Icalina Mary Audrey

BSN II BLOCK 2

Abstract
Patient’s name is Nympha Cabangunay, 32 years old and is married. She lives in
Catbalogan city, Samar and was born on Sept. 9, 1987. She is a Filipino and is a Born Again
Christian. She was diagnosed gravida 2 para 2 (G2P2) pregnancy uterine 38 weeks by
Ballard score, cephalic non reassuring fetal status (record late with deceleration minimal
variability) delivered by emergency primary low segment transverse cesarean section still
alive baby boy. other diagnosis: APGAR 4, 7, 9 clear amniotic fluid baby weight 2215 g baby
length 50 cm pre-labor rupture of membranous x 17 hours s/p in cesarean IUD insertion
colon true knot umbilical.

INTRODUCTION
Patient NC, 32 years old, Gravida 2 Para 2 (G2P2) married to

COMPREHENSIVE NURSING HEALTH HISTORY

A. General Data
Name: CABANGUNAY NYMPHA GALIGAO
Address: CATBALOGAN, SAMAR
Age: 32 Sex: FEMALE Date of birth: 09/09/1987
Nationality: Filipino Religion: BORN AGAIN CHRISTIAN
Civil Status: MARRIED
Educational Attainment: COLLEGE GRADUATE
Date of Admission: 12/04/19
Hospital: Eastern Visayas Regional Medical Center

Diagnosis:

(GORDON’S ASSESSMENT OF THE MOTHER)

A. Reason for Admission
Patient was admitted due to her pregnancy and no illnesses or diseases noted.
B. Obstetric History
Patient stated that she had her menarche at the age of 14, the year of 2001. Her
periods usually lasted about 3 days and she usually experienced dysmenorrhea.
 Year Pregnancy Duration Mode Live Sex/ Place Status of TT
of Labor of Birth/Still Birth of immunization
Deliver Birth Weight Deliver
y y
201 1 2 days NSVD Live Femal RHU Complete
5 Birth e
201 2 30 hrs C.S Live Male EVRMC
9 Birth

C. History of Present Illness:

Patient was admitted due to her pregnancy and no illnesses or diseases noted.
D. Past Health History- Patient rarely experienced getting sick during her childhood
but only ever had cough and mild fever. She had full immunizations and hasn’t
experienced any hospitalizations except when she gave first to her first baby. She
isn’t taking any maintenance medication and isn’t suffering from any chronic
disease.
E. Family History
Patient’s parents are both alive and healthy without any diseases or maintenance
medications. Her father is 61 years old and her mother is 53 years old. Patient
stated that there is a history of high blood pressure from her father’s side of the
family and no hereditary diseases from her mother’s side.

F. Environmental History
Patient’s house is rented and they live there as a nuclear family. Their drainage
system is closed and their water source is piped and their garbage is kept through
city collection.

G. Functional Health Pattern.

A. Health Perception and Maintenance Management Pattern
The patient’s general health has been good and she has only experienced colds
and mild fevers throughout her life and the patient never drinks or smokes or
takes parts in any vices. Patient tries to maintain normal body weight and eats
healthy foods and follows whatever her healthcare provider instructs her.
 B. Nutritional and Metabolic Pattern.
Patient’s daily food intake are fruits, fish and vegetables with rice, patient refrains
from consuming too much meat and drinks 8 to 12 glasses or more per day. She
regularly moves her bowels and has no known food allergies.
C. Elimination Pattern
Patient has no odor problems as well as problems with elimination since she
stated that she regularly urinates clear or light yellow urine
D. Activity Exercise Pattern
Patient stated that she sometimes has enough energy to complete desired
activities. Patient stated the she do not exercise and during her leisure time she
cleans the house, watching television and sleeps.
E. Sleep-Rest Pattern
Patient sleeps for 8 hours and do not have difficulty in sleeping. Patients sleep is
continuous and do take naps in the afternoon. She watch television and also
taking naps after cleaning the house to relax herself.

F. Cognitive Perceptual Manner

Patient does not wear any eyeglasses or hearing aids and do not have a problem
when it comes to hearing and vison. Sometimes, patient forgot to do what she is
going to do and according to her the easiest way of learning is through teaching.
To manage pain, patient stated that she uses “banyos” to ease the pain.
G. Self-perception and Self-concept Pattern
Patient describe herself as kind, patient and loving and she has no problem with
the changes at her body. Patient stated that she get annoyed because of her
children.
H. Role Relationship Pattern
Patient lives with her family and stated that there is no difficulty in handling a
problem. Patient stated that to solve a problem each member of the family should
talk to each other. Patient’s family does depends on her and feels worried about
her pregnancy. Patient stated that she do not have a problem in handling her
children and her family feels part of the neighborhood they are in.
I. Sexuality-Reproductive Pattern
Patient stated that there is no change in terms of sexual relationship with her
partner. Patient had two sex partner and she was only 20 years old when she
had her first sexual contact. Patient is sexually active and uses pills as a
contraceptive.
J. Coping-Stress Pattern
Patient does not get tense and. Patient stated that her live in partner is the most
helpful in talking things and is available anytime. There was no changed in her
life for the last two years. She handles problem through praying.
K. Value-Belief Pattern
Patient do not generally get things that she like out of life. Patient stated that
religion is really important and being hospitalized does not interfere with any
religious practices.
PHYSICAL ASSESSMENT OF THE MOTHER

8am 12 noon
Temperature (°C) 37.6 36.1
Pulse Rate ( bpm) 125 115
Respiratory Rate (cpm) 60 51
Vital Signs:
 1. Integument- The patient’s skin is yellow on the upper and lower extremities. Hair is
evenly distributed and upon palpation there were no nodules, masses noted.
Patient’s skin is warm to touch and skin turgor is positive.
2. Head- patient’s eyes were round and the color of the eyes were black but the sclera
was yellow. Nose is in the midline between the eyes and upon palpation sinuses
were not palpable. NO cleft palate
3. Neck- is symmetric and upon palpation no bulging masses noted. The thyroid
cartilage and corticoid cartilage moved upward symmetrically as the client swallows.
Trachea is in the midline. No tenderness and enlargement noted
CLINICAL MANAGEMENT
A. Urinalysis Result

Parameters Results SI Reference Conventiona

unit Range l
Result Unit Reference
Range
Macroscopic 0.0000
Examination
Color Yellow 0.0000
Clarity Turbid 0.00
Chemical 0.000
Examination
pH 6.0 0.00
Specific Gravity 1.026 0.00
Leukocyte Negative <trace 0.00
Blood Trace <trace 0.00
Glucose Negative <trace 0.00
Nitrate + <trace 0.00
Protein ++ <trace 0.00
Urobilinogen Normal <trace 0.00
Ketone Negative <trace 0.00
Biluribin + <trace 0.00
Creatinine 50.00 mg/dL 10-300 0.0000
Albumin Over mg/dL 10-150
Microscopic/Urine
Fluoroscence
Flow Cytometry
PLUS cells 114.9 /uL 0-17 20.89 /HPF 0-3
Red Cells 554.5 /uL 0-11 100.82 /HPF 0-2
Squamous 23.8 /uL 0-17 4.33 /HPF 0-3
Epithelial Cells
Bacteria 1148 /uL 0-278 263.37 /HPF 0-50
Mucus Threads 3.37 < 0.00
moderate
Hyaline Casts - 0.00

B. APGAR SCORE

Sign 0 1 2 1 5 10
minute minutes minutes
Heart Rate Absent Below 100 Above 100 2
 Respiration Absent Slow Irregular Crying 2
Lustily
Muscle Flaccid Weak Cry Flexion 2
Tone Hypoventilate Active
d some flexion
Reflex No Grimace Cough or 1
Response cry
Color Blue, Pale Baby Pink Completely 2
Extremeties Pink

A. DRUG STUDIES ( MOTHER)

Drug Name Drug Class Mechanism Indications Contraindi Side Nursing

of Action cations effects/Adverse Consideration
Reaction
Generic: Therapeuti Bacteriacidal: Patient’s Contraindic Side Effects/ Before:
Cephalexin c: Inhibits Indication: ated with Adverse History: Penicillin
Bactericidal synthesis of Treatment allergy to Reaction: or cephalosporin
Pharmacol bacterial cell for infection. cephalospor CNS: headache, allergy, pregnancy,
Brand: ogic: wall, causing General: in or dizziness, or lactation
Cephalospo Antibiotic cell death Respiratory penicillin. lethargy, Physical: Renal
rins tract paresthesiasis function tests,
infections Use respiratory status,
Complete caused cautiously GI: Nausea, skin status; culture
Prescriptio by Streptoc with renal vomiting, and sensitivity tests
n: occus failure, diarrhea, of infected area
500mg QID pneumonia lactation, anorexia, During:
PO e, group A pregnancy abdominal pain, Arrange for culture
beta- flatulence and sensitivity tests
hemolytic Pregnancy pseudomembran of infection before
streptococci Category: ous colitis, and during therapy
Skin and B hepatotoxicity if infection does not
skin Hematologic: Bo resolve.
structure ne marrow Give drug with
infections depression meals; arrange for
caused Hypersensitivity small, frequent
by staphyl : Ranging from meals if GI
ococcus, rash to fever to complications
streptococ anaphylaxis; occur.
cus serum sickness Refrigerate
Otitis reaction suspension,
media Other: Superinfec discard after 14
caused tions days
by S.
pneumoni After:
ae, Instructed patient
Haemophil to Report severe
us diarrhea with
influenzae, blood, pus, or
streptococ mucus; rash or
cus, hives; difficulty
staphyloco breathing; unusual
 ccus, tiredness, fatigue;
Moraxella unusual bleeding
catarrhalis or bruising.
Bone Advised patient to
infections avoid alcohol while
caused taking cephalexin.
by staphyl
ococcus,
Proteus
mirabilis
GU
infections
caused
by Escheri
chia coli,
P.
mirabilis,
Klebsiella

Drug Name Drug Class Mechanism of Indications Contraindi Side Nursing

Action cations effects/Adver Consideration
se Reaction
Generic: Therapeuti Increases Patient’s Contraindic Side Effects: Before:
Ascorbic c: protection Indication: to ated in Transient mild Lab tests:
Acid Supplement mechanism of support wound those soreness may
al the immune healing persons occur at the Periodic Hct &
Pharmacol system, thus General: who have site Hgb, serum
Brand: ogic: supporting Vitamin C is shown of intramuscul
Vitamin C wound healing. recommende hypersensiti ar or subcutan electrolytes.
d for the vity to any eous injection. Monitor for S&S
Complete prevention component Too-rapid intra
of acute
Prescriptio and treatment of this venous admini
n: of scurvy. preparation stration of the Hemolytic
Ascorbic Its parenteral  solution may anemia, sickle
Acid 500mg administration Pregnancy cause
OD is desirable Category: temporary cell crisis.
for patients C faintness or
with dizziness During: Give
an acute defic medication on the
iency or for Adverse right timing
those Reaction:
whose absorp After: Patient &
tion of orally Family
ingested asco Education
rbic acid
(vitamin c) is High doses of
uncertain vitamin C are not
recommended
during pregnancy.
 Take large doses
of vitamin C in
divided amounts
because the body
uses only what is
needed at a
particular time
and excretes the
rest in urine.
Megadoses can
interfere with
absorption of
vitamin B12.
Note: Vitamin
C increases the
absorption of iron
when taken at the
same time as
iron-rich foods.
Do not breast
feed while taking
this drug without
consulting
physician.

Drug Drug Mechanism Indications Contraindication Side Nursing

Name Class of Action s effects/Advers Consideration
e Reaction
Generic: Therapeu Anthralinic Patient’s Contraindicated Side Effects: Before:
Mefena- tic: acid Indication: It in those persons Stomach pain Secure Doctor’s
mic Acid Analgesic derivative. is used to who have shown or diarrhea. order
, anti- Like ease pain. hypersensitivity to
inflammat ibuprofen General: any component of Heartburn.Upse Asses patient’s
Brand: ory, and inhibits Short term this preparation t stomach or condition
Ponstel antipyretic prostaglandin relief of mild throwing up. Inform patient
action synthesis to moderate Pregnancy about the
Complet and affects pain Category: C Constipation. possible side
e Pharmac platelet including effects
Prescrip ologic: function. No primary Gas.
tion: CNS evidence that dysmenorrhe During:
500mg agent is superior to a Dizziness. Give medication
QID aspirin on the right timing
Mefena Headache.
mic Acid After:
500 mg Instruct patient to
Adverse
TID be cautious of the
Reaction:
contraindications
Mild tiredness,
of the drugs
dizziness,
faintness with
rapid IV
administration

Drug Name Drug Class Mechanis Indications Contraindi Side Nursing

m of cations effects/Adver Consideration
Action se Reaction
Generic: Therapeutic: Elevates Patient’s Hyper- Side Effects: Before:
 ferrous Supplement the serum Indication:Die sensitivity constipation; Secure Doctor’s
sulfate al of iron tary Severe upset order
Pharmacolo concentrat supplement for hypotension stomach;
Brand: gic: ion in iron black or dark- Asses patient’s
Feosol, Fer which then colored stools; condition
Iron, Fer- helps to General: Temporary
Gen-Sol, form high To prevent and staining of the Inform patient about
Fer-in-Sol, or trapped treat iron teeth. the possible side
Fer-Iron, in the deficiency effects
Feratab, reticuloen anemia Adverse
FeroSul, dothelial Pregnancy Reaction: During:
Ferra-TD, cells for Category: Dizziness, Give medication on
Ferro-Bob, storage C nausea and the right timing
Lydia E. and vomiting, nasal
Pinkham, eventual congestion, After:
MyKidz Iron conversio dyspnea, Instruct patient to be
10, Slow Fe n to hypotension cautious of the
Complete usable contraindications of
Prescriptio form of the drugs
n: iron
FeSO4+
Folic Acid
500mg BID
Drug Name Drug Class Mechanis Indications Contraindi Side Nursing
m of cations effects/Adver Consideration
Action se Reaction
Generic: Therapeutic: To Patient’s Hypersensit Side Before:
 Gentamycin Anti-infective reduce the Indication: ivity Effects/Adver Secure Doctor’s
Brand: Pharmacolo developm treatment of to gentami se Reaction: order
gic: ent of serious cin and CNS:
Prescription Aminoglycosi drug- infections myasthenia ototoxicity, Asses patient’s
: des resistant b related to gravis is dizziness, condition
13 mg IVTT acteria an jaundice a contraind deafness, Avoid long term use
IM OD d maintain General: ication to headache.
the To reduce the its use. CV: Inform patient about
effectiven development Patients palpitation, the possible side
ess of of drug- should be hypotension, effects
Gentamici resistant bacte well hypertension.
n ria and hydrated GI: nausea, During:
Injection, maintain the during vomiting, Give medication on
USP effectiveness therapy, anorexia, the right timing
(gentamici of Gentamicin and renal weight loss.
n injection Injection, USP function After:
pediatric) (gentamicin should be Instruct patient to be
and injection monitored. cautious of the
other antib pediatric) and Dose contraindications of
acterial dr other antibacte adjustment the drugs
ugs, rial drugs, is required Ensure adequate
Gentamici Gentamicin in impaired breastfeeding,
n Injection, USP renal Report any unusual
Injection, (gentamicin function ties
USP injection
(gentamici pediatric)
n injection should be Pregnancy
pediatric) used only to Category:
should be treat or D
used only prevent
to treat or infections that
prevent are proven or
infections strongly
that are suspected to
proven or be caused by
strongly susceptible
suspected bacteria. When
to be culture and
caused by susceptibility
bacteria. information are
available, they
should be
considered in
selecting or
modifying
antibacterial th
erapy. In the
absence of
such data,
local
epidemiology
 and
susceptibility
patterns may
contribute to
the empiric
selection of
therapy.

(Baby’s drug)

Drug Name Drug Class Mechanis Indications Contraindi

Side Nursing
m of cations effects/Adver Consideration
Action se Reaction
Generic: Therapeutic: Inhibits Patient’s Hypersensit Side Before:
Ampicillin Antibiotic cell-wall Indication: ivity Effects/Adver Secure Doctor’s
Brand: Pharmacolo synthesis treatment of to ampicillin se Reaction: order
gic: during serious CNS:
Prescriptio penicillin bacterial infection Patients agitation, Asses patient’s
n: multiplicati related to should be dizziness, condition
129 mg on jaundice well headache. Avoid long term use
IVTT causing General: hydrated CV: heart
IM OD cell death Treatment of during failure Inform patient about
infections therapy, GI: nausea, the possible side
caused by and renal vomiting, effects
susceptible function anorexia, Inspect the injection
strains of should be weight loss. site.
shigella monitored. Diarrhea, During:
salmonella. Dose abdominal Give medication on
adjustment pain the right timing
Meningitis is required
caused by in impaired After:
neisserai renal Instruct patient to be
function cautious of the
contraindications of
Prevention of the drugs
bacterial Pregnancy Ensure adequate
growth and Category: breastfeeding,
eliminating B Report any unusual
invading ties
organism

B. NURSING CARE PLAN (Mother)

ASSESMENT NURSING OUTCOME Planning Nursing Intervention Evaluation

CUES DIAGNOSIS IDENTIFICATION
Interventions Rationale
Subjective: Risk for After 8 hours of Independent: Sufficient fluid Goal Partially
“Dire pa ak naka constipation duty the patient will Encourage the is needed to Met
uro sukad sa pag related to be able to: patient to take in keep the fecal After 8 hours of
anak” post-partum fluid 2000 to 3000 mass soft. duty
for 2 days Patient identifies mL/day the patient
 measures that verbalized
prevent or treat Encourage patien Movement acknowledgement
constipation. t for some promotes and understands
physical activity peristalsis. about the need to
Patient verbalizes and exercise. increase of oral
measures that will fluid intake and eat
prevent recurrence A balanced diet food with rich in
of constipation. that comprises fiber
adequate fiber,
fresh fruits,
vegetables, and
grains

ASSESMENT CUES NURSING OUTCOME Planning Nursing Evaluation

DIAGNOSIS IDENTIFICATION Intervention
Interventions Rationale
Objective: Effective After 8 hours of Independent: Goal Partially
Patient is able breastfeeding duty the patient Met
position properly the will be able to: Encourage Adequate After 8 hours of
infant client to drink hydration is duty the patient
Verbalize at least 2000 must, to showed
understanding of ml of fluid per provide understanding
breastfeeding day. enough milk and responses to
techniques. always
Review To help breastfeed the
Promotes techniques for sustain baby.
effective expression breastfeeding
breastfeeding and storage of activity.
behaviors breast milk.

Advised To prevent
mother not to injury on the
withdraw nipple.
immediately
her nipple
during
breastfeeding
or ongoing

Instruct client To promote

to maintain good nutrition
breastfeeding and growth of
to at least 6 the baby.
months without
water or food
or
supplements

ASSESMENT NURSING OUTCOME Planning Nursing Evaluation

 CUES DIAGNOSIS IDENTIFICATION Intervention
Interventions Rationale
Objective: Risk for After 8 hours of duty Independent: GOAL MET
Cord showed infection the patient will be Note for risk Identifying the
greenish in related to able to: factors for area of which After 8 hours of
color; dry inadequate occurrence of serves as duty the patient’s
intact without primary Giving proper infection beneficial mother was able to :
any infection defenses hygiene method of environment
(exposed cleaning the for bacterial Note for the risk of
umbilical cord) remaining umbilical growth will occurrence of
cord help the client infection
recognize
areas that will Able to understood
need thorough the importance of
cleaning. cord care

Encouraged To save her

mother to time and
clean it as she energy
baths the baby

Instructed the To able to

mother to stop
report spreading the
abnormalities. infection

Dependent:
Report to the
doctor any To be able to
anomalies order a
noted medication to
prevent
infection

ASSESMENT NURSING OUTCOME Planning Nursing Intervention Evaluation

CUES DIAGNOSIS IDENTIFICATION
Interventions Rationale
Subjective: Jaundice After 8 hours of Independent: GOAL PARTIALLY
related to duty patient will be Encourage To improve MET
disease able to: early morning skin color.
process as a. Will not sunlight Patient did not
Objective: evidenced by exhibit cold jaundice. exhibit cold stress
(+) jaundice yellowish stress
Yellow eyes discoloration of
eyes. b. Patient’s Collaborative Patient’
mother will : To eliminate
be able to Encouraged factors of
 understand mother for jaundice
the breastfeeding because
importance per demand or nutrients are
of exposing at least every lacking
the baby to hour.
early
sunlight

Dependent:
To reduce
Administered infection
Ampicillin
129mg IM
To reduce
Administered jaundice
Gentamicin
13mg IM

ASSESMENT NURSING OUTCOME Planning Nursing Intervention Evaluation

CUES DIAGNOSIS IDENTIFICATION
Interventions Rationale
Subjective: Breastfeeding After 8 hours of duty Independent: GOAL
“ okay man la Enhancement patient will be able Encouraged Advise mother PARTIALLY MET
pag dede ng to: breastfeeding to incorporate Patient was able to
bata” a. Patient’s for 6 months breastfeeding demonstrate good
mother will rooting reflex and
understand was acknowledged
Objective: the Demonstrate by the mother.
importance of different holds To provide
breastfeeding in giving comfort and
breastfeeding lessen energy
b. Patient will such as consumption
demonstrate football hold,
good rooting cross cradle
hold, lying
position,
cradle hold.

Collaborative
: To lessen the
If engorgement
engorgement of the breast
of breast is
observed , call
the attention of
 milk bank
Dependent: Should be
Doctor’s order continue until 6
for months for
continuation of nutrient
breastfeeding consumption

DISCHARGE PLAN
Environment: Upon discharge, patient should be in a safe and sound environment. Should
not stay in a very unsterile place. Significant others should be advised to lower the patient’s
risk for further fracture by assessing home hazards. Must continue early morning sunlight
exposure
Treatment Must continue early morning sunlight exposure
Health Teaching: Advise mother to continue breastfeeding until 6 months without water or
any food or supplements.
OPD: Patient is advised to attend his follow up check-up and bring the tagubililin form in
order for the physician to see progress and advise her on what to do.

Diet: Continue BF

APPENDICES
Doctor’s Order:
Mother: Elma Caldosa

11-19-2019 (11:58 SOAP: Labor pains Doctor’s Order:

am) BP:120/80 Admit under DR service
T: 36.3 Secure consent
P:86 TPR every 4 hrs
R:21 DAT
Diagnostic:
CBC,PLT,BT,HBSAg, Anti
TP, LA
G6P5 (5005) Cont. IVF @ 20gtts/min
LMP: 03-7-19 Hook to CTG
AOG:36 ½ Monitor FHT and UC every
EDC:12-12-19 30 mins
FH:29cm Monitor progress of labor
FHT:140-145 To DR
Pelvic Exam: E/G normal VS every 4hrs
I: I and O every shift
SE: Bluish enlarge Refer
IE: 5cm
dilated,60%,attached,cephalic,SN-
2 (+) BOW

G6P5 (5005) DU 36 ½
AOG,cephalic,DTC,
DR: LLUVIOSO
11-20-19 (-) BM (-) flatus Cont.medication
 (-) freely voiding Monitor VS
BP: 110/70 Perineal hygiene
HR: 88 Encourage BF
RR:20
T:36.7 DR: Tolentino
11-21-19 (-) BM (+) flatus May go home
(+) freely voiding (-) Belding Cont. medication
Cephalexin 500mg QID
Bp:100/70 Mefenamic Acid 500 mg TID
HR:89 Ascorbic Acid 500mg OD
RR:20 FeSO4+ Folic Acid 500mg
T:36.6 BID
For discharge
Follow up: 11-27-19
Refer

CALDOSA, BB BOY

11-20-19 (+) BF May go home anytime after

Good suck NBS.
Follow up checkup after 3
days @ RHNC OPD

Dr. Jordan
11-20-21 (4pm) (+) hematuria For UA
Refer PRN
Dr. Jordan
11-21-19 Hold Discharge
Refer
Dr.Jordan
11-21-19 S/F U/A refer facility
Refer
Dr. Jordan
11-22-19 (11:20 am) Start ampicillin 129mg IVTT
every 12hrs x 7 days
Gentamycin 13mg IVTT every
24hrs x 7 days
Encourage sunlight Exposure
BF per demand
Refer PRN
Dr. Jordan
11-23-19 ( 10:50AM) (+) jaundice For CPT with eye shield
For CBC, PLT,BT,TB,B1.B2,
CRP
Refer
Dr. Jordan