I.

PATIENT ASSESSMENT DATA BASE

A. GENERAL DATA
1. Patient’s Name: SM
2. Address: Tarlac, Pangasinan
3. Age: 31
4. Sex: female
5. Birth Date: October 3 1978
6. Rank in the family: Youngest among 3 siblings
7. Nationality: Filipino
8. Civil status: Married
9. Date of Admission: August 28, 2010 at 12:10 am
10. Order of admission: CBC,U/A, Ketorolac 1 amp IVP every 6 hours, Cefazolin 500mg IVP every 6
hours
11. Attending Physician: Dra. Bautista
B. CHIEF COMPLAIN:
The patient brought to the hospital due to labor pain.

C. HISTORY OF PRESENT ILLNESS:

NOT APPLICABLE
D. PAST HEALTH HISTORY /STATUS
1. Childhood Illnesses: She experienced common colds at rainy season.
2. Immunization: According to the patient she have a complete Immunization.
3. Major Illnesses: According to the patient she does not have major illnesses since childhood.
4. Current medications : According to the patient she there is no current medication
5. Allergies: According to the patient she does not have allergies.

E. FAMILY ASSESSMENT

NAME RELATION AGE SEX OCCUPATION EDUCATIONAL ATTINMENT

FM Mother 49 Female Housewife High school graduate

JM Father 54 Male Farmer High school graduate

F. SYSTEM REVIEW:

1) HEALTH PEFCEPTION - HEALTH MANAGEMENT PATTERN

 Client’s Perception of Health: The patient perceives health as health is wealth.

 Client’s Perception about Illness: In contrast to health the patient perceives illness as “maskit sa bulsa”.
  Health Maintenance and habits: In maintaining her health, she takes vitamins, drink ensure milk and
walking around their compound’ as her exercise.
 Compliance with prescribed medications and treatment: The patient actively cooperates on medications
and treatment being prescribed.

2) NUTRITIONAL- METABOLIC PATTERN

 Appetite: The smells of food can trigger the patient’s appetite.

 Usual Daily Menu
o Food – meat and vegetables
o Water - the patient drinks 8 glasses of water per day.
o Beverages- the patient seldom drink beverages.

3) ELEMINATION PATTERN

 Bowel Habits: According to SM, she usually defecates 2 to 3 times a day.

o Color: Golden Brown
o Odor: normal odor of the stool
o Consistency: semi formed stool
o Laxative use, if any: The patient is riot using any laxatives

 Bladder: The patient usually urinates 6 times a day.

o Color: light yellow with a transparency of turbid color
o Odor: Aromatic
 o Alteration if any: The patient usually urinates small and frequent.

4) ACTIVITY - EXRCISE PATTERN- Self care ability

0 Feeding 0 Dressing I Grooming I Bathing

0 Toileting I Cooking 0 Bed mobility I Home maintenance

LEGEND

0 - Full Care

I - Requires use of equipment

II - Requires assistance or supervisions from others

III - Requires assistance or supervisions from another and equipments and devices

IV - Dependent, doesn’t participate

5) COGNITIVE- PERCEPTUAL PATTERN

 Hearing: Upon whisper test, the patient can repeat word that is being whispered. She is not using any
hearing aids.
  Vision: The patient has normal vision.
 Sensory Perception: Upon applying pressure to the left extremities, the patient responds actively. She can
also differentiate two different odors such as perfume and smell of food.
 Learning Styles: in order for the patient to learn, she read books and by the use of media. In terms of
decision making, she approaches her husband and makes decision together.

6) SLEEP - REST PATTERN

 Sleep habits: Before sleeping, Mrs. SM read pocket books and watch television programs.
 Special sleeping problems: Mrs. SM doesn’t have any alterations/problems in her sleeping pattern.
 Hours of sleep: Usually, the patient steeps at 10pm up to 6am and she takes afternoon nap for about 3
hours.
 Sleeping alterations: According to the patient, he doesn’t experience any alterations during her sleep
hours.
 Sleeping Aids: Her sleeping aids are reading, and watching television program.

7) SELF PERCEPTON AND SELF-CONCEPT PATTERN

 Feeling about current state: Despite of her condition, the patient still thinks positively because, she
believes that” being optimistic is a factor for fast recovery.”
 Description of self: She describes herself as “ayos lang naman ako at masaya kahit mahirap ang buhay.”
 Known capabilities and weaknesses: Mrs. SM stated that her family is her strengths and weakness.
 Self worth: The patient stated that “mahalaga ako para sa mga anak ko”.

8) ORAL RELATIONSHIP PATTERN

 According to the patient, she establishes a harmonious relationship towards her family and significant others.

9) SEXUALITY- REPRODUCTIVE PATTERN

The patient can still perform sexual activity together with her husband.

MENSTRUAL HISTORY

Her first menarche was when she was 13 yrs. old. Usually, her menstruation last for three week and can she spend
2-3 pads per day. She also had mentioned of experiencing dysmenorrheal during first day of menstruation.

1O) COPING- STRESS TOLERANCE PATTERN

 Perception of stress and problems in life: She perceives stress and problems as “sakit ng ulo”.
 Coping methods and support systems used: The patient copes up with stress by praying and just relaxing.

11) VALUE— BELIEF PATTERN

The patient is member of Roman Catholic and believes that “ang buhay ay mahalaga at dapat ingatan”.

G. HEREDO-FAMILIAL ILLNESS
MATERNAL: according to the patient there is no disease in their side.
PATERNAL: according to the patient there is no disease in their side.
H. DEVELOPMENTAL HISTORY (according to Erickson, Kohlberg, Fowler)

Theorist Age Sex Patient Description

Erick Psychosocial Development

Erickson Middle- female
aged adult
Assisting teenage children to become responsible and happy adults

Spiritual Development
James Stage-5
Fowler adult
female May be self-conscious about spiritual matters

Social Science and Conscience

Lowrence Stage-4
Kohlberg adult
female Fulfills social duties in order to keep the social system going
I. PHYSICAL ASSESSMENT
A. GENERAL SURVEY
1. Overall appearance and grooming: upon assessment, the patient weak in appearance.
2. Actual height and weight vs. ideal body weight:
3. Symptoms of distress: the patient weak in appearance.
4. Posture, gait:
5. Affect, mood:
6. Relevance and organization of thought:
B. VITAL SIGNS:
Blood Pressure: 110/80 mmHg
Cardiac Rate: 104 bpm
Respiratory Rate: 28 cpm
Temperature: 36.3 ˚ C

C. REGIONAL EXAM – utilize IPPA technique

1. Hair: silky, resilient hair, black in color, thick in hair, and with normal hair distribution upon
inspection.
Head: rounded, smooth skull contour, no lesions noted upon inspection.
 Face: symmetric facial features, palpebral fissures equal in size, symmetric naso labial fold,
symmetric facial movement and no lesions upon inspection.
2. Eyes: hair of eyebrows evenly distributed, skin intact, eyebrows symmetrically aligned, eyelashes
equally distributed, curled slightly out ward, no discharge, no discoloration, lids close
symmetrically, shiny, smooth, and pink palpebral conjunctiva upon inspection.
3. Nose: symmetric and straight, no discharge or flaring, uniform color, not tender, and no lesion
upon palpation and inspection.
4. Ears: color same as facial skin, symmetrical, auricle aligned with outer cantus of eye about 10
degree from vertical, mobile, firm, and not tender, pinna recoils after it is folded upon palpation
and inspection.
5. Mouth and Throat: cyanotic lips, no lesions, smooth tongue, tongue moves freely, pink in color,
and pink mucosal membrane upon inspection.
6. Neck and Lymph nodes: head centered coordinated, smooth movement with no discomfort,
lympnodes not palpable, and no lesions upon palpation and inspection.
7. Skin: light brown in color, warm to touch.
8. Nails: convex curvature, smooth texture, intact epidermis, prompt return to pink.
9. Thorax and Lungs: skin intact, chest wall intact, no tenderness, no masses, abnormal breath
sounds noted (wheezing upon expiration and crackles upon inhalation) upon auscultation.
10. Cardiovascular: with normal rhythm- lubdub,
11. Breast and axilla: no lesion and discharge upon inspection.
12. Abdomen: uniform color, symmetric movement caused by respiration, no tenderness, relax
abdomen with smooth.
 13. Extremities: not perform
14. Genitals: not perform
15. Rectum and Anus: not perform
16. Neurological/ Cranial nerves: not perform

II. PERSONAL / SOCIAL HISTORY:

A. Habits / Vices

a) Caffeine - the patient drinking coffee 2 times a day.

b) Smoking - the patient states that she’s never smokes since teenage years.

c) Alcohol- The patient doesn’t drink alcohol.

d) Tea- she drinks a cup of tea if available.

e) Drugs- she’s not taking any prohibited drugs

B. Lifestyle: she’s doing the household chores.

C. Social Affiliation: The patient can participate in such activities in the community.

D. Rank in the family: She is the youngest of the 3 siblings

E. Travel (within 6 mos.): The patient didn’t travel to far place 6 months prior to admission.

F. Educational Attainment: High School graduate

III. ENVIRONMENTAL HISTORY (LIVING / NEIGHBORHOOD/ CIRCUMSTANCES)
The patient is living together with her husband and children. They are living in a simple bungalow
house far from the municipality. In the backyard they have small poultry and small garden.

IV. PEDIATRIC HISTORY (for neonates / infants and mothers)

NOT APPLICABLE

V. INTRODUCTION (RELATED TO THE DISEASE / CASE OF THE PATIENT)

VI. ANATOMY AND PHYSIOLOGY

 The vagina is a muscular, hollow tube that extends from the vaginal opening to the cervix of the
uterus. It is situated between the urinary bladder and the rectum. It is about three to five inches long in a grown woman.
The muscular wall allows the vagina to expand and contract. The muscular walls are lined with mucous membranes,
which keep it protected and moist. A thin sheet of tissue with one or more holes in it, called the hymen, partially covers the
opening of the vagina. The vagina receives sperm during sexual intercourse from the penis. The sperm that
survive the acidic condition of the vagina continue on through to the fallopian tubes where fertilization may occur.
The vagina is made up of three layers, an inner mucosal layer, a middle muscularis layer, and an outer fibrous layer. The
inner layer is made of vaginal rugae that stretch and allow penetration to occur. These also help with stimulation of the
penis. The middle layer has glands that secrete an acidic mucus (pH of around 4.0.) that keeps bacterial growth down.
The outer muscular layer is especially important with delivery of a fetus and placenta.
Purposes of the Vagina
• Receives a males erect penis and semen during sexual intercourse.

• Pathway through a woman's body for the baby to take during childbirth.

• Provides the route for the menstrual blood (menses) from the uterus, to leave the body.

• May hold forms of birth control, such as a diaphragm, FemCap, Nuva Ring, or female condom.
Thecervix (from Latin "neck") is the lower, narrow portion of the uterus where it joins with the
top end of the vagina. Where they join together forms an almost 90 degree curve. It is cylindrical
or conical in shape and protrudes through the upper anterior vaginal wall. Approximately half its
length is visible with appropriate medical equipment; the remainder lies above the vagina beyond view. It is occasionally
called "cervix uteri", or "neck of the uterus". During menstruation, the cervix stretches open slightly to allow the
endometrium to be shed. This stretching is believed to be part of the cramping pain that many women experience.
Evidence for this is given by the fact that some women's cramps subside or disappear after their first vaginal birth
because the cervical opening has widened. The portion projecting into the vagina is referred to as the portio vaginalis
orectocervix. On average, the ectocervix is three cm long and two and a half cm wide. It has a convex, elliptical surface
and is divided into anterior and posterior lips. The ectocervix's opening is called the external os. The size and shape of the
external os and the ectocervix varies widely with age, hormonal state, and whether the woman has had a vaginal birth. In
women who have not had a vaginal birth the external os appears as a small, circular opening. In women who have had a
vaginal birth, the ectocervix appears bulkier and the external os appears wider, more slit-like and gaping. The
passageway between the external os and the uterine cavity is referred to as the endocervical canal. It varies widely in
length and width, along with the cervix overall. Flattened anterior to posterior, the endocervical canal measures seven to
eight mm at its widest in reproductive-aged women. The endocervical canal terminates at the internal os which is the
opening of the cervix inside the uterine cavity. During childbirth, contractions of the uterus will dilate the cervix up to 10 cm
in diameter to allow the child to pass through. During orgasm, the cervix convulses and the external os dilates. The
uterus is shaped like an upside-down pear, with a thick lining and muscular walls. Located near the floor of the pelvic
cavity, it is hollow to allow a blastocyte, or fertilized egg, to implant and grow. It also allows for the inner lining of the
uterus to build up until a fertilized egg is implanted, or it is sloughed off during menses. The uterus contains some of the
strongest muscles in the female body. These muscles are able to expand and contract to accommodate a growing fetus
and then help push the baby out during labor. These muscles also contract rhythmically during an orgasm in a wave like
action. It is thought that this is to help push or guide the sperm up the uterus to the fallopian tubes where fertilization may
be possible. The uterus is only about three inches long and two inches wide, but during pregnancy it changes rapidly and
dramatically. The top rim of the uterus is called the fundus and is a landmark for many doctors to track the progress of a
pregnancy. The uterine cavity refers to the fundus of the uterus and the body of the uterus. Helping support the uterus are
ligaments that attach from the body of the uterus to the pelvic wall and abdominal wall. During pregnancy the ligaments
prolapse due to the growing uterus, but retract after childbirth. In some cases after menopause, they may lose elasticity
and uterine prolapse may occur. This can be fixed with surgery. Some problems of the uterus include uterine fibroids,
pelvic pain (including endometriosis, adenomyosis), pelvic relaxation (or prolapse), heavy or abnormal menstrual
bleeding, and cancer. It is only after all alternative options have been considered that surgery is recommended in these
cases. This surgery is called hysterectomy. Hysterectomy is the removal of the uterus, and may include the removal of
one or both of the ovaries. Once performed it is irreversible. After a hysterectomy, many women begin a form of alternate
hormone therapy due to the lack of ovaries and hormone production. At the upper corners of the uterus are the fallopian
tubes. There are two fallopian tubes, also called the uterine tubes or the oviducts. Each fallopian tube attaches to a side of
the uterus and connects to an ovary. They are positioned between the ligaments that support the uterus. The fallopian
tubes are about four inches long and about as wide as a piece of spaghetti. Within each tube is a tiny passageway no
wider than a sewing needle. At the other end of each fallopian tube is a fringed area that looks like a funnel. This fringed
area, called the infundibulum, lies close to the ovary, but is not attached. The ovaries alternately release an egg.
When an ovary does ovulate, or release an egg, it is swept into the lumen of the fallopian tube by the frimbriae.
Once the egg is in the fallopian tube, tiny hairs in the tube's lining help push it down the narrow passageway toward the
uterus. The oocyte, or developing egg cell, takes four to five days to travel down the length of the fallopian tube. If enough
sperm are ejaculated during sexual intercourse and there is an oocyte in the fallopian tube, fertilization will occur. After
fertilization occurs, the zygote, or fertilized egg, will continue down to the uterus and implant itself in the uterine wall where it
will grow and develop. If a zygote doesn't move down to the uterus and implants itself in the fallopian tube, it is called a
ectopic or tubal pregnancy. If this occurs, the pregnancy will need to be terminated to prevent permanent damage to the
fallopian tube, possible hemorrhage and possible death of the mother.
Mammary glands are the organs that produce milk for the sustenance of a baby. These exocrine glands are enlarged
and modified sweat glands. The basic components of the mammary gland are the alveoli (hollow cavities, a few
millimeters large) lined with milk-secreting epithelial cells and surrounded by myoepithelial cells. These alveoli join up to
form groups known as lobules, and each lobule has a lactiferous duct that drains into openings in the nipple. The
myoepithelial cells can contract, similar to muscle cells, and thereby push the milk from the alveoli through the lactiferous
ducts towards the nipple, where it collects in widenings (sinuses) of the ducts. A suckling baby essentially squeezes the
milk out of these sinuses. The development of mammary glands is controlled by hormones. The mammary glands exist in
both sexes, but they are rudimentary until puberty when - in response to ovarian hormones - they begin to develop in the
female. Estrogen promotes formation, while testosterone inhibits it. At the time of birth, the baby has lactiferous ducts but
no alveoli. Little branching occurs before puberty when ovarian estrogens stimulate branching differentiation of the ducts
into spherical masses of cells that will become alveoli. True secretory alveoli only develop in pregnancy, where rising
levels of estrogen and progesterone cause further branching and differentiation of the duct cells, together with an increase
in adipose tissue and a richer blood flow. Colostrum is secreted in late pregnancy and for the first few days after giving
birth. True milk secretion (lactation) begins a few days later due to a reduction in circulating progesterone and the
presence of the hormone prolactin. The suckling of the baby causes the release of the hormone oxytocin which stimulates
contraction of the myoepithelial cells. The cells of mammary glands can easily be induced to grow and multiply by
hormones. If this growth runs out of control, cancer results. Almost all instances of breast cancer originate in the
lobules or ducts of the mammary glands.

VII. PHATHOPHYSIOLOGY

Release of FSH by
the anterior pituitary gland

Development of the Graafian follicle

Production of estrogen (thickening

of the endometrium)

Release of the luteinizing hormone

Ovulation (release of mature ovum from the graafian follicle)

Ovum travels into the fallopian tube

Fertilization (union of the ovum and sperm in the ampulla)

Zygote travels from the fallopian tube to the uterus

Implantation

Development of the fetus/embryo &

placental structure until full term.
VIII. LABORATORY AND DIAGNOSTIC EXAMINATIONS
DATE:
TYPE OF EXAMINATION: Complete Blood Count

Test result FLAG Limit Reference Range Limit 1

WBC 9.7 G/L [ * ] 4.1 – 10.9 GL
LVM 2.9 30.6% [ * ] 0.6 – 4.1 10.0 – 58.5 % L
MID 0.6 5.9%M [ * ] 0.0 – 1.8 0.1 – 24.0 % M
GRAN 6.2 64.1%G 2.0 – 7.8 37.0 - 92.0 % G
RBC 5.33 T/L 4.20 – 6.30 T/L
HGB 115 G/L L 120 – 180 G/L
HCT 372 L/L .370 - .510 L/L
MCV 69.8 fL L 80.0 – 97.0 fL
MCH 21.6 pg L 26.0 – 32.0 pg
MCHC 309 g/L L 310 – 360 g/L
PLT 256 L/L URI 140.0 – 440 L/L

 MID cells may include less frequently occurring, and rare cells correlating to monocytes, eosono[hils, basophils,
blast, and other precursor with cells.

IX. DRUG STUDY

Generic Name: Cefazolin

Brand Name: Ancef

Drug Classification: Cephalosporine

Dosage: [Usual]: 500mg to 1g IV q8h. 

[Moderate to severe]: 500mg – 1 gram q6-8h. 
[life-threatening]: 1–1.5g q6h. 
[Maximum dosage/day]: 12 grams.

Indication: Cefazolin is mainly used to treat bacterial infections of the skin. It can also be used to treat moderately severe bacterial infections
involving the lung, bone, joint, stomach, blood, heart valve, and urinary tract. It is clinically effective against infections caused by staphylococci and
streptococci of Gram-positive bacteria. These organisms are common on normal human skin. Resistance to cefazolin is seen in several species of
bacteria.

MECHANISM OF SIDE EFFECTS CONTRAINDICATION ADVERSE REACTION NURSING

ACTION CONSIDERATION

This drug is
bactericidal and have
the same mode of
action as other beta-
lactam antibiotics
(such as penicillins)
but are less
susceptible to
penicillinases.
Cephalosporins disrupt
the synthesis of the
peptidoglycan layer of
bacterial cell walls.
The peptidoglycan
layer is important for
 allergic reactions  hypersensitivity. to Serious Reactions Monitor closely for signs
like skin rash, drug/class/compon. and symptoms of
itching or hives,  caution if renal  neutropenia hypersensitivity
swelling of the impairment  thrombocytopenia reactions, including
face, lips, or  caution if hypersens.  anaphylaxis anaphylaxis.
tongue to PCN • Check drug blood level
 Stevens-Johnson
 breathing  caution if abx-assoc. weekly. Therapeutic
syndrome
problems colitis hx peak ranges from 30 to
 pseudomembranous
 fever or chills  caution if seizure 40 g/L; therapeutic
colitis
 redness, disorder trough, 5 to 10 mg/L.
 nephrotoxicity • Assess BUN and
blistering, peeling  caution if concurrent  seizures
or loosening of nephrotoxic agents creatinine levels every 2
the skin, including days, or daily in patients
inside the mouth with unstable renal
function.
cell wall structural  seizures • Monitor urine output
integrity. The final  severe or watery Common Reactions daily. Weigh patient at
transpeptidation step diarrhea least weekly.
in the synthesis of the  sore throat • Assess hearing before
 diarrhea
peptidoglycan is  stomach pain or and during therapy; stay
 rash
facilitated by cramps alert for hearing loss.
transpeptidases known  vomiting Patient may require
 trouble passing  nausea
as penicillin-binding urine or change baseline and weekly
proteins (PBPs). PBPs  abdominal pain audiograms.
in the amount of
bind to the D-Ala-D-Ala  anorexia • Check I.V. site often
urine
at the end of  elevated liver for phlebitis.
 unusual bleeding
muropeptides transaminases • Watch for "red-man"
or bruising
(peptidoglycan  urticaria syndrome, which can
precursors) to  thrombophlebitis result from rapid
crosslink the  diarrhea infusion. Signs and
peptidoglycan. Beta-  genital or anal symptoms include
lactam antibiotics irritation hypotension, pruritus,
mimic this site and  loss of appetite and maculopapular rash
competitively inhibit  nausea, vomiting on face, neck, trunk, and
PBP crosslinking of  pain or redness limbs.
peptidoglycan. where injected • Monitor CBC. Watch
for signs and symptoms
of blood dyscrasias.
• Closely monitor
respiratory status. Stay
alert for wheezing and
dyspnea.
☞ Monitor vital signs
and cardiovascular
status, especially for
vascular collapse and
other signs of impending
cardiac arrest.

Patient teaching

• Tell patient he may

take with or without
food.
• Instruct patient to take
 oral drug exactly as
prescribed for as long as
prescribed, even if
symptoms improve.
• Explain importance of
prophylactic I.V. therapy
to patients at risk for
endocarditis who are
scheduled for invasive
procedures.
☞ Advise patient to
promptly report rash,
hearing loss, breathing
problems, and signs and
symptoms of "red-man"
syndrome,
nephrotoxicity, and
blood dyscrasias.
• As appropriate, review
all other significant and
life-threatening adverse
reactions and
interactions, especially
those related to the
drugs and tests

Generic Name: Ketorolac tromethamine

Brand Name: Toradol

Drug Classification: Nonsteroidal anti-inflammatory
Dosage: 30mg/amp1 amp IM
Indication: Short term management of pain (not to exceed 5 days total for all routes combined)
MECHANISM OF
ACTION
- Inhibits prostaglandin
synthesis, producing
peripherally mediated
analgesia
- Also has antipyretic and
anti-inflammatory
properties.
- Therapeutic
effect:Decreased pain
SIDE EFFECTS CONTRAINDICATION ADVERSE REACTION NURSING
CONSIDERATION
- CNS: - Hypersensitivity Adverse reaction rates - Patients who have
1) drowsiness - Cross-sensitivity with increase with higher asthma, aspirin-induced
2) abnormal thinking other NSAIDs may doses of ketorolac allergy, and nasal polyps
3) dizziness exist¨Pre- or tromethamine. are at increased risk for
4) euphoria perioperative use Practitioners should be developing hypersensitivity
5) headache- - Known alcohol alert for the severe reactions. Assess for
- RESP: intoleranceUse complications of rhinitis, asthma, and
1) asthma cautiously in: treatment with ketorolac urticaria.
2) dyspnea 1) History of GI tromethamine, such as - Assess pain (note type,
- CV: bleeding G.I. ulceration, bleeding location, and intensity)
1) edema 2) Renal impair-ment and perforation, prior to and 1-2 hr following
2) pallor (dosage reduction may postoperative bleeding, administration.
3) vasodilation be required) acute renal failure, - Ketorolac therapy should
- GI: 3) Cardiovascular anaphylactic and always be given initially by
1) GI Bleeding disease anaphylactoid reactions, the IM or IV route. Oral
2) abnormal taste and liver failure (see therapy should be used
3) diarrhea Boxed WARNING, only as a continuation of
4) dry mouth WARNINGS, parenteral therapy.
5) dyspepsia PRECAUTIONS, and - Caution patient to avoid
6) GI pain DOSAGE AND concurrent use of alcohol,
7) nausea ADMINISTRATION). aspirin, NSAIDs,
- GU: These NSAID-related acetaminophen, or other
1) oliguria complications can be OTC medications without
2) renal toxicity serious in certain consulting health care
3) urinary frequency patients for whom professional.
- DERM: ketorolac tromethamine - Advise patient to consult
1) pruritis is indicated, especially if rash, itching, visual
2) purpura when the drug is used disturbances, tinnitus,
3) sweating inappropriately. weight gain, edema, black
4) urticaria stools, persistent headche,
 - HEMAT: or influenza-like
1) prolonged syndromes
bleeding time (chills,fever,muscles
- LOCAL: aches, pain) occur.
1) injection site pain - Effectiveness of therapy
- NEURO: can be demonstrated by
1) paresthesia decrease in severity of
- MISC: pain. Patients who do not
1) allergic reaction, respond to one NSAIDs
anaphylaxis may respond to another.

X. LIST OF IDENTIFIED PROBLEMS ACCORDING TO PRIORITY

a) Acute pain related to post-operative surgical incision
b) Activity intolerance related to pain

XI. NURSING CARE PLAN

 ASSESSMENT NURSING ANALYSIS PLANNING INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

Subjective: Acute pain The client After 12 hours Perform a Pain is a subjective After nursing
“Masakit iyong related to experiencing the shift, the comprehensive experience and interventions
inoperahan nila” as post- pain due to her client’s pain assessment of must be described the goal was
verbalized by the operative CS operation. will be pain to include by he client in order met
patient. surgical Pain is a typical lessened location, to plan effective
incision sensory characteristics treatment. -The client’s
Objective: experience that After 10 onset, duration, pain was
-facial grimace may be minutes client frequency, The use of lessened
-pale described as the will be able to quality, intensity noninvasive pain
unpleasant perform pain or severity and relief measures can -The client was
VS: awareness of a management: precipitating enhance the able to perform
BP- 110/80 mmHg noxious -deep factors of pain therapeutic effects deep breathing
RR- 28 bpm stimulus or breathing of pain relief exercise
PR- 104 bpm bodily harm. technique Teach the use of medications.
Temp- 36.3˚C Individuals non-
experience pain Every 4 hours, pharmacologic Assessments of vital
by various daily the client vital techniques: signs is an important
hurts and signs will be -deep breathing component of the
aches, and monitored technique physical therapy
occasionally examination and
through more Monitor client’s should be included
serious injuries vital signs in the examination
or illnesses. of all patients
XII. ONGOING APPRAISAL

The patient shows progressive recovery and is responding well to both medical and nursing interventions.