CHAPTER I

INTRODUCTION

M.J.B from carigara, Leyte. 22 years of age. Primigravida and primipara (primigravida, a woman who is
pregnant for the first time. Primipara, a woman who gave birth for the first time.) delivered her first child on
november 4 though cesarean section. Cesarean Section is a surgical operation for delivering a child by cutting
through the wall of the mother's abdomen. The client had to go CS operation due to fetal’s postion which is frank
breech. A frank breech is the most common breech presentation especially when a baby is born at full term. The
Baby of the client was confined to the NICU. Thus, she exhibits breast engorgement due to unable to breast
feed. Breast engorgement is a problem that is common in the early days and weeks of breastfeeding. Once your
baby is born, your breasts are given a signal to start full milk production. Blood flows to your breasts, and your
milk usually comes in 1 to 4 days after the birth. Breast engorgement is when your breasts get full and sore. After
application of warm compress at both breast, the client was able to breast feed to her baby at NICU.
Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and
development. Virtually all mothers can breastfeed, provided they have accurate information, and the support of
their family, the health care system and society at large.Client was Day x5 of being PCS, the client was positive
for dengue infection. Dengue (pronounced DENgee) fever is a painful, debilitating mosquito-borne disease
caused by any one of four closely related dengue viruses. These viruses are related to the viruses that cause
West Nile infection and yellow fever. She experiences episode of fever on Nov 8, 2019, and exhibits rashes at
upper part of the chest. Fever -when a human's body temperature goes above the normal range of 36–37°
Centigrade (98–100° Fahrenheit). It is a common medical sign. Other terms for a fever include pyrexia and
controlled hyperthermia. Based on data gathered, tiped sponge bath was performed. Tepid sponge bath -is a
therapeutic bath by washing all around of the body with warm water to decrease body temperature. Warm water
that used were 32oC (nail warm) and 37oC (warm).

Epidemiologic of the disease:

Dengue viruses are spread to people through the bite of an infected Aedes species (Ae. aegypti or Ae.
albopictus) mosquito. Dengue is common in more than 100 countries around the world. Forty percent of the
world’s population, about 3 billion people, live in areas with a risk of dengue. Dengue is often a leading cause of
illness in areas with risk.

Ideal management:

 There is no specific medication to treat dengue.

 Treat the symptoms of dengue and see your healthcare provider.
 If you think you have dengue
 See a healthcare provider if you develop a fever or have symptoms of dengue. Tell him or her
about your travel.
 Rest as much as possible.
 Take acetaminophen (also known as paracetamol outside of the United States) to control fever
and relieve pain.
 Do not take aspirin or ibuprofen!
 Drink plenty of fluids such as water or drinks with added electrolytes to stay hydrated.
For mild symptoms, care for a sick infant, child, or family member at home.
 CHAPTER II

COMPREHENSIVE NURSING HEALTH HISTORY

PERSONAL PROFILE OF THE CLIENT

The client MJB was born on January 3, 1997. She is now 22 years of age. She lives at Carigara , Leyte
and currently not employed. She is a college graduate under the program of secondary education. She is now
single. Her support person at the moment is Evelyn Tuyom, the client’s mother, and has no occupation.

Before pregnancy the client was having menstruation every month, she is regular and has a duration
ranging of 3 days to 1 week. She describes the amount of blood flow of her menstruation as moderate. The client
also stated that she experiences dysmenorrhea during her every menstruation.

The client’s pregnancy history is primigravida and primipara. Her last menstruation period was on January
17, 2019. The client stated that her pregnancy was not planned. The length of labor of client was more than 24
hours. She gave birth for the first time on November 4, at RHNC-EVRMC. The presentation of the fetus was
breech. Thus, the mode of delivery was cesarean section. There was anesthesia used.

Duration Mode Live place of Status of

of Birth/
Year Pregnancy Sex weight
of labor delivery Still delivery Immunization
birth
RHNC-
2019 24 hrs CS / Male 3.1 kg EVRMC 0

HISTORY OF PRESENT ILLNESS

The client was first had fever on Novemeber 4, 2019 at 11:24 AM. It was when few hours after her
child delivery. She then experienced second episode of fever on November 6, 2019. The client MJB was
suspected to have Dengue Infection and referred to Dengue Rapid Test. On November 8, 2019, the clients,
DTR came out to be positive, and at the same day experienced the third episode of fever at 10:50 AM

PAST MEDICAL HISTORY

The client stated the she does not remember any childhood disease. The client did not received
immunization for pre-pregnancy. She does not have allergies. The only surgery she undergone was cesarean
section. She has not also been diagnosed with any mental illnesses.

FAMILY HISTORY
 The father of the client is alive and well, 60 years of age. The mother of the client is alive and has
hypertension. She is 54 years of age. The type of family the client has is blended.

ENVIRONMENTAL HISTORY

The house of the client is owned while the lot is rented. The typre of toilet they had is water sealed and
the water supply is from water piped.There are two ways of garbage disposal they practice, it is burning the
biodegradable and the plastics is by city collection.

Infant data:

The name of the infant was Jhon Ezekiel. Sex is male, and has a weight of 3.1 kilogram at birth

REVIEW OF FUNCTIONAL HEALTH PATTERNS

 Health perception and health maintenance management pattern

The client stated that she does not experiences colds in the past. For her the most important thing to keep
the body healthy is to have exercise and always eat vegetables. She also verbalizes “ayaw pagliningkod”
instead do household chores. She does not use or tried tobacco nor drugs. But she drinks alcohol or beer
when she was college, but according to her, she stopped drinking alcohol after college.

 Nutritional and metabolic pattern

the client stated that after her child delivery, she has low apetite. At November 8, she said that her appetite
was back. She has no eating discomforts nor diet restrictions. The client stated that the usual food she eat is
rice, vegetables, dried fish, fish, and paksiw. She drinks water and seldomly drinks soft drinks.

 Elimination pattern

The client M.B. stated that she eliminates every other day. She has no difficulty in elimination and in
urinating. After her pregnancy, she experiences excess perspiration. Her last elimination was on November 7
at noon time.

 Sleep rest pattern

The client stated the she has trouble falling asleep. She does not do anything about it and just uses
cellphone when she cannot sleep

 Cognitive perceptual pattern

The client has no difficulty in hearing. She also does not wear eyeglasses. There was no chages in her
memory lately and has no difficulty in learning things

 Sexuality- reproductive pattern

The client stated that she only has one sexual partner and was not sexually active after the last months of her
pregnancy. Client was having menstruation every month before pregnancy, she is regular and has a duration
ranging of 3 days to 1 week. She describes the amount of blood flow of her menstruation as moderate. The
client also stated that she experiences dysmenorrhea during her every menstruation.

 Coping- stress mechanism

The client stated that the biggest change happen to her life in the past two years is having a chil and verbalized
“nababaraka ak” because the situation is unplanned and she is not ready for this big changes. The client has
no methods in handling problems or anxiety like this.

NURSING HEALTH ASSESSMENT

Physical Assessment

A. General survey

The client was groomed accordingly to the environment and situation. The client’s hair was also combed. The
client was awake alert and oriented. The client responds appropriately to the questions.

Vital Signs:

Temperature: 36.4 Respiratory Rate: 28

Pulse rate: 86 Blood Pressure: 100/60

B. Organ system assessment

 The integument

The client has a light skin complexion. On nov 8, The client exhibits rashes at the upper chest but disappeared
after two hours. The skin was smooth, and goes back to its original form within 2 secs. Hair was black and curl.
The hair is also firm and crisp. Nails was clean and properly trimmed. The nails of the client was pinched and
goes back to color pink within 2 secs. No clubbing noted.

 The head

No bulging masses observed in the head and the face. The head and face feels warm and no lesions palpated.
The eyes were symmetric. The client exhibits puffy eyelids and prominent fold of tissue inferior to the lower
eyelid. The Upper and lower conjuctivas were pink and moistened. The sclera is white and the eyeball is not
protruding. The cliet was able to perform the 6 cardinal eye movements without pain felt. The ears was
symmetric, clean and was able to heard two syllable word at both ears. Nose was symmetric and each nostril
is patent.

 The neck

No budging masses observed at the neck of the client. Trachea was alighed in the center. No enlarged lymph
nodes palpated. The neck feels warm when palpated
  The thorax and lungs

No bulging masses observed at the posterior and anterior thorax. The posterior thorax raises and goes doen
symmetrically when breathing. The posterior and anterior thorax was warm and no bulging masses nor lesions
palpated.

 The abdomen

The abdomen of the client was observed to have lower abdominal distention and is supported by a binder. The
clients abdomen was also observed to have darkish color compared to the other parts of the body. A
rectangular wound dressing was noted at the cesarean surgical cut.

 The musculoskeletal

The client’s extremeties were symmetric. And has even distribution of hair. The clients extremeties were warm
to touch. The client lowere extremeties were observed to be swollen. The lower extremities was pinched and
color turns back after 2 seconds.
 CHAPTER IV

CLINICAL MANAGEMENT

 URINALYSIS TEST
-A test of the urine. It involves checking the appearance, concentration, and content of the urine.
Abnormal urinalysis test result may point to a disease
Clinical significance:
-A urinalysis is used to detect and manage a wide range of disorders, such as urinary tract infections,
kidney disease and diabetes.

Nursing Responsibilities
Before:
-Orient the client that she she will undergo urinalysis and explain the purpose of the procedure.
-provide the client for a sterile, disposable container.
During:
-Instruct the client to collect atleast 10 ml of the specimen
-Instruct the client to void directly into a clean, dry container.
-Instruct to clean the labia with soapy water and rinse well before urinating
-Instruct to client to perform hand washing after urinating.
After:
-Instruct the client to drink water to replace fluid loss
-Upon collection of urine specimen, bring immediately the specimen to the lab.

URINALYSIS RESULT
Result date: 11/04/19 2:40:59 PM Room/ward: Emergency Room

Reference Reference
Parameters Result SI/Unit Result unit
range range

Microscopic Examination
Color Amber
Clarity Hazy

Chemical Examination
PH 5.5
espicific gravity 1.034
Leukocyte Negative
Blood Negative
Glucose Trace
 Nitrite Negative
Protein ++
Urobilinogen Normal
Ketone ++
Bilirubin Negative
Creatinine 100.00 mg/dL 10-300
Albumin Over mg/dL 10-150

Microscopic/ Urine
flourescense flow
cytometry
Pus Cells 8.30 /uL 0-17 1.51 /HPF 0-3
Red Cells 3.30 /uL 0-11 0.60 /HPF 0-2
Squamous epithelial cells 22.20 /uL 0-17 4.04 /HPF 0-3
Bacteria 120.70 /uL 0-278 21.95 /HPF 0-50
Mucus Threads 12.97 <moderate 0.00
Hyaline Casts 8.10 0.00

URINALYSIS RESULT
Result date: 11/8/19 Room/ward: Room 1- OB surgical 4th Floor- LR

Reference Reference
Parameters Result SI/Unit Result unit
range range

Microscopic Examination 0
Color Yellow
Clarity Slightly

Chemical Examination
PH 5.5
espicific gravity 1.011
Leukocyte +++
Blood +++
Glucose Negative
Nitrite Negative
Protein +
Urobilinogen Normal
Ketone ++
Bilirubin Negative
Creatinine 10.00 10-300
Albumin 80.00 10-150

Microscopic/ Urine
flourescense flow
cytometry
Pus Cells 312.10 0-17 56.75 0-3
Red Cells 70.60 0-11 12.84 0-2
Squamous epithelial cells 3.90 0-17 0.71 0-3
Non-squamous epithelial
cells 79.50 0.00
Transitional epithelial cells 1.30 0.00
Renal Tubullar epithelial
cells 78.20 0.00
Bacteria 60.90 0-278 11.07 0-50
Mucus Threads 0.81 <moderate 0.00

 CBC Testing
-A complete blood count (CBC) is a series of tests used to evaluate the composition and concentration
of the cellular components of blood.
Clinical significance:
-The CBC provides valuable information about the blood and to some extent the bone marrow, which is
the blood-forming tissue.
Nursing Responsibilities:
Before:
-Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
-Seek for consent of the client because the procedure is invasive.
-Encourage to avoid stress if possible because altered physiologic status influences and changes
normal hematologic values.
-Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of
lipidemia.
During:
-Apply manual pressure and dressings over puncture site on removal of dinner.
 -Monitor the puncture site for oozing or hematoma formation.
After:
-Instruct to resume normal activities and diet.

CBC Result
Result date: 11/ 04/19 7:52:44 PM Room/ward: Emergency Room

Examination Result Unit RR

Hemoglobin 130 g/L 120-150
Hematocrit 0.39 U/L 0.35-0.47
RBC 4.24 X10^12/L 4.2-5.4
WBC H 17.54 X10^9/L 4.8-10.8

Differential count
Neutrophils H 0.87 0.43-0.65
Lymphocytes L 0.03 0.20-0.45
Monocytes 0.08 0.05-0.12
Eosinophils 0.01 0.01-0.03
Basophil 0.01 0-0.01

MCU 92 fL 81-99
MCH 31 pg 27-31
MCHC 330 g/L 330-360
Platelet 175 X10^9/L 150-400
Blood Type “O”
RH Positive

CBC Result
Result date: 11/ 04/19 10:45:17 PM Room/ward: Emergency Room

Examination Result Unit RR

Hemoglobin 146 g/L 120-150
Hematocrit 0.42 U/L 0.35-0.47
RBC 4.73 X10^12/L 4.2-5.4
WBC H 20.91 X10^9/L 4.8-10.8

Differential count
 Neutrophils H 0.92 0.43-0.65
Lymphocytes L 0.02 0.20-0.45
Monocytes 0.05 0.05-0.12
Eosinophils 0.01 0.01-0.03
Basophil 0.00 0-0.01

MCU 89 fL 81-99
MCH 31 pg 27-31
MCHC 350 g/L 330-360
Platelet 178 X10^9/L 150-400

CBC Result
Result date: 11/05/19 8:58:18 PM Room/ward: Room 1- OB surgical 4th Floor- LR

Examination Result Unit RR

Hemoglobin L 115 g/L 120-150
Hematocrit L 0.33 U/L 0.35-0.47

CBC Result
Result date: 11/6/19 Room/ward: Room 1- OB surgical 4th Floor- LR

Examination Result Unit RR

Hemoglobin L 104 g/L 120-150
Hematocrit L 0.29 U/L 0.35-0.47
RBC L 3.33 X10^12/L 4.2-5.4
WBC H 14.49 X10^9/L 4.8-10.8

Differential count
Neutrophils H 0.89 0.43-0.65
Lymphocytes L 0.07 0.20-0.45
Monocytes L 0.04 0.05-0.12
Eosinophils L 0.00 0.01-0.03
Basophil 0.00 0-0.01

MCU 88
MCH 31
 MCHC 360
Platelet 212 X10^9/L 150-400

 SEROLOGY TEST
- Serologic tests are blood tests that look for antibodies in your blood. They can involve a number of
laboratory techniques. Different types of serologic tests are used to diagnose various disease
conditions.
-Serologic tests have one thing in common. They all focus on proteins made by your immune system.
This vital body system helps keep you healthy by destroying foreign invaders that can make you ill. The
process for having the test is the same regardless of which technique the laboratory uses during
serologic testing.
Clinical Significance:
- Antigens are substances that provoke a response from the immune system. They’re usually too small
to see with the naked eye. They can enter the human body through the mouth, through broken skin, or
through the nasal passages. Antigens that commonly affect people include the following: bacteria,
fungi, viruses, parasites.
Nursing Responsibilities:
Before:
-Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
-Seek for consent of the client because the procedure is invasive.
During:
-Monitor the puncture site for oozing or hematoma formation.
After:
- Instruct the client to avoid using that arm for heavy lifting for the rest of the day.

SEROLOGY RESULT
Result Date:11/04/19 6:22:30 PM Room/ Ward: Emergency Room

Examination Result Unit RR

Anti- TP Nonreactive
HBsAG Nonreactive

SEROLOGY RESULT
Result Date:11/06/19 6:55:17 PM Room/ Ward: Room 1- OB surgical 4th Floor- LR

Examination Result Unit RR

Dengue NSI Antigen Negative
 Dengue IgG Positive
Dengue IgM Positive

 CHEMISTRY TEST
-information about how your body is functioning. A basic metabolic panel is a combination of tests that
helps them assess important functions in your body. Your sodium, potassium, and chloride levels will
be tested as part of your electrolyte panel. Electrolyte balance is essential to the normal functioning of
the muscular, cardiovascular, and nervous systems.

Clinical significance:
The basic metabolic panel can give your doctor a good idea as to whether you have any serious
problems with blood filtration,acid/base balance of your blood, blood sugar levels, electrolyte levels.
This can help uncover a variety of medical issues, including: kidney problems, lung problems, problems
with your pancreas or insulin metabolism

Nursing Responsibilities:
Before:
-Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
-Seek for consent of the client because the procedure is invasive.
-Encourage to avoid stress if possible because altered physiologic status influences and changes normal
hematologic values.
During:
-Apply manual pressure and bandage to remain in place for 10 to 20 minutes to stop any bleeding.
-Monitor the puncture site for oozing or hematoma formation.
After:
- Instruct the client to avoid using that arm for heavy lifting for the rest of the day.

CHEMISTRY RESULT
Result Date:11/06/19 6:55:51 PM Room/ Ward: Room 1- OB surgical 4th Floor- LR

Examination Result Unit RR

Sodium 137.5 mmol/L 135-148
Potassium L 3.26 mmol/L 3.5-5.3
Chloride 104.4 mmol/L 98-107

Surgical management/ Special procedures: Cesarean Section

Nursing Care:

Preoperative Measures
Measures that should be taken to ensure the woman’s safety during surgery.
1. secure the informed consent from the patient.

2. Inform the client about the consent and the risks and benefits of the procedure must be explained in a
language that the woman understands.

3. Upon admission, provide the woman with a clean hospital gown and her hair is pulled into a ponytail.

4. Ensure that the woman’s nails should be free from nail polish or any acrylic fingernails because nails
are used to assess capillary refill.

5. Insert catheter to the woman if there is doctors order and ensure that the urine is freely flowing

6. Start intravenous solution such as Ringer’s if prescribed to ensure that the woman is fully hydrated,

7. Documentation of nursing care up until the woman leaves the hospital must be complete and factual.

8. Upon transport to surgery, ensure that the woman is lying on her left side to
prevent supine hypotension.

9. Ensure that the side rails are up, and the woman is covered with a blanket.

10. Instruct the support person to give encouragement to the woman.

Intraoperative Measures

1. Assist the woman first to move from the transport stretcher to the operating table.

2. Encourage the woman to remain on her side or insert a pillow under her right hip to keeher body slightly
tilted to the side to prevent supine hypotension.

3. talk to her gently and let her lean on you while you gently restrain her because it would be difficult for a
woman in labor to remain in a curved position during administration of the anesthetic

4. Perform skin preparation. Shaving away abdominal hair and washing the skin over the incision site with
soap and water could reduce the bacteria on the skin.

5. The woman is then positioned with a towel under her right hip to move abdominal contents away from
the surgical field and lift her uterus away from the vena cava.

6. The woman would be covered by a sterile drape to block the flow of the bacteria from her respiratory
tract to the incision site and also block the woman’s and support person’s lines of sight from the incision
site.

7. Scrub the incision area by an antiseptic, and place additional drapes around the area so that only a
small area of the skin is exposed.

8. Prepare the woman and the support person for the sights they might see.
Postpartal Care
1. Use a pain rating scale to allow a woman to rate her pain. Check for analgesic prescribe by the doctor.

2. Instruct the woman to ambulate in a unilateral movement because this is the most effective method to
relieve gas pain.

3. Inform the woman that she should not take acetylsalicylic acid or aspirin because this can interfere with
blood clotting and healing.

4. Instruct the woman to place a pillow on her lap as she feeds the infant to deflect the weight of the infant
from the suture line and lessen the pain.

5. Teach Football hold for breast feeding. It is a way to keep the infant’s weight off the mother’s incision.

6. Note carefully the woman’s first bowel movement after surgery because if no bowel movement has
been observed, the physician may order a stool softener, a suppository, or an enema to facilitate stool
evacuation.

7. Teach the woman to eat a diet high in roughage and fluid and to attempt to move her bowels at least
every other day to avoid constipation.

8. Remind the woman to drink plenty of water

9. Reassure the woman that it is normal not to have bowel movements for 3 to 4 days postoperatively,
especially if there is enema administered before surgery.

DISCHARGE PLAN:

Medication

-Check for take home medication prescribed by the doctor

-Health educate about the drug, its mechanism of action, General indication, patient’s indication, and its side
effects and/or adverse effects
-Instruct the client to take the take home drugs prescribed by the doctor at a right timing, right dose, right route.
-Instruct the client to stop immediately medication if Hypersensitivity or adverse reactions occurs

Exercise

-For postpartum cesarean section, Advice client to avoid extraneous activities such as running, jumping.
- The client can have around 15 minutes of walking for exercise

Diet
-Instruct the client to eat foods high in protein such as fish, chicken, meat, diary foods, nuts, dried beans and
peas. Also foods high in Vitamin C such are oranges, grapefruits, strawberries, melons, amd papayas. Foods
high in iron such as red meats, liver, dried beans, dried fruits and iron enriched cereals.
 CHAPTER V

Appendices

Physician’s order/ Progress notes.

Date & Time SOAP ORDERS

11/4/19 Referral: from RHU Pls admit under OB services
Capoocan (beech) Service consent
>Not coordinated Start IVF PUV 1Lx308HOV
LMP: 1/17/19 2 days PTA + fever NPO
AOG 41 4/7 -cough -colds Diagnosis
EDC 10/24/19 CBC, BT, RN
61PO VS 120/90 19 UA
106 37.7 HBsAG, anH-Teu
PmH+ +warm to touch For E Primary CS
unremaw Gravel uteru Secure consent
FH 31 Inform on/ Anes/ NICU
PNCU FHT 170-175 Cefazolin 1g W AWST after
Stry UC cord clamping
Cru cat Baseline CT6
E6 quosl normal Monitor FHT and UC every
1 nullifarous 15 MD
SE Insert FBC and attach
IE cx 9cm dilated
Fully , Frank breech VS every hov
St O, -BOW TO on
Refn.
A1G1P0 PU 41 4/7 Uo
AOG, Frankbreech, 1L
TIC usal insertion

*corg OuLR table To DR RH

CS
11;24 AM Temp: 38.7 C Give paracetamol 300 mg
IVTT
For temp 38 C
11/4/19
12;45 pm
 O2 supplementation
BP: 103/60 Nasal cannula
PR: 118 Monitor Vital signs every 15
RR: 16 minsx 2H
: 99% Every 70 mins until only 6
Regulate IVF, PLR 1L + 20
“u” of oxytocin at 30 gtts/min
IVF to follow, D5LR IL + 20
“u” of oxytocin
D5LR IL
D5LR IL
Medications:
1.cefazolin 1g IVTT every 8
hours
2. Metronidazole 500g IVTT
every * hours
3. paracetamol 600mg IVTT
every 6h x 8 doses
4. Tramadol 50g IVTT
every 6 hours
5. Nemitidine 50 g every 8h
11/04/19
2:45 pm

11/05/19 -BM, +GO=200 cc May have clear liour with …

9:00 am No other subjective cues and hard boiled egg once…
9 hours post ep T 36.7 RR 20 Cont. WF and W med
HR 90 BP:100/60 Out FBC this PM

Exclusive…
…. BID
VS every 4h
 refer
11/6/19 + pl.. Soft diet
7:30 AM -BM, freely voiding Repeat cbc today
Day 2 PCS No other subjective D/C IV meds and leminat IVF
complaints Start PO
T=36.7 1.Cefuroxime 500 mg/cap 1
PR=96 cap TID
RR=20 2. Ascorbic acid OD
BP=120/80 3.Ferrous Sulfate + folic acid
tab 1 tab BID
4. Celecoxib 200 mg/ cap 1
cap BID

Insert 2 rectal Bisacoldyl syn

OD
perineal cell BID
increase… ambulation
cleanse dressing fodu
VS every 4 hours and record
Refer
Add
DTR
Temp 38.1
Paracetamol 300 mg IVTT
NOW and every 4 hrsfor
temp ≥38 C round the clock

r/c IAI Reinsert IVF PLR 1L@ 30

gtts/ min now
D/c PO meds cefuroxime
Start IVTT meds
1. Ampicillin 1gram IVTT
( ) ANST every 6
hours
2. Metronidazole 300 mg
IVTT ( ) ANST every
8 hours
3. Gentamycin 240 mg
IVTT ( ) ANST OD
Perined ccc BID
TSB for fever
Ranitidine 30 mg IVTT NOW
Vit. B complex 1 tab TID
Serum K determination
May stew ….
11/7/19 +BM x1, +Platus DAT
8:40 AM Freely voiding Cont. IVF
T=36.2, PR=92 Cont. meds
RR=20, BP 120/80 Start KCL 1 tab TID x 3days
Continue breastfeedinf
Pen….d BID
Change dressing NOW
VS every 4 hours
…
refer
11/08/19 +BM x1, +Flatus DAT except dark colored
7:00 AM Freely voiding. No other foods
subjective complaints Cont. IVF
T=36.4, RR:19 Cont. medications
PR: 97, BP:110/70 ..
Perineal cue BID
IgM PONM Refer to IM for ……..+ …. of
IgG dengue….
VS every 4 hrs
WOF bleeding episode and
refer
I & O every…
Refer
11/9/19 +BMx1, freely voiding, DAT except dark colored
9:00 AM +flatus, no other subjective foods
…..febrile 11/8/19 at 10:50 complaints Cont. IVF PLR 1L x8hrs
AM T=36.4, PR=83 Cont. medications
RR=19 BP=110/20 Hold FeSO4+FA lab ferrous
No vaginal bleeding Serial CBC monitoring every
24 hours
Please H-up referral to IM-
infection
WOF ef episode of
bleeding,…., abdominal pain
VS every 4 hours and record
Repeat K today
refer
 11/9/19 For repeat CBC with PH
12:50 PM tomorrow AM
IVF: PLR I @ 30 gtts/min
Increase oral fluid intake
VS monitoring every 4H
WOF hypotension, narrowed
pulse pressure, bleeding
Cont. cefuroxime 500mg/cap.
1 cap BID
Increase oral fluid intake
Paracetamol 500 g/ tab every
4 H for temp of ≥ 37.8 C +
headache
FU close watch

Recommendations:

Emphasize the Self protective meausure , one of the 5S of the DOH. Since this is the client’s first time to acquire
dengue infection. It is important to prevent the client from acquiring again the same infection at the second time.
According to the University of California, one of the most vexing challenges in the battle against dengue virus is
getting infected once can put people at greater risk for a more severe infection down the road. Thus self
protection should be emphasized like using mosquito net, mosquito repellant, etc. especially that it is the season
of dengue infection.
 Chapter VI

References

 https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/complete-blood-count-cbc/

 https://www.healthline.com/health/basic-metabolic-panel#procedure

 https://www.healthline.com/health/serology#followup

 https://www.google.com/search?q=frank+breech&oq=frank+breech&aqs=chrome..69i57j0l3.4301j0j4&c
lient=ms-android-oppo-rev1&sourceid=chrome-mobile&ie=UTF-8

 https://www.mayoclinic.org/tests-procedures/urinalysis/about/pac-20384907

 https://www.sciencedaily.com/releases/2011/12/111221151713.htm

 https://www.cdc.gov/dengue/symptoms/index.html

 https://www.google.com/amp/s/nurseslabs.com/cesarean-birth/%3famp