintain a safe related to the of nursing environment e.g. keeping the all necessary objects out be of babys reach.

1. To reduce accidental After 1 hour of injury to the baby. nursing interventions, the baby was 2. Indicator for need of provided care

weakness of the interventions, mother to baby will

Objective: -

provide care for provided care and 2. Ascertain knowledge safety mother. by

the baby is the baby. place in the bed

the of needs/injury prevention information, and motivation to prevent injury. with making

assistance and safety by positive the mother.

changes, thus, promoting safety and security.

3. Handle infant gently. Limit use/release restraints periodically. 4. Initiate safety

3. Skin /tissues are more fragile and at greater risk for damage. 4. Preventing injuries and

precautions as individually appropriate e.g. bed in low position, padded side rails, infection precautions, and medications in child proof. 5. Instruct the mother to place the baby nearer to her.

complications is a prime responsibility of parents

and care givers.

5. This is to guard the baby from any falls.

CUES

NURSING DIAGNOSIS

OBJECTIVES

INTERVENTIONS INDEPENDENT:

RATIONALE

EVALUATION

Subjective: not applicable

Risk imbalance Nutrition: than

for At the end of 2 1. Identify the infants risk hours of nursing for malnutrition. the 2. Determine whether

1. Provide opportunity for After 2 hours of timely intervention. 2. nursing

less interventions,

Providing usual and interventions, feedings to infant is the baby was well able to be by

body baby will be able to the infant is breastfeed or be breastfeed and formula feed and typical the provided by good pattern of feedings during the a 24 hour period. 3. Emphasize the importance of wellbalanced nutritious intake.

typical important

Objective: thin

requirements in related to

being and early growth.

breastfed the mother.

appearance

weakness of the nutrition mother breastfeeding the baby in mother.

3.

Providing

age

appropriate guidelines to children as well as to

parents/care providers may help them in making

healthy choices. 4. Consult dietitian. 4. Useful in determining individual nutritional needs and diet/feedings. 5. Refer to home care 5. To asses with initiation therapeutic

resources unless indicated by specific condition or illness.

of home nutrition therapy when used.

V. Actual Nursing Management (SOAPIE) for the mother

Sakit kaayo akong tahi, as verbalized by the patient.

S

-Facial grimace - pain scale of 8/10

O

- Presence of episiotomy

Acute pain related to episiotomy secondary to childbirth

At the end of 30 minutes of nursing intervention, the patients pain

P

will be lessened from pain scale of 8 to 6. Independent: 1. Positioned the patient in a side lying. 2. Provided comfort measures such as back rubs. 3. Encouraged to take the medication on the right amount/dose and time as ordered by the physician.

4. Demonstrated and encouraged use of relaxation technique

such as deep breathing exercises.

5. Encouraged to verbalize the intensity of pain.

After 30 minutes of nursing interventions, patients pain was lessened from pain scale of 8 to 6.

daghan-daghan pa ang akong dugo gikan panganak, as

S

verbalized by the patient.

-postpartum wound
O

-weak

Risk for infection related to postpartum wound

A

At the end of 1 hour of nursing interventions, patient will be able to prevent from getting an infection.
P

Independent: 1. Instructed to always wash hands before and after in contact to wound. 2. Encouraged intake of protein and calorie rich foods.
I

3. Instructed to do perineal care. 4. Maintain or teach asepsis for dressing changes and wound care. 5. Instructed to take the medication Co-amoxiclav 500mg 1 tab BID as ordered by the physician.

After 1 hour of nursing intervention, patient was able to prevent getting an infection.

dili pa na ko kaya ang maglihok-lihok kay sakit pa ako tahi, as

S

verbalized by the patient.

-body malaise -presence of episiotomy

O

-inability to ambulate

Activity intolerance related to generalized weakness secondary to postpartum wound

A

At the end of 1 hour of nursing interventions, patient will be able to ambulate and regain strength.
P

Independent: 1. Encouraged to take the prescribed medication as ordered by the physician. 2. Recommended to maintain bed rest.
I

3. Instructed the patient about proper positioning (e.g. side lying). 4. Encouraged to eat nutritious food for faster recovery. 5. Instructed to change position every two hours.

After 1 hour of nursing intervention, patient was able to regain strength

Wala koy gana mukaon kay luya pa akong lawas `` as verbalized by the patient.

-- restless
O

-weak in appearance Risk for imbalance nutrition: less than body requirements related to changes in digestive process/absorption of nutrients secondary to

fatigue

At the end of 1 hour of nursing interventions, the patient will be able to eat and regain strength.
P

Independent: 1. Encouraged to do oral hygiene on regular basis. 2. Encouraged the patient to eat food with high calories and increase adequate fluid intake.
I

3. Explained the importance of having a good nutrition. 4. Encouraged the patient to eat foods of her choice. 5. Instructed to limit visitors as needed.

After 1 hour of nursing intervention, patient was to eat and regain strength.

lisod kog tulog kay saba ang palibot, as verbalized by the patient.
S

- fatigue - weakness
O

- noisy and crowded

Sleep pattern disturbance related to ambient noise

A

At the end of 1 hour of nursing interventions, patient will be able to have comfort and manage to rest and fall asleep.
P

Independent: 1. Instructed to drink milk before bedtime 2. Encouraged to have relaxation technique before bedtime such as deep breathing exercise.
I

3. Instructed to limit or provide linens to have comfort and promote sleep. 4. Encourage to limit visitors. 5. Provide comfort such as back rubbing.

After 1 hour of nursing intervention, patient was able to have comfort and manage to rest and fall asleep.

V. Actual Nursing Management (SOAPIE) for the newborn

Not applicable

Fresh cut umbilical cord

Risk for infection related to exposed umbilical cord

At the end of 1 hour of nursing interventions, patient will be able to prevent from getting an infection.

INDEPENDENT: 1. Encouraged mother to bond her baby and keep it warm I 2. Instructed mother to wash hands before and after contact to the baby. 3. Instructed to mother in proper cleaning the umbilical cord. 4. Reminded mother to avoid exposing the baby from unclean environment. 5. Instructed the mother to have a check-up when things go wrong.

After 1 hour of nursing interventions, patient was able to protect E from getting an infection.

Not applicable

Abnormal breath sounds crackles

Risk for aspiration related to presence of secretions A At the end of 30 minutes of nursing interventions, patient will be able to experience no aspiration as evidence by noiseless respiration

Independent: 1. Instructed to elevate head 2. Instructed mother to position infant properly 3. Recommended mother to breastfeed baby from time to time 4. Reminded mother to let her baby burp after breastfeeding 5. Instructed to maintain position

At the end of 30 minutes nursing intervention, patient was able to E experience no aspiration as evidence by noiseless respiration

Not applicable

Cool skin

Hypothermia related to cold environment

At the end of 30 minutes of nursing interventions, the baby will be P able to prevent from having hypothermia.

INDEPENDENT: 1. Monitored vital signs (e.g., T, RR, HR) I 2. Instructed mother to keep baby warm. 3. Demonstrated proper bundling of baby. 4. Placed knit cap on infants head. 5. Instructed mother about the importance of proper clothing of baby.

After 30 minutes of nursing interventions, baby was able to E display core temperature within normal range.

Not applicable

The baby is place in the bed

Risk for injury related to the weakness of the mother to provide safety for the baby.

At the end of 1 hour of nursing interventions, the baby will be provided care and safety by the mother.

INDEPENDENT: 1. Instructed the mother to place the baby nearer to her. I 2. Encouraged to raise the side rails as necessary. 3. Taught the mother in the proper handling of the baby. 4. Instructed the mother to arrange the things that could cause any injury to the baby. 5. Encouraged the mother to lower the bed position.

After 1 hour of nursing interventions, the baby was provided care E and safety by the mother.

Not applicable

Thin in appearance

Risk for imbalance Nutrition: less than body requirements related to the weakness of the mother in breastfeeding the baby

At the end of 2 hours of nursing interventions, the baby will be breastfeed and will be provided good nutrition by the mother.

INDEPENDENT: 1. Instructed the mother to beast feed the baby for at least I 6months to 2 years. 2. Encouraged mother to pay attention on the babys nutrition. 3. Instructed the mother to visit the pediatrician to check for babys health. 4. Reminded the mother for the needed vitamins of the baby. 5. Encouraged the mother to have a complete immunization .

After 2 hours of nursing interventions, the baby was able to be E breastfed by the mother.

VI. Drug study Generic Name of Ordered Drug Coamoxiclav Brand Name Classification Dose/ Date Ordered Frequency Route Mechanism of Action Contraindication Specific Indication Side Effects Nursing Precautions

Augme ntin

1-14-11

Antibiotic

500mg 1 tab PO BID (8am-6pm)

A combination of a penicillin and a substance called clavulanic acid. It kills bacteria by interfering their ability to form cell walls. The bacteria therefore breakdown and die.

To kill the bacterias since the patient has in the postpartu m.

Contraindicated with an allergy to its ingredients,

Headca he, itching

Use with caution in patients with a history of allergies, kidney and liver disease.

history of jaundice or rash, and liver disease caused by the medication. diarrhe a, vomitin g, nausea and jaundic e.

Name of patient: Irish Balacuit Classification Dose/ Frequency Route Contraindication Specific Indication Side Effects

Generic Name of Ordered Drug Mefenamic acid

Brand Name

Date Order ed

Mechanism of Action

Nursing Precautions

Dolfenal

1-1411

Antiinflammatory and analgesic

500mg 1 cap PRN

It inhibits the growth and

To relieve pain

Hypersensitivity to mefenamic acids and with GI problems.

CNS: dizzine ss, headac he, insomni a. CV: periphe ral edema. Skin: rash.

.Assess for allergic reaction:rash, fever, pruritus urticaria:prod uct should be discontinued.

replication of caused by susceptible bacterial organism perineal sutures.

Generic Name of Ordered Drug Ferrous Sulfate

Brand Name

Date Order ed

Classification Dose/ Frequency Route

Mechanism of Action

Contraindication Specific Indication

Side Effects

Nursing Precautions

(Feosol)

1-1411

Iron supplement

1cap OD PO

Elevates the serum iron concentratio n, which

To prevent Patients with iron deficiency anemias delivery. allergy to any ingredients ; sulfite allergy, hemochromatosis , hemosiderosis, hemolytic anemias.

CNS: CNS toxicity, acidosi s coma and death with e G.I: G.I upset anorexi a

History: allergy to any ingredient, sulfite, hemachromat is. Encouraged to drink it with

then helps to after form HgB or trapped in the reticuendoth elial cells for storage and eventual conversion to a usable form of iron.

overdos calamansi juice for faster absorption.

VI. Discharge Planning

Patient was advised to take her prescribed medications at exact time MEDICATION with the right dosage, route and frequency. These drugs were as follow: Co-amoxiclav 500mg 1 cap BID, Mefenamic acid 500mg I cap PRN, Ferrous sulfate1 cap OD PO. Patient was also taught the rationale of each medication and its possible side effects. Medications should be taken religiously. Strict compliance must be observed

EXERCISE

Encouraged patient to avoid extraneous activities to prevent exhaustion. Encourage also performing activity gradually such as walking to improve blood circulation, maintain good body posture, relieves pain and promotes comfort. Patient was also taught and encouraged to do deep breathing exercises to maximize lung expansion for proper oxygenation.

TREATMENT

Encouraged the patient to follow strict regimen in cleaning the perineal area. Patient was also taught to use alternative herbal medicine to wash her perineal area such as boiling the guava leaves.

OUT PATIENT

Advised the patient to return one week after discharge on January 21, 2011 on OPD. In addition, the check-up will note any changes in the health status of the patient for further analysis.

DIET

Advised the patient to eat fruits and vegetables especially those rich in protein for it repair the tissue and prevent further tissue breakdown. This includes fish, meat and eggs. Also foods rich in iron to prevent anemia. This also boosts the immune system to fight against infection.

VIII. References y y y Doenges, M., et al.(2002). Nursing Care Plans 6th edition. Thailand: F.A. Davis Company (Reprinted). Pgs 911- 912, http://www.google.com.ph/mefenamic acid Deglin, J. H. and April Hazard Vallerand(2005). Daviss Drug Guide for Nurses 10th edition. Thailand: iGroup Press Co., Ltd. pp 257-258, 264-266, 419421,