Revised 2019

Mindanao State University

COLLEGE OF HEALTH SCIENCES
Marawi City

Name of Student: _Patient X___________________________ Clinical Instructor: ______________________ _____________________

Area of Assignment: _OB WARD________________________________ Date Submitted: _____________________________________________

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name: _Patient X________________________________ Address: _Korondal City, South Cotabato___________________________________________________ Age: 30 years

Sex: _F_______ Religion: Roman Catholic______ Civil Status: _Single_________________________ Occupation: _Business Woman_____________________________

HABITS

Frequency Amount Period/Duration

1. Tobacco a day 4-5 Sticks for week

2. Alcohol 3 times 4 Bottles a month
3. OTC-drugs/ non-prescription drugs X X X

A. CHIEF COMPLAINTS:

B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.

A case of 30 years old pregnant women was admitted with present condition that started 2 days prior to admission, while the patient was watching television she suddenly saw
a moderate bleeding from her vagina and felt a severe pain in her lower back and abdomen with rapid contraction on her uterus. Her husband rushes her to the hospital and she
was advised to be confined when they found out that the baby was already suffering fetal distress with a fetal heart rate of 31b/m.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)

Patient’s previous hospitalization involved her last two normal pregnancies, wherein she felt nape pain and headache within 3 months and decided to have an ultrasound and
found out the position of the baby was in a low transverse position. Lastly, they found out that the position of the baby was back in a cephalic position during the seventh month
of pregnancy through an ultrasound.

Since the patient was 18 years old, she used to drink alcoholic beverages, caffeine-rich drinks and enjoyed eating salty foods and by 20 years old, she thought she was having a
high blood pressure but did not seek any medical consultation because she felt like she could tolerate the headache. Instead, she is taking herbal medicines like garlic to improve
her condition, but, despite continued consumption of herbal intakes, she still noticed nape pain and headache, where she finally decided to have a check-up in their barangay to
get proper medication to lower her blood pressure.

FAMILY HISTORY WITH GENOGRAM

Acquired Diseases: Heredo- familial Diseases:

Hypercholesterolemia Diabetes
Kidney Disease Heart Diseases
Tuberculosis Hypertension
Alcoholism Cancer
Drug Addiction Asthma
Hepatitis A Epilepsy
B Mental Illness
MALE C Rheuma/Arthritis

Others (pls. specify) Others (pls. specify)

FEMALE

D. PATIENT’S PERCEPTION OF:

1. Present Illness

“Masakit ang tahi ko” as verbalized by the patient. In English, the patient’s stitches are hurting.

2. Hospital Environment

“Malinis naman dito dahil lagi naman nilang nililinisan”, as verbalized by the patient. In English, the patient stated that the place was clean because it is being regularly cleaned.

E. SUMMARY OF INTERACTION
 The interaction with the patient and her S.O was cooperative; both of them answered the questions well and were able to fill in all the necessary information by interviewing
them.
Physical Examination
Name: Patient X ___________________________________
Chief Complaint upon Initial Assessment: _Vaginal Bleeding and Severe Lower Back Pain
Chief Complaint upon Final Assessment: _Pain on incision site on abdomen_________________
Initial Vital Signs: Temp: 36.9°C RR: 42cpm __ PR: 98bpm O2Sat: _96% BP: _190/120mmHg Pain Score: 8/10_
Initial Assessment
Received patient awake, alert and oriented to date, time and place, person and
responds to stimuli. Speech is of appropriate age and flows easily and maintains eye
contact can smile and frown appropriately. Patient’s vital signs are as follows:
Temperature = 36.9°C; BP= 190/120mmHg, Respiratory rate = 42cpm; heart rate =
GENERAL 98bpm, O2Saturation = 96%.
HEAD: Smooth Skull contour; no Nodules or masses. Hair is well distributed and
black in color. No head lice infestation and dandruff noted. Face is symmetrical.
EYES: Both sclera are white. Pupils (4mm) equally round, reactive to light and
accommodation and pale Conjunctiva.
EARS: Symmetrical ears and equal size. No buildup of cerumen/ear wax. No pain
HEENT
noted upon palpation and no presence of swelling and both ear auricles non tender.
NOSE: Nose is symmetrical in shape and same in color with face. Patient can
breathe with one nostril when other is closed. No presence of discharge and no
presence of bumps and tenderness. No pain noted and non-tender Sinuses
THROAT: No lesions evident and no swelling noted. No lesions present at the
tongue. Lips are symmetrical with no lesions noted.
Patient has poor skin turgor due to the presence of interstitial fluids on area of
edema becomes dry and shiny. Her skin also is pallor and pail nail beds due to the
blood loss during the post-surgical procedure/ post cesarean delivery. 3-4 capillary
refill upon blanching manifested of decrease RBC’s due to edema. Body temperature
INTEGUMENTAR
is 36.9°C. Hair is well distributed and black in color. No head lice infestation and
Y
dandruff noted.
Height: _5’10_____________
Weight: __173lbs _________
BMI: _24.82______________
Final Assessment (Last Day)
Received patient awake, alert and oriented to date, time and place, person and
responds to stimuli. Speech is of appropriate age and flows easily and maintains
eye contact can smile and frown appropriately.
Patient’s vital signs are as follows: Temperature = 39.2°C; BP= 140/110mmHg;
Respiratory rate = 24 cpm; heart rate = 117 bpm, O2Saturation = 97%
HEAD: Smooth Skull contour; no Nodules or masses. Hair is well distributed and
black in color. No head lice infestation and dandruff noted. Face is symmetrical.
EYES: Both sclera are white. Pupils (4mm) equally round, reactive to light and
accommodation and pale Conjunctiva.
EARS: Symmetrical ears and equal size. No buildup of cerumen/ear wax. No pain
noted upon palpation and no presence of swelling and both ear auricles non
tender.
NOSE: Nose is symmetrical in shape and same in color with face. Patient can
breathe with one nostril when other is closed. No presence of discharge and no
presence of bumps and tenderness. No pain noted and non-tender Sinuses
THROAT: No lesions evident and no swelling noted. No lesions present at the
tongue. Lips are symmetrical with no lesions noted.
Patient has poor skin turgor due to the presence of interstitial fluids on area of
edema becomes dry and shiny. Her skin also is pallor and pail nail beds due to the
blood loss during the post-surgical procedure/ post cesarean delivery. 3-4
capillary refill upon blanching manifested of decrease RBC’s due to edema. Body
temperature is 39.2°C. Hair is well distributed and black in color. No head lice
infestation and dandruff noted.
 Respiratory Rate is 42cpm. Symmetrical chest shape & size. No barrel chest and
use of accessory muscles, (scalene and sternocleidomastoid) muscles while
RESPIRATORY breathing. Patient appears to have resonant lung sound upon auscultation.
S1 corresponds with each carotid pulsation. S2 immediately follows after S1 and
no extra heart sounds and murmurs upon auscultation. Equal in pulse rate,
CARDIOVASCULA rhythm of carotid arteries, and amplitude of 2+ upon palpation. No bruits upon
R auscultation of the carotid arteries, and jugular vein not distended. Capillary refill
of nail beds is 3-4 second manifested of decrease RBC’s due to edema. Peripheral
pulses (radial, Brachial) are equal in pulse rate and rhythm and no bulging veins.
Patient is on vol/vol replacement regulation. No vomiting or difficulty of
DIGESTIVE swallowing observed.
Pain in the abdomen is persistent from moderate to severe. Vaginal bleeding and
rapid uterine contractions are still continuous.
The patient was inserted an indwelling Foley catheter. She had her bowel
movement on her second day on the hospital.
EXCRETORY
Symmetrical and equal muscle mass, tone and strength and rate of muscle
MUSCULOSKELET strength are 4 in all four extremities.
AL
Patient has no deficit functions for sensory, cerebellar and cerebral neurologic
NERVOUS examination; has smell, taste, sight, touch, and hearing senses are developing and
functioning well.
Patient is a 30 years old mother who has 2 children. Last menstrual period was at
ENDOCRINE
11/06/13 and an obstetric status of G3T2P0A0L2. Thyroid gland is in butterfly in
shape in midline position, non-palpable lobes, not enlarged, and rises as patient
swallow.
Respiratory Rate is 24cpm. Symmetrical chest shape & size. No barrel chest and
use of accessory muscles, (scalene and sternocleidomastoid) muscles while
breathing. Patient appears to have resonant lung sound upon auscultation.
S1 corresponds with each carotid pulsation. S2 immediately follows after S1 and
no extra heart sounds and murmurs upon auscultation. Equal in pulse rate,
rhythm of carotid arteries, and amplitude of 2+ upon palpation. No bruits upon
auscultation of the carotid arteries and jugular vein not distended. Capillary refill
of nail beds is 3-4 second manifested of decrease RBC’s due to edema. Peripheral
pulses(radial, Brachial) are equal in pulse rate and rhythm and no bulging veins.
Patient is on vol/vol replacement regulation. No vomiting or difficulty of
swallowing observed.
Pain is persistently felt moderately on incision area in the abdomen.
Patient’s bowel routine is once or twice a day. The stool color is brown or
sometimes yellow in a usual amount. She voids 5 times a day with a urine color of
yellow.
Symmetrical and equal muscle mass, tone and strength and rate of muscle
strength are 4 in all four extremities.
Patient has no deficit functions for sensory, cerebellar and cerebral neurologic
examination; has smell, taste, sight, touch, and hearing senses are developing
and functioning well.
Patient is a 30 years old mother who has 2 children. Last menstrual period was at
11/06/13 and an obstetric status of G3T2P0A0L2. Thyroid gland is in butterfly in
shape in midline position, non-palpable lobes, not enlarged, and rises as patient
swallow.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Inhibits cell-wall Treatment of: Skin and Contraindicated with G.I.:  Determine previous
synthesis during bacterial skin structure infections, patients hypersensitivity hypersensitivity
08-04-14 500mg, 1 capsule q 8hrs
multiplication, leading to Otitis media, Sinusitis, to penicillin, infectious  Diarrhea reactions to
PO cell death, shows Respiratory infections, monucleosis  Nausea penicillin.
enhanced activity toward Genitourinary infections.  Vomiting  Check patient’s
Recommended: gram-negative bacteria  Abdomin temperature.
Generic name:
compared to natural and al pain  Monitor sign and
PO (Adults): 250–500mg
Amoxicillin penicillinase – resistant symptoms of
q 8hrs or 500–875mg q Resp:
penicillin. urticarial rash.
12 hr.
 Rash Respiratory
Brand Name:  Wheezing

Amoxil Other:

 Super-infections
(Oral and rectal
Classification: candidiasis)
 Fever
Antibiotic
 Anaphylaxis

Pregnancy category B

DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Elevates the serum iron Prevention and Contraindicated with CNS:  Advice patient to
08-04-14 concentration which treatment of Iron patients hypersensitivity take medicine as
then helps to form High deficiency anemia and to drug and severe prescribed.
1 tab BID PO x 30 days or trapped in the dietary supplement for hypotension  Dizziness  Caution patient to
reticuloendothelial cells Iron.  Headache make position
Generic name: Recommended:
for storage and eventual changes slowly to
CV:
Ferrous Sulfate PO (Adults): Deficiency – conversion to a usable minimize orthostatic
120-240mg/day in 2-4 form of iron.  Hypotension hypotension.
divided doses.  Hypertension  Encourage patient to
 Tachycardia comply with
Brand Name: additional
GI: intervention for
Brisofer
hypertension like
 Nausea proper diet, regular
exercise, lifestyle and
Classification: Derm:
changes and stress
 Flushing management.
Iron Preparation
 Dyspnea

Pregnancy category A

DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration
Date Ordered: Prescribed: Inhibits prostaglandin Treatment to relieve the Contraindicated with G.I.:  Discontinue drug
synthesis and affects symptoms period pain patients hypersensitivity promptly if diarrhea,
08-04-14 500mg, 1 cap every 6 platelet function.  Nausea
and treat heavy periods. to drug and ulceration dark stools,
hrs. PO  Vomiting hematemesis, or rash
It also provides short  Constipa occur and do not use
Recommended: term relief of pain in tion
Generic name: again.
conditions such as:
PO (Adults): 500mg q Other:
Mefenamic 6hrs PRN muscle and joint injuries.
 Blurred Vision

Brand Name:

Ponstan

Classification:

Analgesic NSAID

Pregnancy category C

DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration
Date Ordered: Prescribed: Blocks vasoconstriction Treatment of diabetic Contraindicated with CNS:  Monitor blood
and aldosterone- nephropathy in patients patients hypersensitivity pressure and drug.
08-06-14 100mg, 1 tab OD, PO secreting effects of to losartan Pregnancy  Headach  Notify Physician of
with type 2 diabetes and
angiotensin II at various (2nd and 3rd trimester) e symptoms of
Recommended: hypertension.  Dizziness
receptor sites, including hypotension.
vascular smooth muscle  Syncope  Always count the
Generic name: PO (Adults) – 50mg OD
and adrenal glands. Also dose given.
GI:
Losartan increases urinary flow  Assist patient when
and enhances excretion  Dry Mouth moving.
of chloride, magnesium
calcium, and phosphate. CV:
Brand Name:

Cozaar  Hypotension

Classification:

Antihypertensive

Pregnancy category C
(1st trimester), D (2nd and
3rd trimester)
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Inhibits influx of Alone or with other Contraindicated with CNS:  Monitor heart rate
extracellular calcium agents in the patients hypersensitivity and rhythm and
08-06-14 10mg OD, PO ions, thereby decreasing  Headach
management of to drug. blood pressure
myocardial contractility, e especially at start of
Recommended: hypertension, angina  Dizziness
relaxing coronary and therapy.
vascular muscles, and pectoris, and vasospastic  Drowsin
Generic name: PO (Adults): 5-10mg OD
decreasing peripheral angina. ess
Amlodipine resistance.  Fatigue
 Weaknes
s
Brand Name: CV:
Norvasc  Bradycardia
 Hypotension
 Palpitations
Classification:
Resp:
Antihypertensive
 Shortness of
breath
 Dyspnea
Pregnancy category C  Wheezing
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Stimulates alpha- Management of mild to Contraindicated with CNS:  Monitor blood
adregenic receptors in moderate hypertension. patients hypersensitivity pressure and pulse
08-07-14 75mg 1 tab PRN > CNS, decreasing to dug.  Drowsin rate frequently.
160/90 PO sympathetic outflow, ess  Observe patient for
inhibiting  Dizziness tolerance to drug’s
Generic name: Recommended:  Fatigue
vasoconstriction, and therapeutic effects,
Clonidine hydrochloride PO (Adults): 100mcg bid, ultimately reducing  Sedation which may require
increase 100- blood pressure.  Weaknes increasing dosage.
200mcg/day q 2-4 days s  Monitor patient for
 Malaise signs and symptoms
Brand Name:  Depressi of adverse
on cardiovascular
Catapres
reactions.
CV:
 Inform patient that
 Orthostatic dizziness upon
Classification: standing can be
 Hypotension
 Bradycardia minimized by rising
Cardiovascular agent; slowly from a sitting
central-acting;  Severe rebound
or lying position and
antihypertensive; hypertension
avoid sudden
analgesics
GI: position changes.

 Constipation
Pregnancy category C  Dry mouth
 Nausea
 Vomiting
 Anorexia
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Through the produce Mild pain and fever. Contraindicated in Derm:  Instruct patient to
analgesia by blocking patients hypersensitive take with meals have
08-07-14 1 amp IV STAT PRN For > pain impulse by to drug.  Rash a plenty of water
38.6 oC inhibiting synthesis of  Urticaria when taking this
prostaglandin in CNS that Use cautiously in drug.
Recommended: patients with long term Others:
Generic name: synthesize pain receptor  After negative
alcohol use because
PO (Adults): 325-650mg to stimulation.  Hypoglycemia sensitivity must be
Paracetamol therapeutic doses causes done.
q 4-6hrs or 1g 3-4 times
hepatotoxicity in these
daily or 1300mg q 8hrs
patients.

Brand Name:

Aeknil

Classification:

Nonopoid Analgesic

Pregnancy category B
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Inhibits cell-wall To prevent endocartitis Contradicted in patients’ CNS  Monitor sodium level
synthesis during bacteria in patients having GI hypertensive to drug or because each gram
08-02-14 1gm q hrs TIV multiplication procedures other penicillin.  Lethargy of ampicillin contains
 Hallucinations 2.9 mEq of sodium.
Use cautiously in  Seizures  Watch for signs and
patients with other drug GI symptoms of
Generic: allergies because of hypersensitivity, such
possible cross-sensitivity,  Nausea as maculopapular
Ampicillin  Vomiting
and in those with rash, urticarial, and
mononucleosis because  Diarrhea anaphylaxix.
of high risk of  Glossitis
Brand: maculopapular rash.

Ampicillin-N

Classification:

Antibiotic
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Inhibits reuptake of Moderate moderately Contradicted in patients’ CNS  Assess patient’s
serotonin and severe pain hypertensive to drug or level of pain
08-02-14 50 mg
norepinephrine in CNS. other opioids, those with  Dizziness atleast 30 mins
acute intoxication from  Confusion before
TIV alcohol.  Fatigue administration.
 Drowsiness  Monitor the
Generic: Every 6 hrs.
GU bowel and
bladder function
Tramadol  Renal Failure  Monitor for
GI physical and
psychological
 Nausea drug
Brand:
 Anorexia dependence
Ultram  Constipation  Monitor patient
for signs and
symptoms of
potentially life-
Classification: threatening
serotonin
Opioid Agonist syndrome, which
Analgesics may range from
shivering and
diarrhea to
muscle rigidity,
fever, mental-
status changes,
and seizures.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Reduces gastric acid To prevent Mendelson’s  Hypersensitivity CNS  Assess vital signs
secretion and disease (The aspiration to drug or its  Monitor CBC and
08-02-14 50mg IVq 8”X4 doses
bicarbonate production, of stomach contents into components  Headache liver function
the lungs during  Alcohol  Agitation test
creating a protective
obstetric anaesthesia) intolerance (with  Anxiety
coating on gastric
some oral GI
Generic: mucosa product)
 History of acute  Nausea
Ranitidine Hydrochloride  Vomiting
porphyria
 Diarrhea
 Constipation
Brand:  Abdominal
discomfort or
Zantac pain
Hematologic

 Reversible
Classification: granulocytopenia
 Thrombocytopen
Anti-ulcer drug ia
Hepatic

 Hepatitis
Skin

 Rash
Other

 Pain at IM
injection site
 Burning
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Replaces magnesium and For seizures  Hypermagnesem  Syndrome joint-  Monitor patients
maintains magnesium ia swelling, fever closely during
08-02-14 4mg IM At buttock Every  Heart block  Anemia and following
level; as an
4 hours  Myocardial  Agranulocytosis infusions.
anticonvulsant, reduces
damage  Hepatitis Observe
muscle contractions by
 Active labor or  Glomerulonephri orthostatic
Generic: interfering with release precautions.
within 2 hours of tis
of acetylcholine at delivery  Acute renal
Magnesium Sulfate
myoneural junction failure

Brand:

Sulfamag

Classification:

Anti-hypertensive
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: A direct-acting Pre-eclampsia CNS  Monitor patient’s

vasodilator that reflexes blood pressure
08-02-14 50mg TID for BP of
arteriolar smooth  Peripheral and pulse rate.
160/100 neuritis Hydralizine may
muscle.
 Headache be given with
 Dizziness diuretics and
Generic: GI beta blockers to
decrease sodium
Hydralizine  Nausea retention.
 Vomiting  Don’t confuse
 Constipation hydralazine with
Brand: hydroxyzine or
apresoline with
Alphapress Apresazide
 Instruct the
patient to take
oral form with
Classification: meals to increase
absorption.
Antihypertensive
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: A direct-acting Amoebic liver abscess Hypersensitivity to drug, CNS  Inform patient to
vasodilator that reflexes other nitroimidazole report fever,
08-02-14 50mg TID for BP of
arteriolar smooth derivatives, or parabens  Dizziness sore throat,
160/100 (topical form only)  Headache bleeding or
muscle.
 Ataxia bruising
 Vertigo  Inform patient
Generic:  Insomnia that drug may
GI cause metallic
Metronidazole
taste and may
 Nausea discolor urine
 Vomiting deep brownish-
Brand:  Diarrhea red
 Abdominal pain
Flagyl  Anorexia

Classification:

Antiprotozoal
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Date Ordered: Prescribed: Inhibits aldosterone  Essential  Hypersensitivity CNS  Monitor

effects in distal renal hypertension to drug electrolyte levels
08-04-14 50mg Cap TID
tubule, promoting  Anuria  Headache (especially
 Acute or renal  Drowsiness potassium).
PO sodium and water
insufficiency  Lethargy Watch for signs
excretion and potassium 
 Hyperkalemia Ataxia and symptoms of
Generic: retention.  Confusion imbalances and
GI metabolic
Spironolactone
acidosis
 Vomiting  Monitor weight
 Diarrhea and fluid intake
Brand:  Cramping and output. Stay
 GI Ulcers alert for
Aldactone SKIN indications of
fluid imbalance
 Rash  Monitor CBC
 Pruritus with white cell
Classification: differential
 Advise patient to
Potassium – Sparing restrict intake of
diuretic high potassium
foods.

Name Patient X
Admitting Chief Complaint Moderate vaginal bleeding; Moderate to severe back and abdominal pain with rapid uterine contractions
Impression/Diagnosis Abruption Placenta
Date/Time of Admission 8/2/14 ; 4:05am
Diet: Low salt, low fat diet ______
Type of Operation (if any) : Cesarean Section __________
NORMAL PATTERN BEFORE HOSPITALIZATION
1.ACTIVITIES- REST According to the patient, she usually
enjoys watching television until
a. Activities midnight and uses her phone more
often. She sometimes had afternoon
b. Rest
naps for 1-2 hours. Habitually, she
c. Sleeping pattern sleeps at 2am or 3am and wakes up
at 9am or 10am.
2.NUTRITIONAL- METABOLIC
Patient likes to eat noodles and salty
a. Typical intake(food, fluid) foods including junk foods. She also
eats vegetables such as bitter gourd,
b. Diet
lady finger, string beans and green
c. Diet restrictions beans. She usually takes 4-5 glasses
of water and 2-3 cups of coffee a
d. Weight day. During meal, she consumes 2-3
cups of rice and enjoys eating it with
e. Medications/supplement meats and egg dipped with soy
food sauce. She follows no diet or has no
diet restrictions. She is also taking
supplements such as folic acid, iron
NURSING ASSESSMENT II
Inclusive Dates of Care 8/2/14 – 8/14/14
Allergies Seafood
INITIAL
According to the patient, she is
sleep deprived and restless due to
pain and discomfort. She is
sometimes uncomfortable and thus,
she cannot enjoy and perform her
usual routine.
Patient is instructed of nothing by
mouth or NPO (nothing per orem).
She is restricted to drink foods and
fluids.
IV is given to prevent dehydration;
Hydralazine 5mg and Mangnesium
Sulfate is given to regulate blood
pressure prior to operation;
Age 30y/o
_______ __
CLINICAL APPRAISAL
DAY 1
Patient cannot perform her usual
activities. She performs her ADL
with assistance. She has sleep
disturbances due to pain on incision
site.
Patient eats 3-4 pandesal or soup
during breakfast with coffee or milk.
During meals, she eats hospital-
prepared foods. Typical foods
prepared are rice with egg/chicken
and vegetables. She also drinks
water for an average of 3-5 glasses a
day.
Patient is on low salt, low fat diet
and takes iron supplements such as
Ferous Sulfate.
Sex F____
DAY 2
Patient cannot perform her usual
activities. She performs her ADL
with assistance and is sometimes
dependent. She is currently bed rest
and usually have afternoon naps and
sleeps for about 6-8 hours.
Patient eats "lugaw", bread or soup
during breakfast. She eats hospital
prepared foods during meals.
Typical foods prepared are rice with
egg/chicken and vegetables. She
also drinks milk, and water with an
average of 3-5 glasses a day.
Patient is still on low salt, low fat
diet and takes ferrous sulfate for
iron supplementation.
Medications are continuous except

3. ELIMINATION
a. Urine (frequency, color,
transparency)
b. Bowel (frequency, color,
consistency)
4. EGO INTEGRITY
and calcium.
Patient's bowel routine is 1-2 times
daily. The stool is usually color
brown in solid appearance. She
voids 2-3 times a day with urine that
appears yellow and transparent.
Patient's bowel routine is 1 as of the
day with color brown stool and in
solid appearance. She voids twice as
of the day with yellow, transparent
urine output with blood spots.
IV is given together with oxytocin
for uterine contraction 20 'u' to
prevent excessive bleeding;
Ranitidine 50mg IV is also
administered for gastric acidity due
to NPO; Ampicillin to prevent
bacterial multiplication;
Metronidazole
Patient is inserted with indwelling
Foley catheter with a urine output
of 30 cc, in yellow color, and is
transparent. Patient was not able to
release stool.
for oxytocin. Additional medications
include amlodipine 10mg tab,
mefenamic acid cap, spinirolactone
50mg, Amoxicillin 500mg, Catapres,
Paracetamol 500mg
Patient is still on indwelling Foley
catheter and is able to void with
10cc, dark yellow, transparent urine
output. Patient has able to release
stool once with brown colored stool
and in solid appearance.

a. Perception of self
b. Coping Mechanism
c. Support System
d. Mood/Affect
Patient's perceives herself as a Patient’s main support system Patient’s main support system
strong mom. Her main support includes her husband and her 2 kids. includes her husband and 2 kids.
systems are her husband and 2 kids. She is usually sensitive and irritable. She is coping up by eating adequate
She is sometimes moody and often foods and takes prescribed
gets irritated easily. medicines to regain her energy and
for fast recovery.
Patient’s main support system
includes her husband and 2 kids. She
is coping up by eating adequate
foods and takes prescribed
medicines to regain her energy and
for fast recovery
5. NEURO-SENSORY

a. Mental state Patient is coherent and well- Patient responds correctly when Patient responds correctly when Patient responds correctly when
oriented. She also behaves asked and conveys emotions asked and conveys emotions asked and conveys emotions
accordingly. appropriately. Patient is well appropriately. Patient is well appropriately. Patient is well
b. Condition of five senses: oriented and is conscious. oriented and is conscious. oriented and is conscious.

(sight, hearing, smell, taste,
touch)
Patient’s five senses are intact and
functioning well; patient responds
to objects of stimulation that he
sees, hears, and touches. She can
also able to smell odors and taste
foods well.
Patient’s five senses are intact and
functioning well; patient responds
to objects of stimulation that he
sees, hears, and touches. She can
able to smell and taste well.
Patient’s five senses are intact and
Patient’s five senses are intact and
functioning well; patient responds
functioning well; patient responds
to objects of stimulation that he
to objects of stimulation that he
sees, hears, and touches. She can
sees, hears, and touches. She can
able to smell and taste well.
able to smell and taste well.

6. OXYGENATION Vital signs were not assessed. Patient’s vital signs are as follows: Patient’s vital signs are as follows: Patient’s vital signs are as follows:
Patient has no history of respiratory Temperature = 36.9°C; BP= Temperature = 37.1°C; BP= Temperature = 39.2°C; BP=
a. Vital signs problems prior to admission. 190/120mmHg, Respiratory rate = 140/110mmHg; Respiratory rate = 140/110mmHg; Respiratory rate =
42cpm; heart rate = 98bpm, 24cpm; heart rate = 67 bpm, 24 cpm; heart rate = 117 bpm,
Temperature
O2Saturation = 96%. O2Saturation = 96%. O2Saturation = 97%
Respiratory rate
Patient appears to have resonant Patient appears to have resonant Patient appears to have resonant
Heart rate lung sound upon auscultation. lung sound upon auscultation. lung sound upon auscultation.

Blood pressure

b. Lung sounds

c. History of Respiratory

Problems

7. PAIN-COMFORT Onset of pain started a day prior to Pain in the abdomen and back is Pain is felt moderately on incision Pain is persistently felt moderately
admission. Patient felt moderate to persistent from moderate to severe. area in the abdomen and is on incision area in the abdomen and
a. Pain (location, onset, severe abdominal and back pain and Vaginal bleeding and rapid uterine alleviated by administration of is alleviated by continuous
 character, intensity,
duration,
associated symptoms,
aggravation)
b. Comfort
measures/Alleviation
c. Medications
8. HYGIENE AND ACTIVITIES
OF DAILY LIVING
9. SEXUALITY
a. female (menarche, menstrual
cycle, civil status, number of
children, reproductive status)
b. male (circumcision, civil
status, number of children)
was associated with rapid uterine
contractions and moderate vaginal
bleeding.
Patient prompt medical assistance
from Laguna Medical Center.
Patient takes a bath once daily but
sometimes when she feels
uncomfortable, she takes a bath
twice during morning and in the
evening before going to bed.
Patient can able to perform ADL
independently such as bathing,
eating, sitting, walking, etc.
Patient’s last menstrual cycle was at
11/06/13, single with 2 kids, and an
obstetric status of G3T2P0A0L2.
contractions are still continuous. Tramadol 50mg through IV given
every 6 hours.
Patient is not able to take a bath but Patient is not able to take a bath but
sponge bath is applied to her with sponge bath is applied to her with
the assistance of her husband. the assistance of her husband. She
usually takes a sponge bath twice or
Patient can perform some ADL thrice a day.
independently such as dressing or
voiding but usually needs assistance Patient can perform some ADL
when walking, sitting, etc. independently such as eating or
voiding but usually needs assistance
when dressing, sitting, etc.
Patient’s last menstrual cycle was at
Patient’s last menstrual cycle was at
11/06/13, single with 2 kids, and an
11/06/13, single with 2 kids, and an
obstetric status of G3T2P0A0L2.
obstetric status of G3T2P0A0L2.
administration of Tramadol 50mg
through IV given every 6 hours
Patient is not able to take a bath but
sponge bath is applied to her with
the assistance of her husband. She
usually takes a sponge bath twice or
thrice a day.
Patient can perform some ADL
independently such as eating or
voiding but usually needs assistance
when dressing, sitting, etc.
Patient’s last menstrual cycle was at
11/06/13, single with 2 kids, and an
obstetric status of G3T2P0A0L2.
 LABORATORY AND DIAGNOSTIC PROCEDURES
NAME OF THE NURSING
DATE RESULT NORMAL VALUE INTERPRETATION NURSING IMPLICATION
PROCEDURE RESPONSIBILITY

8/2/14 Hemoglobin 5.4 g/dl M: 13-18 g/dl LOW Oxygen transport is  To prevent this,
F: 12-16 g/dl accomplished by hemoglobin. advise mother to
I: 11.3-13 g/dl Hemoglobin picks up oxygen increase food intake
Child: 11.5-14.8 g/dl in the lungs and releases rich in iron like
NB: 13.6-19.6 g/dl oxygen to the other tissues. malunggay. Iron is in
whole grains, nuts,
Hematocrit is percentage of and legumes.
total blood volume composed
of red blood cells. The
hematocrit measurement is
affected by the number and
size of RBC because it is based
on volume. There’s a decrease
in hematocrit count due to
decrease in RBC.

Hematocrit 16 M: 40-50% Inadequate iron intake can

F: 37-43% impair hemoglobin
I: 35-40% production. Consequently,
Child: 38-44% RBC do not fill up with
NB: 50-58% hemoglobin during their
formation and they remain
smaller than normal

8/3/14 Sodium 145.6 135-145 HIGH Sodium is the major  Monitor serum
electrolyte of ECF that moves sodium levels
easily between intravascular  Monitor fluid losses
and spaces and moves across and gains
cell membrane. It controls and  Check urine specific
regulates the volume of fluids gravity
and maintains water balance  Observe for
throughout the body. There is excessive intake of
increase serum sodium high sodium foods
reabsorption because there is  Look for excessive
increase blood pressure. thirst
 Potassium 3.85 3.5-5.0 NORMAL Potassium is the major cation  Maintain healthy
of ICF. It maintains fluid and lifestyle
electrolyte balance and also  Intake of 50 to 100
essential in regulation of acid- mEq daily is enough
base balance by cellular to maintain
exchange. potassium.

Chloride 107.5 97-107 HIGH Chloride is an electrolyte in

extracellular anion found in
blood and interstitial fluid. It  Keep safe and well
helps maintain proper fluid hydrated
and acid-base balance in the  Instruct to avoid
body. It also acts with sodium caffeine and alcohol
to maintain osmotic and  Proper dietary intake
pressure in blood and has
important buffering action of
oxygen and carbon dioxide
exchange in RBC.

8/7/14 Hemoglobin 6.3 g/dl M: 13-18 g/dl LOW When the hemoglobin level is  To prevent this,
F: 12-16 g/dl below 12mg/dl (hematocrit < advise mother to
I: 11.3-13 g/dl 33), iron deficiency is increase food intake
Child: 11.5-14.8 g/dl suspected. Inadequate iron rich in iron like
NB: 13.6-19.6 g/dl intake can impair hemoglobin malunggay. Irons are
production. Consequently, in the whole grains,
RBC do not fill up with nuts, and legumes.
hemoglobin during their
formation, and they remain
smaller than normal.

Hematocrit 16% M: 40-50% LOW

F: 37-43%
I: 35-40%
Child: 38-44%
NB: 50-58%

RBC 1.84 X 10/L M: 4.5-6.2 X 10^23/L LOW The primary function of RBC is
F: 4.0-5.4 X 10^23/L to transport oxygen from
I: 3.8-5.9 X 10^23/L lungs to the various tissues of
Child: 3.8-5.4 X 10^23/L the body and to assist in
 NB: 5.0-7.0 X 10^23/L transport of carbon dioxide
from the tissues to the lungs.

WBC 4.5-10.5 X 10^9/L WBC protects the body

against microorganisms and
removes dead cells and debris.

Platelet 410 x 10^9/dl 150-500 X 10^9/dl NORMAL Platelets are cell fragments
involved with preventing
blood loss.

8/12/14 Hemoglobin 7.2 g/dl M: 13-18 g/dl LOW When the hemoglobin level is  To prevent this,
F: 12-16 g/dl below 12 mg/dl (hematocrit advise mother to
I: 11.3-13 g/dl <33), iron deficiency is increase food intake
Child: 11.5-14.8 g/dl suspected. rich in iron like
NB: 13.6-19.6 g/dl malunggay. Iron is in
whole grains, nuts,
Hematocrit 21% M: 40-50% LOW Inadequate iron intake can and legumes.
F: 37-43% impair hemoglobin
I: 35-40% production. Consequently,
Child: 38-44% RBC do not fill up with
NB: 50-58% hemoglobin during their
formation, and they remain
smaller than normal.

8/13/14 Hemoglobin 9.2 g/dl M: 13-18 g/dl LOW When the hemoglobin level is  To prevent this,
F: 12-16 g/dl below 12mg/dl (hematocrit advise mother to
I: 11.3-13 g/dl <33), iron deficiency is increase food intake
Child: 11.5-14.8 g/dl suspected. rich in iron like
NB: 13.6-19.6 g/dl malunggay. Iron is in
whole grains, nuts,
and legumes.
Hematocrit 27% M: 40-50% LOW Inadequate iron intake can
F: 37-43% impair hemoglobin
I: 35-40% production. RBC do not fill up
Child: 38-44% with hemoglobin during their
NB: 50-55% formation, remain smaller
than normal.
SUMMARY OF INTRAVENOUS FLUID
DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED

8/02/14 4:00 PM D50 37 NaCl 500cc 44 cc/hr 7 hours 8/02/14 11:03 PM

8/03/14 6:00 AM D5IMB 500cc 40 cc/hr 9 hours 8/02/14 4:00 PM

8/03/14 4:00 PM D5NR IL 40 cc/hr 9 hours 8/02/14 1:15 AM

SUMMARY OF MEDICATION
 DATE MEDICATIONS- dosage, frequency, route Remarks

8/02/14 Hydralazine 5mg TID Well administered, been given on the exact
time indicated

8/02/14 Magnesium Sulfate 4g now then 5g TID on each buttocks then 5mg TID on alternating
buttocks every 4 hours until 24 hours postpartum Well administered, been given on the exact
time indicated

Well administered, been given on the exact

Hydralazine Hydrochloride 10ml time indicated
8/02/14

8/02/14 Well administered, been given on the exact

Terbutaline Sulfate
time indicated

Well administered, been given on the exact

Ampicillin 2g IV; ANST then 1g every 6hrs
8/02/14 time indicated

8/02/14 Tramadol 50mg slow IV Every 6hrs; 4 doses ANSTU Well administered, been given on the exact
time indicated
8/02/14 Ranitidine 50mg IV every 8hrsx 4 doses ANSTU Well administered, been given on the exact
time indicated

Well administered, been given on the exact

8/02/14 Voluvea 500ml time indicated

Well administered, been given on the exact

8/02/14 Ampicillin 1 g every 6hrsx24hrs time indicated

8/04/14 Amoxicillin 500mg 1 cap BID x 7days Well administered, been given on the exact
time indicated

Well administered, been given on the exact

8/04/14 Metronidazole 500mg 1 cap BID x 7 days time indicated

8/04/14 Ferrous Sulfate 1 tab BID x 7 days Well administered, been given on the exact
time indicated

Well administered, been given on the exact

8/04/14 Mefenamic Aacid 500mg 1 cap every 6hrs
time indicated

Well administered, been given on the exact

8/04/14 Amlodipine 10mg 1 cap BID x 30 days time indicated
8/04/14 Spiroglactone 50mg 1 cap TID x 7 days Well administered, been given on the exact
time indicated

Well administered, been given on the exact

8/06/14 Amlodipine 10 tab OD (5pm)
time indicated

Well administered, been given on the exact

8/06/14 Losartan 50mg tab OD (6AM) time indicated

8/07/14 Paracetamol 1 amp FV Well administered, been given on the exact

time indicated

Well administered, been given on the exact

8/07/14 Paracetamol 8mg 1 tab every 4 hours time indicated

8/07/14 Losartan 75mg Well administered, been given on the exact

time indicated
 ANATOMY AND PHYSIOLOGY

Reproductive system functions:

1. Production of female sex cells

2. Reception of sperm cells from the male
3. Nurturing the development of and providing nourishment for the new individual
4. Production of female sex hormones

UTERUS

 It is hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and anterior to the rectum.
 The body of the uterus is the uppermost part and forms the bulk of the organ.
 The portion of the uterus between the points of attachment of the fallopian tubes is termed the fundus. ]
 The isthmus of the uterus is a short segment between the body and the cervix. During pregnancy, this portion also] enlarges greatly to aid in accommodating the growing fetus.
 The cervix is the lowest portion of the uterus. ]

FUNCTIONS

1. The function of the uterus is to receive the ovum from the fallopian tube.
2. It provides a place for implantation and nourishment.
3. It furnishes protection to a growing fetus.
4. When a fetus matured, it expels it from a woman’s body.]

PLACENTA

 The placenta (Latin for “pancake,” which is descriptive of its size and appearance at term) arises out of the continuing growth of trophoblastic tissue. Its growth parallels that of the
fetus, growing from a few identifiable cells at the beginning of pregnancy to an organ 15 to 20 cm in diameter and 2 to 3 cm in depth, covering about half the surface area of the internal
uterus at term.]

FUNCTIONS

1. It provides nutrition. Transport nutrients and water soluble vitamins.

2. Exchanges. Fluid and gas transport
3. Facilitated transport
4. Active transport of amino acid, calcium and iron
 CIRCULATION in the placenta

 As early as the 12th day of pregnancy, maternal blood begins to collect in the intervillous spaces of the uterine endometrium surrounding the chorionic villi.
 By the third week, oxygen and other nutrients, such as glucose, amino acids, fatty acids, minerals, vitamins, and water, osmoses from the maternal blood through the cell layers of
the chorionic villi into the villi capillaries. From there, nutrients are transported to the developing embryo.]

ENDOCRINE FUNCTION of the placenta

 Aside from serving as the conduit for oxygen and nutrients for the fetus, the syncytial (outer) layer of the chorionic villi develops into a separate, important hormone-producing
system.
 Human Chorionic Gonadotropin, estrogen, progesterone, and Human Placental Lactogen (Human Chorionic Somatomammotropin).

PLACENTAL PROTEINS

 The placenta also produces several plasma proteins. The functions of these have not been well documented, but it is thought that they may contribute to decreasing the
immunologic impact of the growing placenta through being part of the complement cascade.

UMBILICAL CORD

 The umbilical cord is formed from the fetal membranes (amnion and chorion) and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta.
 Its function is to transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta.
 An umbilical cord contains only one vein (carrying blood from the placental villi to the fetus) but two arteries (carrying blood from the fetus back to the placental villi).]
 PATHOPHYSIOLOGY

ABRUPTIO PLACENTA
PRECIPITATING FACTOR PREDISPOSING FACTOR
Age Maternal Hypertension (PIH, Chronic
Family History Hypertension)
Medical History Decrease resiliency of blood vessel at placental bed Premature Rupture of Membranes
Lifestyle Women with Previous Abruption
Maternal Hyperhomocysteinemia
Chorioaminionitis
Torn or ruptured blood vessels Traumatic Injury
Sudden Decompression of the Uterus
Uterine Anomalies
Partial Separation Short Umbilical Cord
Multiparity
Race or ethnicity

Partial Portion Detached Central Portion Detached

Total Separation
Mild to moderate vaginal bleeding Blood trapped to intact peripheral portion

Concealed Hemorrhage
Increase uterine wall irritability Fluids enter muscle fibers

Progressive separation Uteroplacent Decrease Maternal

Fetal Death
at apoplexy Platelet Shock
Uterine Tetany
Board-like
rigidity
Uterine tetany
Fetal Hypoxia Disseminated Organ Failure Abdominal and
Intravascular Back Pain
Coagulation
Fetal distress (DIC)
Fetal death

Emergency delivery
 MEDICAL MANAGEMENT

ACTUAL 08/02/14
08/02/14 Pre OP Care
 Admission of patient Post OP Care
 Secure Consent  To ward with close monitoring
 Ni per OS  O2 Inhalation at 3 LPM
 Intravenous Fluid Normal Saline Solution 1L x 8 hours  Monitor Vital Signs
 Insert Indwelling Foley Catheter  NPO
 Watch out for Magnesium Toxicity Medications:
 Monitor Fetal Heart tone  Ampicillin 2g IV: every 6 hours
Prescribed Medications:  Tramadol 50mg: every 6 hours
 Ranitidine 50 mg Iv: every 8 hours
 Hydralazine 5mg TID for BP of > 160/100
 Monitor Intake and output every 2 hours
 Magnesium Sulfate 4g
 Blood transfusion
Laboratory: 08/03/14
 CBC with PC  Diet as tolerated
 Blood Urea Nitrogen and Creatinine  Monitor vital signs
 Serum Glutamic Oxaloacetic Transaminase (SGOT)  Continue Medications
 For actual pro-thrombin time
08/02/14  Still for: SGOT, BUN and Creatinine, Sodium, Potassium,
(3:40 AM) Chloride
 Remove Indwelling Foley Catheter
 Still for blood transfusion
 Direct to operating Room for E Cesarean Section
 Apply abdominal binder
Medicine:
08/04/14
 Hydralazine Hydrochloride 10 ml  Low salt, low fat diet
 Terbulatine Sulfate ½ ampule SL Medications:
 Inform OR Nurse/Chief of Clinic/Pedia/Anes/JDO/ OB  Amoxicillin 500 mg x 7days
gyne  Metronidazole 500 mg BID x 7 days
 08/14/14
 May go home
 Continue meds
 BP monitoring at home.

 Ferrous Sulfate 1 tab BID x 30 days

 Mefenamic Acid 500mg 1 cap every 6 hours
 Amlodipine 10 mg 1 cap BID x 30 days
 Spironolactone 50 mg 1 cap TID x 7 days
 Continue Meds
 For change of dressing
08/06/14
 Low salt, Low fat diet
Medicine:
 Decrease amplodipine 10 tab OD
 Start Losartan 50 mg OD
 Continue meds
 Still for blood transfusion
08/07/14
 Continue Oral meds and blood pressure monitoring
08/08/14
 For change of dressing
08/10/14
 Continue medications
08/11/14
 For change of dressing
 Continue medications
08/12/14
 Still for low fat diet
 Continue Medication
08/13/14
 Continue medications
 For daily change of dressing
 For blood transfusion
 NURSING MANAGEMENT

ACTUAL

 Monitored Vital signs

 Continuously evaluated bleeding status
 Evaluated electronic fetal and maternal monitoring tracings
 Evaluated signs of shock-rapid pulse, pallor, cold and moist skin, decrease in blood pressure
 Evaluated decrease of urine output
 Placed patient on bed rest in a lateral position to prevent pressure on the vena cava
 Inserted intravenous catheter into a large vein for fluid replacement.
 Monitored FHR externally and measured maternal vital signs
 Administered O2 to patient
 Inserted Indwelling Foley Catheter
 Prepared pre-operation for cesarean section
 Performed Post-operation care
 Transferred patient to ward room
 Performed bedside care to mother
 Assisted in change of dressing
 Regulated IV
 Administered Medications
 Applied abdominal binder
 Removed Indwelling Foley Catheter
 SURGICAL MANAGEMENT

Abruptio Placentae is the premature separation of the placenta that occurs late in the pregnancy. Once the condition has reached a stage that mightily endangers the life of both
patients, the surgical management that could be put into action are:

 Cesarean delivery. It is the surgical delivery of a baby through a cut (incision) made in the mother’s abdomen and uterus. It might be planned ahead of time if a mother develops
pregnancy complications. It is necessary for fetal and maternal stabilization. Cesarean delivery facilitates rapid delivery and direct access to the uterus and its vasculature. It could avert
further disease progression and possible maternal death cases.

 Hysterectomy. Is an operation to remove uterus through an incision in the lower abdomen. When placental abruption takes place, the placenta comes away from the wall of the uterus.
Usually, the placenta only detaches a little bit, but in some cases the placenta separates completely. This can lead to an emergency delivery of the baby, afterwards, the uterus may be
damaged extensively and that is why a hysterectomy might be performed to remove it.
 DISCHARGE PLAN

NAME _Patient X________________________________________ DATE OF DISCHARGE: _08/14/2014___________________

CONDITION UPON DISCHARGE Must be well __ Nature: Home per request (✓) Discharge against medical advice ( )

 Catapres 75mg 1 tablet PRN for blood pressure ≥160/90

1. MEDICATIONS  Losartan 10mg 1 tablet OD (6am)
 Amlodipine 10mg 1 tablet OD (6pm)
 Amoxicillin 500mg 1 capsule every 8hours for 7 days
 Metronidazole 500mg 1 tablet BID for 7 days
 Ferrous Sulfate 1 capsule BID for 1 month
 Mefenamic Acid 500mg 1 capsule every 8 hours for pain
 Spinorolactone 50mg 1 capsule BID for 7 days

 Encourage morning walks and stretching

2. EXERCISE  Encourage the patient to keep active and adhere to an exercise program and to remain as self-sufficient as possible.

 Sodium restrictions
3. DIET - May vary from 2 to 4 grams depending on the degree of hypertension. The patient should be avoiding foods such
as cured meats, canned soups, and soy sauce.

 Constant monitoring of blood pressure

4. HEALTH TEACHING  Advice to exercise regularly
 Advice to avoid salty and fatty food
 Explain the medications, what they are for, and how they work.

5. SCHEDULE FOR THE NEXT VISIT Follow check-up at the OB department on August 22, 2014, Friday at 1:00PM
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Acute pain related to surgical After 8 hours of nursing Independent
incision as evidenced by intervention, the patient will 1. Monitor the patient’s
“Masakit ang tahi ko.” as verbal report of pain verbalize reduced discomfort vital signs.
verbalized by the patient. and pain. 2. Note location of surgical
Pain scale: 8/10 procedures.
3. Assess referred pain as
OBJECTIVE CUES: appropriate.
4. Note and investigate
 Vital signs
changes from previous
BP: 140/110mmHg
reports of pain.
PR: 67bpm
5. Assess skin color along
RR: 24cpm
with vital signs.
 Facial grimace
6. Provide comfort
 Sleep disturbance measures, quiet
 Displaying guarding environment, and calm
behavior by laying activities.
flat on bed 7. Encourage adequate rest
periods.
8. Instruct and encourage
use of relaxation
techniques such as deep-
breathing exercises.
Dependent
1. Administer opioid
analgesics as
prescribed by the
doctor: Tramadol
50mg TIV every 6
hours.
Independent After 8 hours of nursing
1. To establish baseline intervention, the patient has
data. shown signs of reduced
2. To help determine the discomfort and pain.
amount of post-operative
pain experienced.
3. To help determine the
chances of an underlying
condition that may need
treatment.
4. To rule out worsening of
underlying condition or
development of
complications.
5. Acute pain usually alters
these factors.
6. To promote non
pharmacological pain
management.
7. To prevent fatigue.
8. To distract attention and
reduce tension.
Dependent
1. Inhibits reuptake of
serotonin and
norepinephrine in
CNS.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Hyperthermia related to After 8 hours of nursing Independent
increased metabolic rate as intervention, the patient’s
“Mainit ang pakiramdam ko,” evidenced by increase in temperature will go back to 1. Monitor the patient’s
as verbalized by the patient. body temperature above the normal range. vital signs.
OBJECTIVE CUES: normal range (39.2°C). 2. Perform tepid sponge
bath (TSB) on patient.
 Vital signs 3. Promote surface cooling
T: 39.2°C by undressing/putting on
PR: 117bpm thin and light clothes.
RR: 34cpm 4. Encourage adequate fluid
BP: 140/110mmHg intake.
 Flushed skin 5. Advice to maintain bed
 Warm to touch rest.
 Malaise/weakness
Dependent
1. Administer prescribed
medication ordered as
such: Paracetamol 1 amp.
3000mg >38.6°C.
2. Administer replacement
fluids and electrolytes as
ordered.
Collaborative
1. Refer to laboratory
for tests.
Independent After 8 hours of nursing
intervention, the patient’s
1. To establish baseline temperature has decreased.
data.
2. To promote heat loss by
means of evaporation
and conduction.
3. To promote heat loss by
means of radiation and
conduction.
4. To prevent dehydration.
5. To reduce metabolic
demands and oxygen
consumption.
Dependent
1. Antipyretics inhibits the
enzyme cyclooxygenase
(COX) and interrupt the
synthesis of inflammatory
prostaglandins.
2. To support circulating
volume and tissue
perfusion.
Collaborative
1. To identify causative
factors.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

SUBJECTIVE CUES: Decreased cardiac output After 8 hours of nursing Independent Independent After 8 hours of nursing
related to increased intervention, the patient’s 1. Monitor the patient’s 1. To establish baseline intervention, the patient’s
“Nahihilo ako,” as verbalized peripheral vascular resistance blood pressure will be vital signs. data. blood pressure was reduced.
by the patient. 2. Presence of pallor, cool,
secondary to hypertension as reduced. 2. Observe skin color,
moist skin, and delayed
OBJECTIVE CUES: evidence by BP moisture, temperature, capillary refill may be due
160/120mmHg, patient and capillary refill time. to peripheral
 Vital signs complaining of dizziness. 3. Provide calm, restful vasoconstriction or reflect
T: 39°C surroundings, minimize cardiac
PR: 95bpm environmental decompensation/decreas
RR: 27cpm activity/noise. Limit the ed output.
3. Helps reduce sympathetic
BP: 160/120mmHg number of visitors and
stimulation that
 Pale complexion length of stay. promotes relaxation.
 Body malaise 4. Implement dietary 4. These restrictions can
sodium, fat, and help manage fluid
cholesterol restrictions as retention and, associated
indicated. hypertensive response,
decrease myocardial
workload.
Dependent
1. Administer prescribed Dependent
medication as 1. Stimulates alpha-
ordered: Cataprez 25 adregenic receptors in
mg tab Sublingual > CNS, decreasing
160/90mmHg sympathetic overflow;
inhibiting
vasoconstriction, and
ultimately reducing
blood pressure. It
generally reduces
blood pressure
through the
combined effect of
decreased total
peripheral resistance,
reduced cardiac
output, inhibited
sympathetic activity,
and suppression of
renin release.