INTRODUCTION

“Making the decision to have a baby is momentous. It is to decide forever to have your
heart go walking around outside your body.”-Elizabeth Stone

Pregnancy, additionally referred to as gestation, is that the one or addtional offspring

develops within a lady. It last for regarding 9 months, measured from the date of the woman’s
last discharge amount (LMP). It’s conventionally divided into 3 trimesters, every roughly 3
months long. Once gestation has completed, it goes through a process known as delivery,
wherever the developed fetus that exits from the mother’s womb. There are two types of delivery
Caesarean Section and Normal Spontaneous Vaginal Delivery. NSVD or Normal Spontaneous
Vaginal Delivery is the delivery of the baby through the vaginal route. Caesarean Section or CS
is a surgical incision through the mother’s abdomen and uterus to deliver a baby.
There are complications sometimes found in the mother and the baby that can lead
complications through and after pregnancy or delivery. If there’s problem during labor, the
physician will decide the way of procedure either SVD ( Spontaneous vaginal delivery) or
through Caesarean Section. Some risk factors that a mother may have in pregnancy who are in
high blood,pretem labor, infection, anemia, diseases that has risk for breech delivery, and low
birth weight.

Diagnostic test and procedures done for preterm labor:

Pelvic exam. Your health care provider might evaluate the firmness and tenderness of your
uterus and the baby's size and position. He or she might also do a pelvic exam to determine if
your cervix has begun to open.
Ultrasound. An ultrasound might be used to measure the length of your cervix and determine
your baby's size, age, weight and position in your uterus. You might need to be monitored for a
period of time and then have another ultrasound to measure any changes in your cervix,
including cervical length.
Fetal heartbeat monitoring. A method of checking the rate and rhythm of the fetal heartbeat.
The average fetal heart rate is between 110 and 160 beats per minute. The fetal heart rate may
change as the fetus responds to conditions in the uterus. An abnormal fetal heart rate or pattern
may mean that the fetus is not getting enough oxygen and may mean that an emergency or
cesarean delivery is needed.
Lab tests. Your health care provider might take a swab of your vaginal secretions to check for
the presence of certain infections and fetal fibronectin — a substance that acts like a glue
between the fetal sac and the lining of the uterus and is discharged during labor.
Maturity amniocentesis. Your health care provider might recommend a procedure in which
amniotic fluid is removed from the uterus (amniocentesis) to determine your baby's lung
maturity. The technique can also be used to detect an infection in the amniotic fluid.

There are multiple signs and symptoms and discomforts of pregnancy. Sometimes a
symptom that is considered a discomfort can be considered a complication when it is more
severe. For example, nausea (morning sickness) can be a discomfort, but if, in combination with
significant vomiting it causes a water-electrolyte imbalance, it is a complication known as
hyperemesis gravidarum.

Common symptoms and discomforts of pregnancy include Tiredness, Constipation, Pelvic

girdle pain, Back pain, Braxton hicks contraction, Edema(swelling), Increased urinary frequency,
Varicose veins, Haemorrhoids (piles) or swollen veins at or inside the anal area caused by
impaired venous return, straining associated with constipation, or increased intra-abdominal
pressure in later pregnancy, Regurgitation, Heartburn, Nausea, Stretch marks, and Breast
tenderness is common during the first trimester, and is more common in women who are
pregnant at a young age.

There are 4 stages of labor, which is the process of childbirth, especially the period from the start
of uterine contractions to deliver:
 FIRST STAGE OF LABOR. Begins with regular uterine contractions and ends with
complete cervical dilatation at 10 cm. Divided into a latent phase and an active phase. The
latent phase begins with mild, irregular uterine contractions that soften and shorten the
cervix. Contractions become progressively more rhythmic and stronger. The active phase
 usually begins at about 3-4 cm of cervical dilation and is characterized by rapid cervical
dilation and descent of the presenting fetal part.
 SECOND STAGE OF LABOR. Begins with complete cervical dilatation and ends with
the delivery of the fetus.
 THIRD STAGE OF LABOR. The period between the delivery of the fetus and the
delivery of the placenta and fetal membranes. Delivery of the placenta often takes less than
10 minutes, but the third stage may last as long as 30 minutes. Active management often
involves prophylactic administration of oxytocin or other utero tonics (prostaglandins or
ergot alkaloids), cord clamping/cutting, and controlled traction of the umbilical cord.
 FOURTH STAGE OF LABOR. This has no more expulsions of conceptions. This is
considered as the recovery stage, or the maternal adjustment stage.

The reason why I chose this patient for my case study is because she was the first patient I
was assigned to take care of during the first week of exposure at the OB-ward. She was very
cooperative, responsive, and gave me the details that I needed. I handled and assessed her for 2
days utilizing the OB kit, Physical Assessment, and Nursing Health History guide in
interviewing the patient.
Definition of Terms:
1. APGAR- a quick test performed on a baby at 1 and 5 minutes after birth. The 1-minute score
determines how well the baby tolerated the birthing process. The 5-minute score tells the
health care provider how well the baby is doing outside the mother's womb.
2. Bartholins Gland- are two pea sized compound alveolar glands located slightly posterior and
to the left and right of the opening of the vagina. They secrete mucus to lubricate the vagina
and are homologous to bulbourethral glands in males.
3. Cytotrophoblast - is the inner layer of the trophoblast. It is interior to the syncytiotrophoblast
and external to the wall of the blastocyst in a developing embryo
4. Eclampsia- a condition in which one or more convulsions occur in a pregnant woman
suffering from high blood pressure, often followed by coma and posing a threat to the health
of mother and baby.
5. Gestional Hypertension defined as having a blood pressure higher than 140/90 measured on
two separate occasions, more than 6 hours apart, without the presence of protein in the urine
and diagnosed after 20 weeks of gestation.
6. Morula - a solid ball of cells resulting from division of a fertilized ovum, and from which a
blastula is formed.
7. Proteinuria- the presence of abnormal quantities of protein in the urine, which may indicate
damage to the kidneys.
8. Pseudovascularization -  abnormal or excessive formation of blood vessels .
9. Spontaneous Vaginal Delivery(SVD )- when a pregnant female goes into labor without the
use of drugs or techniques to induce labor, and delivers her baby in the normal manner,
without forceps, vacuum extraction, or a cesarean section.

10.Vasoconstriction- the constriction of blood vessels, which increases blood pressure.

 NURSING HEALTH HISTORY

This is used to have a comprehensive set of information about the patient’s medical history, as
well as the present illness, the patient’s psychosocial history, and basically everything we need to
know about the patient so we could find and connect causative factors that may lead to the
present illness of the patient that we could use as a basis for the nursing care plan.

The interview was done last Aug. 7, 2019. In accordance to the principle of confidentiality and to
maintain the patient’s dignity, I therefore withhold the real identity of the patient and address her
as Patient M.

Patient’s Demographic Profile:

Patient M. was admitted due to labor pain on June 30, 2019. During my interview, I found out
about her personal information. She was born on October 09, 1992 and is currently 26 years old.
Her Last Mentrual Period(LMP) was on October 6, 2018. This is her first pregnancy and she is
not married yet but she has a 30 year-old boyfriend who supports her and their newborn, and
working as a Gasoline Boy at Shell.She lives at Pagatpatan P.4, Butuan City Agusan Del Norte.
She is unemployed, and is supported by her Mother and sometimes her boyfriend.

History of Patient Prior to Admission:

She is a first time mother and according to her, her pregnancy was an accident by her
and her partner. She had regular antenatal check-ups at Butuan Medical Center. She gave birth to
a healthy baby boy.

Prior to admission on June 30, 2019, She was infused D5LR+20 “u” of Oxytoxin. Her
Expected Date of Confinement(EDC) was on June 29, 2019 followed with her Ultrasound. She
had a Normal Spontaneous Vaginal Delivery at Butuan Medical Center and delivered the healthy
baby boy around 3:30pm with a weight of 3,120gm. on June 30, 2019. Her final diagnosis is
G1P1 delivered in Cephalic presentation with an APGAR Score 9,10, Gestional Hypertension.

Doctor’s Order
Upon admission on June 30, 2019
-D5LR 1L+100cc Nifedifene 5g
-Attach Ultra sound result
-Inform OB physian for re-evaluation of MgA
-Mgso4
-Hydralazine 50g IVTTS q hour for bp 120/100 & above
-DAT
-Cefuroxime 500 mg BID
-monitor v/s q 15’x2’, hourly til stable, q 4 hours after
-IVF with D5LR+ 1L+10 “u”
-Oxytoxin D5NM 1L
-16 packsto hypogastrium
-Co-amoxiclav 625mg 1 cap BID PO
-Tramodal+Paracetamol 1 TID PO PRN
-FeSO4 1 cap OD PO
-Amlodipine 10mg 1 tab OD PO

PHYSICAL ASSESSMENT

Physical examination is the process of evaluating objective anatomic findings through the
use of observation, palpation, percussion, and auscultation. The information obtained must be
thoughtfully integrated with the patient's history and pathophysiology.
 Received patient sitting on bed,awake, and with an IVF on June 3, 2019. The patient was
concious, coherent, and relaex as observed. Equipments and supplies that were used in this
procedure were BP apparatus, thermometer, stethoscope, wrist watch with second hand, and
penlight, tape measure, notebook and ballpens. The patient’s vital signs are as follows:
T-36.6
PR-102 beats/min
RR-25 breaths/min
BP-130/70
INSPECTION PALPATION PERCUSSION AUSCULTATION

SKIN  Uniformed skin  Warm to touch.

color; no skin
lesions noted  Well-hydrated
skin and is
resilient;
returns quickly
after 2 seconds
of pinching.

SKULL and  Skull is round and  There were no

FACE proportionate to presence of
the body. nodules, or
masses
 The face is
symmetrical;
absence of edema
noted

EYE  Eyebrows are  Eyelids are

STRUCTUR evenly distributed, intact, no
E and symmetrically discharges
VISUAL aligned. noted.
ACUITY
 Eyelids skin is  Absence of
intact, closes swelling of
symmetrically, lacrimal glands
bulbar conjunctiva noted
is clear with tiny
vessel, and
palpebral
conjunctiva is
pink with no
discharge.
 Sclera is white
and cornea is
shiny.
 Pupils are black,
equally round

EARS and  No lesions,  No presence of

HEARING lacerations, masses nor
ACUITY bruises, and nodules are
swelling noted noted.
 Color is the same
as the facial skin;
Symmetrical

MOUTH and  Lips are pink,  Absence of

OROPHARY smooth and moist, swelling is
NX no lumps; Pink noted
 gums, no swelling
noted, uvula is
positioned in the
midline of the soft
palate.
 Tonsils are not
inflamed; tongue
is in the midline

NOSE and  Nose is  Not tender, no

SINUSES symmetrical lesions; nasal
without nasal septum is intact
discharge: and located in
uniform in color. the mid line.
 External surface
of the patient’s
nose is smooth
and oily.
 Nares were both
patent and no
presence of
lesions, and
mucosa is pink in
color.

NECK  Coordinated  No lesions,

movements; equal masses,
strength deformities
noted; Absence
of enlarged
lymph nodes
noted

THORAX  Normal chest  Normal chest  A resonant  No adventitious

AND shape, with no size and shape, sound was sounds are
LUNGS visible no tender spots. assessed. heard.
deformities.
 Symmetrical
 No muscle chest
retractions when expansion, and
breathing. tactile fremitus
over the main
stem bronchi in
front and
between the
scapulae in the
back of the
chest.

PEPHIRAL  There was  Capillary refill

VASCULAR symmetric pulse immediately
SYSTEM volumes, no return after 2
(UPPER edema and equal seconds.
AND in size with
LOWER smooth
EXTREMITI movements.
ES)
 No bone
 deformities and
swelling.
 Lower extremities
are equal in size,
with no bone
deformities.

GENITALIA  Absence of
(MEATUS) inflammation  Discharges
noted noted

EXTREMITI  Feet and legs  No signs of

ES are masses and
(CLAVICLE symmetrical in tenderness
S, HIP size, shape and upon
JOINTS) movement. palpation.
Pulses are
strong and
equal
bilaterally.

ABDOMEN  Fundal height of  No tenderness,  Dullness noted  Absence of

13.8 relaxed upon arterial bruit
abdomen and percussion sounds.
 Absence of consistent
redness, swelling, tension are  Distended  Altered bowel
and foul smelling normal. abdomen sounds
odor on the
umbilicus.  Firm and warm
to touch

MUSCULOS  There were no  There were

KELETAL visible bone smoothness in
SYSTEM deformities and movement and
discrepancies presence of
found. increased
muscle tone
 Muscles in the
upper extremities  Absence of
are equal in size. edema and
tenderness
 Range of motion noted.
noted.
Female Reproductive Anatomy

Internal and External Structures

Internal
Internal Structures

Ovaries

 The ovaries are the ultimate life-maker for the females.

 For its physical structure, it has an estimated length of 4 cm and width of 2 cm and is 1.5
cm thick. It appears to be shaped like an almond. It looks pitted, like a raisin, but is
grayish white in color.
 It is located proximal to both sides of the uterus at the lower abdomen.
 For its function, the ovaries produce, mature, and discharge the egg cells or ova.
 Ovarian function is for the maturation and maintenance of the secondary sex
characteristics in females.
 It also has three divisions: the protective layer of epithelium, the cortex, and the central
medulla.
Fallopian Tubes

 The fallopian tubes serve as the pathway of the egg cells towards the uterus.
 It is a smooth, hollow tunnel that is divided into four parts: the interstitial, which is 1 cm in
length; the isthmus, which is2 cm in length; the ampulla, which is 5 cm in length; and the
infundibular, which is 2 cm long and
shaped like a funnel.

 The funnel has small hairs called the fimbria that propel the ovum into the fallopian tube.
 The fallopian tube is lined with mucous membrane, and underneath is the connective tissue
and the muscle layer.
 The muscle layer is responsible for the peristaltic movements that propel the ovum forward.
 The distal ends of the fallopian tubes are open, making a pathway for conception to occur.
Uterus

 The uterus is described as a hollow, muscular, pear-shaped organ.

 It is located at the lower pelvis, which is posterior to the bladder and anterior to the rectum.
 The uterus has an estimated length of 5 to 7 cm and width of 5 cm. it is 2.5 cm deep in its
widest part.
 For non-pregnant women, it is approximately 60g in weight.
 Its function is to receive the ovum from the fallopian tube and provide a place for
implantation and nourishment.

 It also gives protection for the growing fetus.

 It is divided into three: the body, the isthmus, and the cervix. f
 The body forms the bulk of the uterus, being the uppermost part. This is also the part that
expands to accommodate the growing fetus.
 The isthmus is just a short connection between the body and the cervix. This is the portion
that is cut during a cesarean section.
 The cervix lies halfway above the vagina, and the other half extends into the vagina. It has an
internal and external cervical os, which is the opening into the cervical canal.
External

 Lateral to the labia minora are two folds of fat tissue covered by loose connective tissue and
epithelium, the labia majora.
 Its function is to protect the external genitalia and the distal urethra and vagina from trauma.
 It is covered in pubic hair that serves as additional protection against harmful bacteria that
may enter the structure.
Vestibule

 It is a smooth, flattened surface inside the labia wherein the openings to the urethra and the
vagina arise.
Clitoris

 The clitoris is a small, circular organ of erectile tissue at the front of the labia minora.
 The prepuce, a fold of skin, serves as its covering.
 This is the center for sexual arousal and pleasure for females because it is highly sensitive to
touch and temperature.
Perinial Body

 This is a muscular area that stretches easily during childbirth.

 Most pregnancy exercises such as Kegel’s and squatting are done to strengthen the perineal
body to allow easier expansion during childbirth and avoid tearing the tissue.
Hymen

 This covers the opening of the vagina.

 It is tough, elastic, semicircle tissue torn during the first sexual intercourse.
 Pathophysiology of Normal Spontaneous Vaginal Delivery,Eclampsia

Fertilization
(Union of sperm and ovum)

Zygote- Unicelluar
(Interningling of haploid paternal X or Y and maternal 23 X
chromosomes)

In 72 hours become 16 cell organism called Morula

Morula enters the uterus on the 3rd day through peristaltic movement

The inner layer gave rise to

The outer layer rises to the embryo (embryoblast)
theplacenta
(Trophoblast)
Blastocytes attaches to endometrium
on the 6th day

Implantation

Embryonic development begins during

weeks continues through the eight week

3 Stages

 1st stage- increase in cell number and

with elaboration
of cell products.
 2nd stage-morphogenesis/includes
mass cell movement
 3rd stage –different or maturation of
physiologic process

Fetal Development is from 9th week to birth

 Newborn baby via Vaginal Delivery

Unknown Etiology

Inadequate placentation

Uterine spiral arteries are poorly

invaded by cytotrophoblast

Uterine spiral arteries are

Cytotrophoblast failed to replace tunica
poorly invaded by
media
cytotrophoblast

Incomplete
pseudovascularization

Decreased placental
perfusion

vasoconstriction
Constrictive properties of the
arterioles remained

Increase blood pressure

Endothelial dysfunction

Glomerubar endothelium is
damaged

Filtration capacity falls

Proteinuria

Edema
 LABORATORY RESULT

TEST RESUL REFERENC INTERPRETATIO Analysis

T E N
WBC 17.4 5.0-10.0 Increased Increased than normal WBC
is called leukocytosis.It may
due to:Infections, most often
those caused by bacteria,
Tissue damage lacerations
RBC 4.60 M: 4.5-5.2 Normal
F: 3.4-5.6
Hemoglobin 113 M: 135-175 Decrease loss of blood (traumatic
F: 125-165 injury, surgery, bleeding,
colon cancer, or stomach
ulcer),
nutritional DEFICIENCY (ir
on, vitamin B12, folate)
Hematocrit 0.35 M: 0.40-0.52 Decrease  Some causes include:
F:0.36-O.48 Excessive loss of blood from,
for example, severe trauma,
or chronic bleeding from sites
such as the digestive tract
(e.g., ulcers, polyps, and
colon cancer), the bladder or
uterus (in women, heavy
menstrual bleeding.)
MVC 77.0 82-92 Normal
MCH 24.5 27-32 Decrease Low MCH levels can also
appear in a body that is
lacking key vitamins. People
who do not get enough B
vitamins such as folate and
B12 may show low MCH
concentrations on their tests. 
MCHC 336 320-380 Normal
Platelet 166 150-400 Normal
DIFFERENTIAL COUNT
Neutrophils 0.85 0.50-0.70 Increase increased percentage of
neutrophils may be due to:
Acute infection Acute stress
Eclampsia (seizures or coma
in a pregnant woman)

Lymphocyte 0.10 0.20-0.40 Normal

s
Monocytes 0.05 0.2-0.6 Normal
Blood Type B+
 Drug Study

Name of Date Classification Dose/ Mechanism of action Indication Contraindication Side Effects Nursing
Drug ordered Frequency And Precautions Responsibilities
Generic
(Brand)
Amlodipine Antihypertensive 10 mg i tab -Binds to -Alone or with -Hypersensitivity CNS: -Monitor blood
(Norvasc) s PO OD dihydropyridine and other agents in the -Sick sinus Anxiety, pressure and pulse
Antiarrythmics nondihydropyridine management of syndrome dizziness, prior to therapy
Antianginals cell membrane hypertension, -Blood pressure of fatigue, during dosage
Vascular receptor sites on angina pectoris, <90 mmHg extrapyradima titration, and
headache myocardial and and vasospastic -Use cautiously to l disorder, periodically
supressants vascular smooth- (Prinzmental’s) patient with severe headache, throughout therapy.
Calcium channel muscle cells and angina hepatic lethargy,
blockers inhibits influx of impairment light- -Monitor intake and
extracellular calcium -Geriatric patients headedness output ratios and
ions across slow calciu -History of serious CV: daily weight. Assess
channels. This congestive heart Arrhythmias, for signs of
decreases intracellular failure or chest pain, congestive heart
calcium level, arrhythmias hypotension, failure (peripheral
inhibiting smooth- palpitation edema,
muscle cell EENT: Dry rales/crackles,
contractions and mouth dyspnea, jugular
relaxing coronary and GI: venous distention)
vascular smooth Abdominal
muscles, decreasing cramps or -Assess location,
peripheral vascular pain, duration, intensity,
resistance, and constipation, and precipitating
reducing systolic and flatulence, factors of patient’s
diastolic blood nausea and anginal pain
pressure. Decreased vomiting
peripheral vascular GU: Urinary -Instruct patient to
resistance also frequency immediately notify
decreases myocardial health care providers
workload, oxygen of dizziness, arm or
demand, and possibly leg swelling,
angina. Also, by difficulty of
inhibiting coronary breathing, hives, or
artery muscle cell rash
contractions and
restoring blood flow, -Encourage taking
drug may relieve Amlodipine with
Prinzmental angina. food to reduce GI
upset

-May cause
dizziness. Caution
patient to avoid
hazardous activities

-Encouraged patient
to comply with
additional
interventions for
hypertension such
discontinuation of
smoking, avoiding
alcohol and
softdrinks
consumptions, and
stress management
 Name of Date Classification Dose/ Mechanism of action Indication Contraindication Side Effects Nursing
Drug ordered Frequency And Precautions Responsibilities
Generic
(Brand)
Celecoxib 6/30/19 COX 2 - NSAID 200mg BID -Celecoxib, a selective This medication is Before using Severe headac - Take this
cyclooxygenase-2 a nonsteroidal anti- this medication, tell he, medication
(COX-2) inhibitor, is inflammatory drug your doctor or pain/swelling/ by mouth as directed
classified as a (NSAID), pharmacist your warmth in the by your doctor,
nonsteroidal anti- specifically a medical history, groin/calf, usually once or twice
inflammatory drug COX-2 inhibitor, especially signs daily. To decrease the
(NSAID). The which relieves pain of: asthma (includi of kidney prob chance
inhibition of and swelling ng a history of lems (such as of stomach upset, this
prostaglandin E2 (inflammation). It worsening change in the drug is best taken
synthesis which (a is used to breathing after amount of with food. The
mediator of pain) treat arthritis, acute taking aspirin or urine), dosage is based on
results from the pain, and menstrual other difficult/painfu your medical
inhibition of COX-2, pain and NSAIDs), liverdise l condition and
and helps to alleviate discomfort. The ase, stomach/intesti swallowing, sy response to treatment.
pain symptoms. pain and swelling ne/esophagus probl mptoms of Take this medication
relief provided by ems (such as heart at the lowest effective
this medication bleeding, ulcers, failure (such dose and only for the
helps you perform recurring heartburn as prescribed length of
more of your ), heart swelling ankle time 
normal daily disease (such s/feet, unusual - Take this
activities. as angina, heart tiredness, medication with a full
attack), high blood unusual/sudde glass of water (8
pressure, stroke, bl n weight gain). ounces or 240
ood disorders (such milliliters) unless
as anemia, your doctor directs
bleeding/clotting you otherwise. Do
problems), growths not lie down for at
in the nose (nasal least 10 minutes after
polyps). taking this
medication.
- If you are taking
this drug on an "as
needed" basis (not on
a regular schedule),
remember that
pain medications wor
k best if they are used
as the first signs of
pain occur. If you
wait until the pain has
worsened, the
medication may not
work as well.
 Name of Date Classification Dose/ Mechanism of action Indication Contraindication Side Effects Nursing
Drug ordered Frequency And Precautions Responsibilities
Generic
(Brand)
Co- 6/30/19 Antibiotic 625mg I cap A road-spectrum This antibiotic -Contraindicated Nausea, diarrh -Do not use the
Amoxiclav BID PO antibiotic of the treats only bacterial in patients medical ea, dizziness, l suspension with
fluoroquinolone class. infections. It will history, especially ightheadednes feeding tubes because
It is active against both not work for virus of: diabetes, heart  s, headache, the suspension may
Gram-positive and infections (such problems (such as or trouble clog the tube.
Gram-negative as common recent heart sleeping may
bacteria. It functions cold, flu). Using attack), joint/tendo occur. -The dosage and
by inhibiting DNA any antibiotic when n problems (such length of treatment is
gyrase, and a type II it is not needed can as tendonitis, bursit Tell your based on your
topoisomerase, cause it to not work is), kidney doctor right medical condition
topoisomerase IV, for future disease, liver disea away if you and response to
necessary to separate infections. se, mental/mood have any treatment. Drink
bacterial DNA, thereby disorders (such serious side plenty of fluids while
inhibiting cell division. as depression), my effects, taking this
asthenia gravis, including: medication unless
nerve problems unusual your doctor tells you
(such as peripheral bruising/bleedi otherwise.
neuropathy), seizur ng, signs of a
es, conditions that new infection -Take this medication
increase your risk (such as at least 2 hours before
of seizures (such new/persistent or 6 hours after
as brain/head fever, taking other products
injury, brain persistent sore that may bind to it,
tumors, throat), signs decreasing its
cerebral atheroscler of kidney prob effectiveness. Ask
osis). lems (such as your pharmacist
change in the about the other
amount of products you take.
urine, red/pink Some examples
urine), signs include: quinapril, se
of liver proble velamer,
ms (such as sucralfate, vitamins/
unusual minerals (including
tiredness, stom iron and
ach/abdominal zinc supplements),
pain, and products
persistent naus containing magnesiu
ea/vomiting, m, aluminum,
yellowing eyes or calcium (such as
/skin, dark antacids, didanosine
urine). solution, calcium
supplements).

-Calcium-rich foods,
including dairy
products (such as
milk, yogurt)
or calcium-enriched
juice, can also
decrease the effect of
this medication.
 Name of Date Classification Dose/ Mechanism of action Indication Contraindication Side Effects Nursing
Drug ordered Frequency And Precautions Responsibilities
Generic
(Brand)
Ferrous 6/30/2019 Iron preperation 1 cap OD PO Elevates the serum iron -Prevention and -Contraindicated CNS-CNS -Asses for allergy to
Sulfate concentration, and is treatment of iron – with allergy to any toxicity,acidos any
then converted to Hgb deficiency ingredients allergy. is,coma and ingredient,sulfate,he
or trapped in the anemias (hemochromatosis) death with mochromomatosis,ha
reticuloendothelial cells -drug-drug , overdose emolytic anemias
for storage and eventual decreased nti- (hemosiderosis),ha -monitor blood
conversion to a usable infective response emolytic animeas GI:GI studies
form of iron. to upset,anorexia, -confirm that client
ciproflaxacin,norfl nausea,vomiti does have iron
oxacin,ofloxacin;d ng,constipatio deficiency anemia
ecreased n,diarrhea,dark -administer the right
absorption with stools,tempora drug in the right dose
antacids,cimetidin ry staining of and route and the
e;decreased effects teeth(liquid right time
of levodopa if prepararions) -give drug with
taken with meals(avoiding
iron;increased milk,eggs,coffee, and
serum iron levels tea)
with -do not take this drug
chloramphenicol with antacids nor
tetracyclines unless
prescribed
-warm patient that
stool may be dark or
green
-arrange for periodic
monitoring of Hot
and Hbg levels
-report severe GI
upset,lethargy,rapid
respiration, and
constipation.
-document and record
 Name of Date Classification Dose/ Mechanism of action Indication Contraindication Side Effects Nursing
Drug ordered Frequency And Precautions Responsibilities
Generic
(Brand)
Magnesium 6/30/19 Anticonvulsant 4gms slow -Confactor of many -IV or IM -Contraindicated - Assess possibility
sulfate IVTT enzyme systems preeclampsia or with allergy to SLE:syndrom for interactions w/
involved in eclampsia magnesium e joint- other drugs or herbal
neurochemical -To correct or products;heart swelling, products the patient
transmission and prevent block,myocardial (fever)reactio may be taking
muscular hypomagnese mia damage;fecal n,anemia,agra especially anything
excitablity;prevents or in patients or impaction,intestina nulocytosis,he that may impact
controls seizures by parenteral l and biliary tract patitis,glomer blood pressire before
blocking nutrition obstruction, ulonephiris,ac start treatment.
neuromuscular -Do not give ute renal -monitor patients
transmission;attracts during 2 hours failure. closely during and
and retains water in the preceding delivery following
intestinal lumen and because of risk of infusions,Observe
distends bowel to magnesium orthostatic
promote mass toxicity to the precautions.
movement and relieve neonate
constipation.
 Problems Identified & Prioritized

Nursing Diagnosis Date Identified Date Evaluated

July 3, 2017 July 8, 2019

1.) Risk For Infection
July 5, 2017 July 8, 2019
2.) Self-Care Deficit
July 2, 2017 July 8, 2019
3.) Disturbed Sleep
Pattern
July 5, 2017 July 8, 2019
4.) Readiness for
Enhanced Self-health
Management
July 2, 2017 July 8, 2019
5.) Readiness for
Enhanced Comfort
 NURSING CARE PLAN #4
ASSESSMENT NURSING OBJECTIVES/EVALUA NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSI TION CRITERIA
S
S: “matod pas Readiness Short term: Within 8 Independent: Independent: Short Term: after 8
akong laboratory for enhanced hours of nursing hours of nursing
1.) Ascertain client’s beliefs about health and 1.) Belief in ability to accomplish desired
kulang daw kog self-care interventions the patient interventions, the
her ability to maintain health action is predictive of performance
dugo mag pa management will be able to determine 2.) Determine client’s current health status and 2.) To note any threats that could contribute to
patient was able to
abono ko ani?” r/t prevent responsibility for perception of possible threats to health the condition of the patient determine
O: Anemia managing treatment 3.) Acknowledge individual efforts and 3.) Provides positive reinforcement responsibility for
regimen capabilities to reinforce movement toward encouraging continued progress towards managing treatment
- Relaxed attainment of desired outcomes desired goals regimen
as 4.) Provide emotional support and 4.) To help improve patient’s confidence
observed encouragement 5.) This will give her confidence that she can
- Requeste 5.) Teach patient simple decision-making choose wisely among options
d for techniques 6.) To assist in management of stress and
blood 6.) Encourage use of exercise, and relaxation promote general health
transfusio skills 7.) Blood transfusion helps in replacing lost
n 7.) Discuss the importance of blood components of blood from NSVD
transfusion 8.) To give the patient a sense of control over
8.) Educate family about the importance of the present situation
allowing the patient to think and act for
herself Dependent:
Dependent:
9.) To compare and note any problems
9.) Monitor the laboratory results of the Dependent:
patient noting CBC results
Collaborative: 10.) To request for a laboratory
procedure
10.)Refer to the Medical Technician, as
ordered
 NURSING CARE PLAN #3
ASSESSMENT NURSING OBJECTIVES/EVALU NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS ATION CRITERIA

S: “igang kayo Disturbed Within 8 hours of Independent: Independent: after 8 hours of

diri maglisod ko sleep pattern nursing interventions the nursing interventions,
1.) Identify presence of factors known 1.) Sleep patterns may arise from internal
ug tulog” r/t ambient patient will be able to the patient was able
to interfere sleep and external factors
O: temperature report increased sense of 2.) Note environmental factors such as
to report increased
well-being and feeling 2.) These factors can reduce client’s ability sense of well-being
unfamiliar or uncomfortable room,
- Restless as rested to rest and sleep and feeling rested .
and uncomfortable temperature
observed 3.) To ascertain intensity and duration of
3.) Assess client’s usual sleep patterns
- Sleepy problems
and compare with current sleep
eyed noted 4.) To promote physical comfort
disturbance
- Decreased 4.) Provide bedtime care such as 5.) To provide comfortable ventilation
ventilation straightening the bed sheets 6.) To avoid interruption and to provide
in the room 5.) Manage environment for privacy as well
- Warm to hospitalized client, such as 7.) Promotes rest periods from watching
touch ventilation by fanning the patient over the newborn
6.) Instruct the s/o to keep the noise 8.) Provides warmth and comfort
down when the patient is sleeping
7.) Encourage the patient to sleep
when the newborn is sleeping
8.) Advise to change clothes, if
necessary Dependent:
Dependent:
9.) This is to provide assistance in falling
9.) Administer sleep medications as and staying asleep
prescribed
 NURSING CARE PLAN #2
ASSESSMENT NURSING OBJECTIVES/EVALUA NURSING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSI TION CRITERIA
S
S: “ wala pako Self-care Long Term: within 8 Independent: Independent: Long Term: after 8
naka-ligo sukad deficit r/t hours of nursing hours of nursing
atong isa ka decreased interventions, the patient 1.) Assess the individual strengths and 1.) To determine her ability to bathe interventions, the
adlaw” motivation will be able to skills of the client independently patient was able to
O: demonstrate techniques 2.) Determine hygiene supplies 2.) To provide completion of activity demonstrate
and lifestyle changes to 3.) Note existing conditions 3.) To identify causative or contributing techniques and
- Clammy meet self-care needs 4.) Active-listen to the client’s concerns factors lifestyle changed to
skin 5.) Practice and promote short term goal 4.) Exhibits regard for client’s values and meet self-care needs
noted setting and achievement beliefs
- Warm to 6.) Establish partnership with client’s s/o, 5.) To recognize that today’s success is as
touch if appropriate important as any long-term
- Unchang 7.) Discuss the importance of proper 6.) For motivation or behavioural
ed personal hygiene modification
clothes 8.) Perform cleansing bed bath, if 7.) For the patient to gain more
- Dry hair permitted information
noted 9.) Instruct the patient to clean the 8.) To freshen up the patient
- Untidy as perineum 9.) To prevent infection
observed Dependent:
Dependent:
10.) Assist with medication regimen
as necessary 10.) To ensure the patient is taking
proper medications
DISCHARGE PLAN

M- Prescribed medications at home, if prescribed

E - Advised patient to stay away from a polluted area

- Instructed the patient to avoid smoking areas
- Emphasized the importance of a well-ventilated area

T - Advised to go at the OPD or clinic for follow-up check-ups

H– Encouraged adequate rest periods, or when the baby is sleeping

- Emphasized the importance of immunizations

- Demonstrated the proper personal and perineal care
- Instructed the patient to perform passive exercise for circulation
- Instructed the patient to clean the breast/nipple before breastfeeding
- Discussed the benefits of breastfeeding
- Reminded of the breastfeeding cues of the infant
- Demonstrated the different positions of breastfeeding
- Advised the mother to perform cord care regularly
- Demonstrated the proper infant tub bath

O – Instructed the patient and s/o to report any signs of infections such as foul smelling odor
of lochia, redness and swelling of perineum, fever, bleeding, and headache

D – Advised the mother to increase fluid intake

- Instructed to increase fiber intake such as fruits and vegetables
- Encouraged to avoid eating junk food habitually

S – Encouraged patient according to their beliefs and practices