Saint Louis University College of Nursing

Nursing Care plan

SUBMITTED BY: NARAG, MA. THERESA A. BSN II BLOCK 17 GROUP E

SUBMITTED TO:

I.

PATIENT S PROFILE Name: Age: Sex: Address: Religion: Educational attainment: Civil status: Birth date: Birthplace: Nationality: Admitting physician: Attending physician: Rm #: 032-3

Baretto Desiree 32 Female sison, Pangasinan; Lower Dagsian Baguio City Roman Catholic College graduate Married June 7, 1977 Filipino Catalan Marcial

II.

GORDONS FUNCTIONAL HEALTH PATTERNS

HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN The client, before hospitalization, was very health conscious because of pregnancy. Habit such as eating a well balance diet, having enough rest, and without having any vices is what she does towards good health. She has the history of abortion during the first and second pregnancy that is why, she really live carefully to avoid what had happened in the past. She consulted a private Doctor in order to take care of her entire pregnancy. She did not lack of check-ups in her pregnancy. The client also avoids things that would make him tired especially in her work that is why she used to stop to be a machine operator supposedly until she will be going to deliver the child. She claimed she has a good lifestyle. NUTRITIONAL METABOLIC PATTERN Physical assessment reveals the client s status regarding nutrition. She is medium body build, and is neat in appearance. She has smooth skin integrity. Hair is slightly oily. Nails are cut. Eyes and ears are ok. There s also no problem in speaking. No lesions present on the mouth and bucal mucosa that may hinders client s ability to eat. Upper and lower extremities can be move without any problems, disregarding the client s condition after procedure is done. The client eats 3 times a day which is during breakfast, dinner and lunch. She prefer often vegetables and with some meat. She can eat 2 to 3 cups of rice, and food is approximately 1 cup. She also eats snacks during late in the afternoon. She usually eats her breakfast during 8 in the morning, lunch during 12 in the afternoon, and 7 in the evening. She eats more during lunch than breakfast. The client takes multivitamins when still pregnant. She drinks plenty of water, and milk. ELIMINATION PATTERN During pregnancy, the client defecates 3 to 4 times in a week. Stool is hard in consistency, and brownish in color. She urinates 5 to 7 times in a day which is yellowish in color and is estimated 1 cup per urination. No pain claimed during urination. She used laxatives (suppository) during the labor process.

Prior to admission, the client experienced bleeding. The client claimed that there s presence of clots, and it is concentrated red in color. After completion curettage (which she was also experienced twice in the past), the client experience mild bleeding. She uses sanitary pads, and consumed 2 pads during the shift. It is red in color, no clots, and moderately soaks. The client seldom perspires due to frequent rest and climate. ACTIVITY EXERCISE PATTERN The client has no particular exercise during pregnancy. She often prefer resting, reading books, singing, watching TV, and surfing the net because of the fear that she might experience again abortion. Doing simple household chores such as wiping table, folding of clothes, and sweeping the floor serves as her exercise. There s no affectation on her condition when doing those activities. The client used to stop working as an operator of machine when she became pregnant. SLEEP REST PATTERN The client has an adequate rest. She sleeps 6-8 hours or even more without disturbances. She sleeps 9 in the evening, and wakes up in the morning early around 6 to 8. She doesn t take any sleeping pills in order to sleep. She just reads books, or watches tv which enable her to sleep. She often has rest by sitting and by not doing heavy works. COGNITIVE PERCEPTUAL PATTERN The client s sensory functions are normal. She has a good vision, good hearing, could feel pain, and could taste normally. She is oriented to time, to the place, to the people around him, and to the events that had happen to him prior to hospitalization. The client cannot understand her present condition. She experience abortion without knowing what causes it. She is very confused about what s happening to her. SELF-PERCEPTION PATTERN The client claimed that there is something wrong with her. She is living a careful and healthy lifestyle especially during pregnancy and she thought she is healthy but then it s a failure that she still experience such condition. She cries because of feeling hopeless that she couldn t manage having a child. ROLE-RELATIONSHIP PATTERN The client is married, 32 years old and has a husband working abroad. It is a failure to her that she can t have a child with her age. She s not with her husband for almost 2 years. Relationship is alright. There s no present conflict that can be observed but in her situation, the distance between them is very hard for her. There s a feelings of hopelessness and depression on her part that she can t be able to give a child to her husband. She often cries when ask about it. She is guided by her mother. Her family are very supportive and caring. SEXUALITY REPRODUCTIVE PATTERN The client is a female who has difficulty in pregnancy. She was aborted for 3 times. The first child and second pregnancy last only for 2 months and the third last upto 5 months. She has a regular menstruation, 3 to 5 days duration, and 28 to 30 days interval. She sometimes experience dysmenorrhoea before and on the 1st to 2 days of menstruation.

COPING STRESS TOLERANCE The client often cries when experiencing difficulties like what had happened to her. She usually seeks advices from her mother and sisters. She prefers someone to talk to when she can t already handle problems but there are also times that she just wants to be alone to think well what to do especially when it comes to her husband. The client claimed that there are many problems that she had already encountered and with all of those, she had managed to live it. Having aborted is the one she considers as the worst thing happening in her life and she is still adjusting to accept it. VALUE BELIEF PATTERN The client is a religious, person. She attends mass every Sunday. Praying is her another way to cope up with problems. Believing God makes her think that there s a reason why those things happens to her. IV. DIAGNOSTICS RESULTS

V. Arcoxia

DRUG STUDY

Indication: acute pain, treatment for dysmenorrhoea Contraindication: history of hypersensitivity to etericoxib or to any of excipients of arcoxia Adverse effects: hypertention, edema, dizziness, heartburn, nausea, headache, dyspepsia Nursing responsibilities: observe for the adverse effects of the drugs; Monitor vital signs Justification: because of the pain felt by the client because of abortion, ancorxia is given for relief Methergine Indication: post partum haemorrhage caused by uterine atony or subinvolution Mode of action: increases motor activity of the uterus by direct stimulation of the smooth muscle, shortening the third stage of labor, and reducing blood loss Contraindication: pregnant patients, sensitivity to ergot preparations, patient with hypertension or toxemia Adverse effects: CNS- seizures, stroke, dizziness, headache; CV- hypertention, transient chest pain, palpitations; GI- nausea, vomiting, diarrhea; GU- hematuria; EENT-sinusitis Nursing responsibilities: monitor and record vital signs, monitor contactions, store tablets in tightly closed, light-resistant container, monitor characteristic and amount of vaginal bleeding Justification: the client was aborted, and then underwent completion curettage. This events and procedure would result to bleeding and could lead to severity if bleeding is not controlled thus, methergine should be administered to control bleeding and avoid shock. Methergine Indication: prevention of post operative infection

Mode of action: direct acting trichomonocide that works inside and outside the intestines. It s thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bibd to the DNA and inhibit synthesis, causing sell death Contraindication: hypersensitive to drug or other nitroimidazole derivatives and in women in first trimester of pregnancy Adverse effects: CNS- headache, seizures, fever, vertigo, ataxia, irritability; CV- flattened T wave, edema, flushing; EENT- rhinitis, sinusitis, pharyngitis; GI-nausea, vomiting, anorexia; GU- vaginitis, cystitis, polyuria Nursing responsibilities: give oral form with meals, observe patient for the adverse reactions, monitor liver function test, record number, and characteristic of stools Justification: since the client underwent completion curettage, she is at risk for infection, therefore avoiding it to happen, methronidazole is given VI. LIST OF PRIORITIZED NURSING DIAGNOSIS 1. Fatigue r/t post medical procedure as manifested by inability to do the activities of daily living independently Justification: this should be the first to be prioritized, since it is the patient s subjective complaint 2. Acute pain r/t contraction of the uterus secondary to abortion 3. Grieving r/t loss of child secondary to miscarriage 4. Risk for infection r/t post 5. Activity intolerance r/t

PATHOPHYSIOLOGY

Too early uterine contractions caused by some abnormalities temperature decreased of pregnancy (history of consecutive abortion)

Severe pain around the hips, bleeding occurs

Due to bleeding, the hypothalamus signals the heart to respond to bleeding and pain

Completion curettage done for treatment due to bleeding and release of fragments from the uterus

Decreased blood circulation in the body as a result, temperature decreased

Heart pumps more blood to supply the body: Cardiac rate, pulse rate, and respiratory rate increased

Body should function in responding to the procedure

Decrease oxygen carrier Metabolic rate increases due to the energy needed by the system of the

Exhaustion

FATIGUE