Case Study 10 NCP

Nursing Care Plan NCP
CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 1 – Kristinelou Marie N. Reyna
CLIENT NAME : Rachel S. Agapito AGE : 23 SEX : F
REASON FOR ADMISSION : Watery Vaginal Discharge
ADMITTING IMPRESSION: G1P0 Pregnancy Uterine, 39 weeks AOG, Cephalic in latent phase of labor / Prelabor Rupture of Membrane
PHYSICIAN : Dr. Yu / Dr. Hermogenes
Assessment Nursing Scientific Analysis Goal and Nursing Rationale Evaluation

Diagnosis Outcomes Interventions
O: Risk for infection The nursing Short term: Independent: 1. It is important Short term:
Soaked underwear, r/t amniotic diagnosis is risk After 6 hours of 1. Establish rapport to build trust and After 6 hours of
onset of watery membrane for infection nursing to the patient. relationship to the nursing
vaginal discharges, rupture related to interventions, the patient to interventions,
associated with amniotic patient will be understand and the patient was
hypogastric pain membrane able to: communicate able to:
radiating to rupture is a well. It also
lumbosacral area, priority problem A - Free from any improves patient A - Free from
with uterine because the signs and care. any signs and
contraction every 30 protective barrier symptoms of symptoms of
minutes. between the infection such as 2. Assess patient’s 2. To know any infection such as
VS: BP: 90/60 mmHg vagina and the foul smelling or vital signs. deviations from foul
HR: 96 bpm fetus is lost, thus, looking vaginal normal range. smelling/looking
RR: 19 cpm the patient is at drainage vaginal
Temp: 36.5°C risk of being throughout rest of 3. Assess for the 3. These factors drainage,
O2 Sat: 98% invaded by pregnancy. presence or represent a break tachycardia, and
Weight: 63kg pathogenic existence of signs in the body’s hypo-tension
Abdomen: organisms. B – Patient will and symptoms of normal first line of throughout rest
FH: 34cm identify 3 infection. defense and may of pregnancy.
EFW: 3565 g causative risk indicate an -GOAL MET
FHT: 145 bpm factors of infection.
SPE: (+) minimal infections. B – Identified 3
whitish discharges at 4. Perform initial 4. Vaginal exam causative risk
posterior fornix C - Patient will vaginal may be required factors of
area, foul smell verbalize 5 examination, when to confirm infections.
IE: 1 cm, UE ST -5, techniques and the diagnosis, but -GOAL MET
Leaking BOW, lifestyle changes contraction pattern avoid multiple
Cephalic, posterior, to prevent or repeat, or maternal digital vaginal C – Verbalized 5
firm, BISHOP score: reduce risk of behavior indicates exams to reduce techniques and
1 infection. progress. the risk of lifestyle changes
A: G1P0, 39 weeks infection. to prevent or
AOG, Cephalic in D – Patient will reduce risk of
latent phase of maintain vital 5. Monitor 5. Within 4 hours infection.
labor, PROM signs within temperature, after membrane
normal range. pulse, blood rupture, -GOAL MET
pressure, and chorioamnionitis
E – Patient will respiration. incidence D – Maintained
have a follow up increased vital signs within
check up at APS progressively in normal range.
clinic on May 6, accordance with -GOAL MET
2020. the time indicated
by vital signs. E – Had a follow
up check-up at
6. Monitor change 6. Monitoring will APS clinic on
in color, help determine May 6, 2020.
consistency, and any signs of -GOAL MET
amount of vaginal infection of
discharge. vaginal discharge.
7. Maintain sterile 7. To prevent

technique in all introduction of
invasive pathogens and
procedures and contamination.
during perineal
care to the patient.
8. Educate the 8. Having

patient on knowledge and
causative risk being aware of
factors of causative factors
infections that the of infection
patient should reduces likelihood
watch out for. of transmission.
9. Discuss the 9. Knowledge of

importance of ways to reduce or
sterile techniques eliminate germs
and lifestyle reduces the
changes to reduce likelihood of
risk of infection. transmission.
10. Discuss the 10. To make sure

take home meds to the patient/SO
the patient. understands how
and when to take
the medication,
store the
medication and
what is the
medication used
for.
Dependent:
1. To determine
1. Administer
effectiveness of
medications and IV
therapy or
fluids mandated by
presence of side
physician’s orders
effects.
Collaborative:
1. Refer the patient
to attending 1. It signals
physician if there is presence of
worsening of the complications
patient’s health which needs
condition. immediate
interventions.
Nursing Care Plan NCP

Assessment Nursing Scientific Goal and Outcomes Nursing Rationale Evaluation

Diagnosis Analysis Interventions
O: Acute pain r/t Acute pain is a Short term: Independent: Short term:
Soaked underwear, pressure on type of pain that After 8 hrs. of  Assess degree of  Attitudes and After 8 hrs. of
onset of watery adjacent typically lasts less nursing discomfort of the reactions to nursing
vaginal discharges, structures than 3 to 6 interventions, the patient through pain are interventions, the
associated with combined with months, patient will be able verbal and individual and patient was able
hypogastric pain simulation of or pain that is to: nonverbal cues. based on past to:
radiating to both directly related experiences,
lumbosacral area, parasympathetic to soft tissue A – Demonstrate understanding A –Demonstrate
with uterine and sympathetic damage. use of 3 of physiological use of 3 non-
contraction every nerve endings nonpharmacologica changes, and pharmacological
30 minutes. amb patient’s l techniques to cultural techniques to
VS: BP: 90/60 report of pain control pain or expectations. control pain or
mmHg and uterine discomfort. Monitor  Monitor the discomfort.
HR: 96 bpm contractions. frequency, labor progress -GOAL MET
RR: 19 cpm B – Patient will duration and and provide
Temp: 36.5°C verbalize actual intensity of information for B – Verbalize
O2 Sat: 98% reduction of pain uterine the client. actual reduction
Weight: 63kg radiating to contractions. of pain radiating
Abdomen: lumbosacral area. Monitor vital  Establish to lumbosacral
FH: 34cm signs. baseline data area.
EFW: 3565 g C – Patient will and note -GOAL MET
FHT: 145 bpm appear relaxed or changes.
SPE: (+) minimal resting between Assist in use of  Promotes C – Appear
whitish discharges contractions. appropriate relaxation and relaxed or resting
at posterior fornix nonpharmacologi hygiene. May between
area, foul smell D – Patient will be cal techniques block pain contractions.
IE: 1 cm, UE ST -5, able to maintain (e.g., impulses within -GOAL MET
Leaking BOW, vital signs within breathing/relaxati the cerebral
Cephalic, normal range. on techniques, cortex through D – Maintain vital
posterior, firm, abdominal conditioned signs within
BISHOP score: 1 E – Patient will have effleurage) responses and normal range.
A: G1P0, 39 weeks a follow up check- cutaneous -GOAL MET
AOG, Cephalic in up at APS clinic on stimulation.
latent phase of May 6, 2020. Assess and  Ensures any E – Had a follow
labor, PROM monitor BP and deviations from up check-up at
pulse rate every normal range. APS clinic on May
1–2 min after Reduces risk of 6, 2020.
drug maternal -GOAL MET
administration. hypotension.
Discuss the take  To determine
home meds to effectiveness of
the patient and therapy or
SO. presence of
side effects.
Dependent:  IV route is
Administer preferred
appropriate IV because it
medications ensures more
mandated by rapid and equal
physician’s absorption of
orders. analgesic.
Administering
IV drug during
uterine
contraction
decreases
amount of
medication that
immediately
reaches the
fetus.
FDAR CHART

DATE AND TIME FOCUS DATA, ACTION AND RESPONSE

4/26/20 Risk for infection r/t amniotic membrane D: Received patient with soaked underwear, onset of watery
0800 rupture vaginal discharges, associated with hypogastric pain
radiating to lumbosacral area, with uterine contraction every
30 minutes. VS: BP: 90/60 mmHg, HR: 96 bpm, RR: 19 cpm,
Temp: 36.5°C, O2 Sat: 98%
0810 A:
-Administered antibiotics mandated by physician’s orders.
Observed for adverse reaction of the drug.--------------------
0830 -Performed initial vaginal examination to the patient.

Inserted Dinoprostone 0.5 mg gel endocervically for
inflamed, sore vaginal lining. mandated by physician’s
orders.---------------------------------------------------------------------
1150 -Instructed the patient of practicing good hygiene.

Monitored V/S of the patient and charted. Regulated IVF and
charted. ------------------------------------------------------------------
1230 R: Patient is now free from infection and vital signs are
stable.-----------------------------------------------------K. Reyna, RN
4/28/30 Health teaching: Causative risk factors A: Discussed the signs and symptoms of infection to the
0500 patient that the she should watch out for.------------------------
0510 R: Patient verbalized 5 signs and symptoms and identified

causative or risk factors in her current situation.
4/29/20 Health teaching: Dressing Change A: Instructed to the patient of proper dressing.---------------
0900 R: Patient demonstrated she is able to change her own
dressing using aseptic technique.-------------------------------
4/30/20 Discharge Plan A: Advised the patient to take meds at the right time, dose,
0600 frequency and route. Advised the patient to follow-up on
APS clinic on Wednesday, May 6,
2020.-------------------------------------------------------------------------
--------------------K. Reyna, RN
FDAR CHART

DATE AND TIME FOCUS DATA, ACTION AND RESPONSE

4/26/30 Pain D: “Sakit ako pus-on apil sa ubos na parte sa ako likod.” as
0800 patient verbalized. VS: BP: 90/60 mmHg, HR: 96 bpm, RR: 19
cpm, Temp: 36.5°C, O2 Sat: 98%
0510 A:
-Administered pain relief medications mandated by
physician’s orders. Assisted the patient with comfort
measures (e.g., back/leg rubs) and supported legs to a
comfortable position.---------------------------------------------------
R: Patient showcases signs of relief with nonverbal
cues.---------------------------------------------------------------------K.
0630 Reyna, RN
A:
-Monitored V/S of the patient and charted. Encouraged the
patient of deep breathing and relaxation techniques and
adequate rest.-----------------------------------------------------------
R: Patient reports relief of pain at the lower back and states
“Okay na ako tagbati.” ---------------------------------K. Reyna, RN
DRUG STUDY

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  Uterine and Endocervical Gel  Hypersensitivity,  GU: uterine 1. Check physician’s
Dinoprostone gastrointestinal Vaginal Insert: Used Cross-sensitivity may contractile orders.
smooth muscle to “ripen” the cervix occur; some oral abnormalities,
Brand name: stimulation in pregnancy at or liquids contain alcohol warm feeling 2. Observe 10 rights of
Prepidil E  Cervical softening near term when and should be avoided  in vagina. drug administration.
and dilation induction of labor is in patients with  MS: back pain.
Classification:  Increases indicated. known intolerance  Misc: AMNIOTIC 3. Perform hand
Therapeutic: Cervical frequency and Vaginal Suppository:  Safe use during FLUID EMBOLISM, hygiene using aseptic
ripening agent strength of uterine Induction of pregnancy (category fever technique.
Pharmacologic: contraction midtrimester B) or lactation is not
Oxytocics abortion established.
 Use cautiously 4. Bring gel to room
Route: inpatients with temperature just
Vaginal hepatic dysfunction. before administration.
 Adjust dosage Do not force warming
Dosage: inpatients with with external sources.
0.5 mg impaired renal
function 5. Patient should be in
dorsal position with
cervix visualized using
a speculum.
6. Introduce gel with

catheter into cervical
canal using sterile
technique.
7. Observe patient
carefully, after
insertion of the drug.
8. Monitor uterine
contractions and
observe for and report
excessive vaginal
bleeding and cramping
pain. Keep pad count.
9. Monitor vital signs of

the patient.
10. Explain the purpose

of medication and
vaginal exams to the
patient.
11. Instruct patient to

notify health care
professional
immediately if
fever and chills, foul-
smelling vaginal
discharge, lower
abdominal pain and
bleeding occurs.
12. Provide emotional

support throughout
therapy.
DRUG STUDY


PRECAUTION
Generic Name:  Inhibits the action  Short-term  Hypersensitivity, CNS: headache, 1. Check physician’s
Ranitidine of histamine at treatment Cross-sensitivity may malaise, vertigo orders.
theH2 receptor site of active duodenal occur; some oral EENT: blurred vision 2. Observe 10 rights of
Brand name: located primarily in ulcer. liquids contain alcohol GI: constipation, drug administration
Zantac gastric parietal  Maintenance and should be avoided diarrhea, nausea and 3. Do skin testing
cells, resulting therapy for in patients with vomiting 4. Verify correct IV
Classification: ininhibition of duodenal ulcer known intolerance OTHER: anaphylaxis, concentration and
Gastrointestinal gastric acid patient after  Safe use during angioedema, burning rate of infusion.
agent secretion healing of acute pregnancy (category and itching at 5. Allow 1 hour
 Indirectly reduces ulcer B) or lactation is not injection site between any other
Route: pepsin secretion  Gastroesophageal established. antacid and ranitidine
IVTT but appears to have reflux disease  Use cautiously 6. Avoid excessive
minimal effect on  Heartburn inpatients with alcohol.
Dosage: fasting and hepatic dysfunction. 7. Assess patient for
50 mg postprandial serum  Adjust dosage epigastric or
gastrin inpatients with abdominal pain and
concentrations or impaired renal frank or occult
secretion of gastric function blood in the stool,
intrinsic factor or emesis, or gastric
mucus. aspirate
8. Nurse should know
that it may cause
false-positive results
for urine protein;
test with
sulfosalicylic acid
9. Inform patient that
it may cause
drowsiness or
dizziness
10.Inform patient that
increased fluid and
fiber intake may
minimize
constipation
11.Advise patient to
report onset of
black, tarry stools;
fever, sore throat;
diarrhea; dizziness;
rash; confusion; or
hallucinations to
health care
professional
promptly
12.Inform patient that
medication may
temporarily cause
stools and tongue to
appear gray black.
13. Instruct patients to
monitor for and
report occurrence
of drug-induced
adverse reaction.
DRUG STUDY


PRECAUTION
Generic Name:  Therapeutic Action:  Relief of symptoms  Allergy to  CNS: drowsiness, 1. Check physician’s
Metoclopramide Enhances the of acute and metoclopramide extrapyramidal orders.
motility of the recurrent diabetic  GI hemorrhage reactions,
Brand name: upper GI tract and gastroparesis  Mechanical restlessness, 2. Observe 10 rights of
Maxolon increases gastric obstruction or neuroleptic drug administration.
emptying without  Facilitation of small perforation malignant
Classification: affecting gastric, bowel intubation in  Pheochromocytoma Syndrome, anxiety, 3. Assess for allergy to
Antiemetics biliary or pancreatic radiographic  Epilepsy depression, metoclopramide.
secretions. It procedures. irritability, tardive
Route: increases duodenal dyskinesia. 4. Assess for other
IVTT peristalsis which  Management of  CV: arrhythmias contraindications.
decreases intestinal gastroesophageal (supraventricular
Dosage: transit time, and reflux. tachycardia, 5. Keep
10 mg increases lower bradycardia), diphenhydramine
oesophageal  Treatment and hypertension, injection readily
Frequency: sphincter tone. It is prevention of hypotension. available in case
also a potent postoperative  GI: constipation, extrapyramidal
central dopamine- nausea and diarrhea, dry reactions occur (50 mg
receptor antagonist vomiting when mouth, nausea. IM).
and may also have nasogastric  Endo:
serotonin-receptor suctioning is gynecomastia. 6. Have phentolamine
(5-HT3) antagonist undesirable.  Hemat: readily available incase
properties. methemoglobinemi of hypertensive crisis
a, neutropenia,
leukopenia,
7. Monitor for BP
agranulocytosis.
during IV
administration.
8. Monitor for
extrapyramidal
reactions, and consult
physician if they occur.
9. Give direct IV doses

slowly over 1-2
minutes.
10. For IV infusion, give

over at least
15minutes.
11. Caution patient to

avoid driving or other
activities requiring
alertness until
response to medication
is known.
12. Advise patient to

avoid concurrent use of
alcohol and other CNS
depressants while
taking this medication.
13. Inform patient of

risk of extrapyramidal
symptoms, tardive
dyskinesia, and
neuroleptic malignant
syndrome.

notify health care
professional
immediately if
involuntary or
repetitive movements
of eyes, face, or limbs
occur.
15. Document that the

drug has been given.
DRUG STUDY


PRECAUTION
Generic Name:  Inhibits growth of Anaerobic infections:  Hypersensitivity  CNS: seizures, 1. Check physician’s
Metronidazole amoebae by binding Intra-abdominal  Hypersensitivity to dizziness, headache orders.
to DNA, resulting in infections. parabens.  EENT: Tearing
Brand name: loss of helical Gynecologic  First trimester of (topical only) 2. Observe 10 rights of
Flagyl structure, strand infections, Skin and pregnancy.  GI: abdominal pain, drug administration.
breakage, inhibition skin structure anorexia, nausea
Classification: of nucleic acid infections, Lower and vomiting, 3. Assess for infection
Antibacterial, synthesis and cell respiratory tract diarrhea, dry mouth, (vital signs; appearance
Antiprotozoal death. infections, Bone and glossitis of wound, sputum,
joint infections, CNS  Derm: rashes, urine, and stool;
Route: infections, urticarial, mild WBC)at beginning of
IV Septicemia, dryness, skin and throughout
Endocarditis. irritation therapy.
Dosage:  Perioperative  Hemat: leukopenia.
500 mg prophylactic agent  Local: phlebitis at IV
4. Monitor neurologic
in colorectal site.
status during and after
Frequency: surgery.  Neuro: peripheral
q 8hr IV infusions. Inform
neuropathy.
health care
Timing: professional if
numbness, paresthesia,
4:45pm, 12:45am,
8:45am weakness, ataxia, or
seizures occur.
5. Monitor intake and

output and daily
weight, especially for
patients on sodium
restriction. Each 500
mg of premixed
injection for dilution
contains 14 mEq of
sodium.
6. Administer premixed
injection (500 mg/100
mL) undiluted. Do not
refrigerate. Once taken
out of overwrap,
premixed infusion
stable for 30 days at
room temperature.
avoid intake of
alcoholic beverages or
preparations containing
alcohol during and for
at least 3 days after
treatment with
metronidazole.
8. Inform patient that

medication may cause
dizziness or light-
headedness. Caution
patient to avoid driving
or other
alertness until response
to medication is known.
notify health care
professional promptly if
rash occurs.

DRUG STUDY


PRECAUTION
Generic Name:  Inhibits activation of  Antihemorrhagic  Hypersensitivity  CNS: SEIZURES, 1. Check physician’s
Tranexamic acid plasminogen, and antifibrinolytic  Thromboembolic headache, dizziness. orders.
thereby preventing for effective disorders (current,  EENT: visual
Brand name: the conversion of hemostasis in history of, or at risk abnormalities. 2. Observe 10 rights of
Lysteda. plasminogen to various surgical and for)  CV: hypotension, drug administration.
Cyklokapron plasmin. clinical cases, in  Acquired defective thromboembolism,
traumatic injuries, color vision thrombosis. 3. Do skin testing to the
Classification: post-tooth  Subarachnoid  GI: diarrhea, nausea, patient.
Antifibrinolytics agent extraction and other hemorrhage vomiting.
Pregnancy Category B dental procedures.  Concurrent use of  MS: pain 4. Tell the patient to
combination inform the healthcare
Route: hormonal provider if color blind,
IVTT contraception have a history of
stroke, and blood clot.
avoid products
containing aspirin or
NSAIDs
notify health care
professional if heavy
menstrual bleeding
persists or worsens.
7. Administer drug at
the right dosage and
right route in the right
time.
8. Check the patency of

the IV site and IV line.
9. Report severe
allergic reactions such
as rash, itching,
tightness in the chest,
swelling of lips, mouth,
face or tongue.

DRUG STUDY


PRECAUTION
Generic Name:  Stimulates uterine  Induction of labor at Hypersensitive to  CNS: maternal— 1. Check physician’s
Oxytocin smooth muscle, term. drug when vaginal COMA, SEI-ZURES; orders.
producing uterine  Facilitation of delivery is advised fetal, INTRACRANIAL
Brand name: contractions similar threatened Cephalopelvic HEMORRHAGE. 2. Observe 10 rights of
Pitocin to those in abortion. disproportion is  Resp: fetal— drug administration.
spontaneous labor.  Post-partum control present ASPHYXIA,hypoxia
Classification:  Has vasopressor of bleeding after When delivery  CV: maternal— 3. Assess character,
Oxytocics and antidiuretic expulsion of the requires conversion hypotension; fetal, frequency, and
effects. placenta. as in transverse lie arrhythmias. duration of uterine
Route:  GI: nausea and contractions; resting
IVTT vomiting uterine
 F and E: maternal— tone; and fetal heart
Dosage: hypochloremia, rate frequently
10 mg hyponatremia, throughout
water intoxication. administration.
4. Monitor maternal BP
and pulse frequently
and fetal heart rate
continuously
throughout
administration.
5. Monitor patient for

signs and
symptoms (drowsiness,
listlessness, confusion,
headache, anuria) and
notify physician or
other health care
professional if they
occur.
6. Monitor patient
extremely closely
during first and second
stages of labor because
of risk of cervical
laceration, uterine
rupture and maternal
and fetal death.
7. Watch and take note

for any signs and
symptoms.

DRUG STUDY


PRECAUTION
Generic Name:  Bactericidal action  Treatment of  Contraindicated  CNS: Lethargy, 1. Check physician’s
Ampicillin against sensitive infections caused with allergies to hallucinations, seizures orders.
organisms; inhibits by susceptible penicillins,  CV: CHF
Brand name: synthesis of strains of Shigella, cephalosporins, or  GI: Glossitis, stomatitis, 2. Observe 10 rights of
Ampi bacterial cell wall, Salmonella, other allergens. gastritis, sore mouth, drug administration.
causing death. Escherichia coli,  Use cautiously with furry tongue, black
Classification: Haemophilus renal disorders. “hairy” tongue, nausea, 3. Determine previous
Penicillin influenzae, Proteus vomiting, diarrhea, hypersensitivity
Pregnancy Category mirabilis, Neisseria abdominal pain, bloody reactions to
Risk: B gonorrhoeae diarrhea, enterocolitis, penicillins,
.  Meningitis caused pseudomembranous cephalosporins, and
Route: by Neisseria colitis, nonspecific other allergens prior
IVTT meningitidis hepatitis to therapy.
 Prophylaxis in  GU: Nephritis
Dosage: cesarean section in  Hematologic: Anemia,
4. Check IV site
2 mg certain high-risk thrombocytopenia,
carefully for signs of
patients leukopenia,
thrombosis or drug
Frequency: neutropenia, prolonged
q 6 hr reaction.
bleeding time
 Hypersensitivity: Rash,
Timing: 5. Do not give IM
fever, wheezing,
injections in the same
2pm, 8am, 2pm anaphylaxis
site; atrophy can
 Local: Pain, phlebitis,
occur. Monitor
thrombosis at injection
injection sites.
site (parenteral)
 Other: Superinfections
6. Inspect skin daily
—oral and rectal
and instruct patient to
moniliasis, vaginitis
do the same. The
appearance of a rash
should be carefully
evaluated to
differentiate a
nonallergenic
ampicillin rash from a
hypersensitivity
reaction.
7. Instruct patient. to
immediately report
signs and symptoms of
hypersensitivity
reaction, such as rash,
fever, or chills.
8. Tell patient. to
report signs and
symptoms of infection
or other problems at
injection site.

DRUG STUDY


PRECAUTION
Generic Name:  Inhibits  Short-term  Individuals with  CNS: Drowsiness, dizziness 1. Check physician’s
Ketorolac prostaglandin management of complete or partial , headache. orders.
synthesis, moderately syndrome of nasal  GI: Nausea, dyspepsia, GI
Brand name: producing severe, acute pain polyps, angioedema pain, hemorrhage. 2. Observe 10 rights
Toradol peripherally requiring opioid-  Aspirin allergy  GU: oliguria, renal toxicity, of drug
mediated level analgesia.  Peptic ulcer. urinary frequency. administration.
Classification: analgesia.  Significant renal  Derm: exfoliative
Nonsteroidal anti-  It has antipyretic impairment, aspirin dermatitis, stevens- 3. Correct
inflammatory drugs and anti- allergy johnson syndrome, toxic hypovolemia prior to
inflammatory  Recent GI bleed or epidermal administration of
Route: properties. perforation necrolysis,pruritus,pur- ketorolac.
IVTT  Use cautiously with  pura, sweating, urticaria.
impaired hearing; Hemat: prolonged 4. Monitor urine
Dosage: allergies; hepatic bleeding time. output in older adults
1 amp conditions.  Local: injection site pain. and patients with a
 Neuro: paresthesia. history of cardiac
Frequency:  Misc: allergic reactions decompensation,
q8° hr including,anaphylaxis. renal impairment,
heart failure, or liver
Timing: dysfunction as well as
8pm, 4am, 12pm those taking diuretics.
5. Monitor for S&S of

GI distress or bleeding
including nausea, GI
pain, diarrhea,
melena, or
hematemesis.
6. Monitor for fluid

retention and edema
in patients with a
history of CHF.
7. Assess patient's
skin color and lesions,
orientation, reflexes,
peripheral sensation,
clotting times, CBC
and adventitious
sounds.
alertness until
response to the
medication is known.
avoid the concurrent
use of alcohol, aspirin,
NSAIDs,
acetaminophen, or
other OTC
medications without
consulting healthcare
professional.

inform health care
professional of
medication regimen
prior to
treatment or surgery.

consult health care
professional if rash,
itching, visual
disturbances, tinnitus,
weight gain, edema,
black stools,
persistent headache,
or influenza-like
syndrome(chills,
fever, muscle aches,
pain) occurs.
12. Document that

the drug has been
given.
DRUG STUDY


PRECAUTION
Generic Name: Binds to mu-opioid  Relief to moderate  Hypersensitivity  dizziness, headache, 1. Check physician’s
Tramadol receptors. Inhibits to moderately  Cross-sensitivity with somnolence, orders.
reuptake of severe pain opioids may occur anxiety, CNS
Brand name: serotonin and  Patients who are stimulation, 2. Observe 10 rights of
norepinephrine in acutely intoxicated confusion, drug administration.
the CNS. with alcohol, coordination
Classification: sedatives/ hypnotics, disturbance, 3. Assess type, location,
Opiate Analgesics centrally acting euphoria, malaise, and intensity of pain
analgesics, opioid nervousness, sleep before and 2-3 hr
Route: analgesics, or disorder,weakness. (peak) after
IVTT psychotropic agents  EENT: visual administration.
 Patients who are disturbances.
Dosage: physically dependent  CV: vasodilation. 4. Assess BP & RR
1 amp on opioid analgesics  GI: constipation, before and periodically
(may precipitate nausea,abdominal during administration.
Frequency: withdrawal) pain, anorexia,
q8° hr diarrhea, dry mouth, 5. Assess bowel
dyspepsia, function routinely.
Timing: flatulence, vomiting.
6pm, 2pm, 10pm  GU: menopausal 6. Assess previous
symptoms, urinary analgesic history.
retention/frequency Tramadol is not
. recommended for
 Derm: pruritus, patients dependent on
sweating. opioids or who have
 Neuro: hypertonia. previously received
 Misc: SEROTONIN opioids for more than 1
SYNDROME, physical week.
dependence
7. Monitor patient for
seizures.
alertness until
response to medication
is known.
change positions slowly
to minimize orthostatic
hypotension.

avoid concurrent use of
alcohol or other CNS
depressants with
this medication.

DRUG STUDY

PRECAUTION
Generic Name: Binds to mu-opoid  Moderate to  Patients who have  NS: SEIZURES, 1. Check physician’s
Tramadol receptors and moderately severe previously dizziness, headache, orders.
hydrochloride inhibits the reuptake pain (extended- demonstrated somnolence,
of norepiniphrine release formulations hypersensitivity to anxiety, CNS 2. Observe 10 rights of
Brand name: and serotonin indicated for tramadol, stimulation, drug administration.
Dolcet Causes many effect patients who paracetamol and any confusion,
similar to the opoids require around-the- other component of coordination 3. Assess for level of
Classification: - dizziness, clock pain Dolcet or opioids. disturbance, pain relief and
Opiate Analgesics somnolence, nausea, management).  It is also euphoria, malaise, administer prn dose as
constipation, but contraindicated nervousness, sleep needed but not to
Route: does not have the incases of acute disorder,weakness. exceed the
Oral PO respiratory intoxication with  EENT: visual recommended total
depressant effects alcohol, hypnotics, disturbances. daily dose.
Dosage: narcotics, centrally-  CV: vasodilation.
1 tab actinganalgesics,  GI: constipation, 4. Monitor vital signs
opioids or nausea,abdominal and assess for
Frequency: psychotropic drugs pain, anorexia, orthostatic hypotension
TID diarrhea, dry mouth, or signs of CNS
dyspepsia, depression.
flatulence, vomiting.
 GU: menopausal 5. Discontinue drug and
symptoms, urinary notify physician if S&S
retention/frequency of hypersensitivity
 Derm: pruritus, occur.
sweating.
 Neuro: hypertonia. 6. Assess bowel and
 Misc: SEROTONIN bladder function;
SYNDROME, physical report urinary
dependence frequency or retention.
7. Use seizure
precautions for patients
who have a history of
seizures or who are
concurrently using
drugs that lower the
seizure threshold.
8. Monitor ambulation
and take appropriate
safety precautions.
9. Discuss potential
adverse effects to the
patient and instruct
patient to report
problems with bowel
and bladder function,
CNS impairment, and
any other bothersome
adverse effects to
physician.
10. Instruct the patient

not breast feed while
taking this drug.

DRUG STUDY

PRECAUTION
Generic Name:  Increases peristalsis  Treatment of  Hypersensitivity  GI: abdominal 1. Check physician’s
Bisacodyl & motor activity of constipation.  Abdominal pain cramps, nausea, orders.
the small intestines Evacuation of the  Obstruction diarrhea, rectal
Brand name: by acting directly on bowel before  Nausea or vomiting burning. 2. Assess patient for
Dulcolax the smooth radiologic studies or (especially with  F and E: abdominal distention,
muscles. surgery. fever or other signs hypokalemia presence of bowel
Classification:  Part of a bowel of an acute (with chronic use). sounds, and usual
Gastrointestinal regimen in spinal abdomen)  MS: muscle pattern of bowel
agent, Stimulant cord injury patients. weakness (with function.
laxatives chronic use).
 Misc: protein- 3. Assess color,
losing enteropathy, consistency, and
Route: tetany (with amount of stool
Oral PO chronic use). produced.
Dosage:
4. Advise patient not to
2 tab
crush or chew enteric-
coated tablets. Take
with a full glass of
water or juice.
5. Instruct patient not

to administer oral
doses within 1 hr of
milk or antacids; this
may lead to pre-
mature dissolution of
tablet and gastric or
duodenal irritation.
increase fluid intake to
at least 1500–2000
mL/day during therapy
to prevent dehydration.
7. Encourage patients
to use other forms of
bowel regulation
(increasing bulk in the
diet, increasing fluid
intake, or increasing
mobility).
8. Monitor fluid and

electrolyte levels.

DRUG STUDY


PRECAUTION
Generic Name:  Inhibits the enzyme  Relief of signs and  Hypersensitivity  CNS: dizziness, 1. Check physician’s
Celecoxib COX-2. This enzyme symptoms of  Cross-sensitivity headache, insomnia orders.
is required for the osteoarthritis, may exist with
Brand name: synthesis of rheumatoid other NSAIDs,  CV: HF, 2. Observe 10 rights of
CeleBREX prostaglandins. arthritis, ankylosing including aspirin MYOCARDIAL drug administration.
 Has analgesic, anti- spondylitis, and  History of allergic- INFARCTION,
Classification: inflammatory, and juvenile rheumatoid type reactions to STROKE, 3. Assess patient for
Nonsteroidal anti antipyretic arthritis. sulfonamides THROMBOSIS, allergy to sulfonamides,
inflammatory agent, properties.  Management of  History of asthma, edema, aspirin, or NSAIDs.
Antirheumatics acute pain including urticaria, or allergic- hypertension Patients with these
primary type reactions to allergies should not
Route: dysmenorrhea. aspirin or other  Derm: EXFOLIATIVE receive celecoxib.
Oral NSAIDs DERMATITIS,
 Advanced renal STEVENS-JOHNSON 4. Assess patient for
Dosage: disease SYNDROME, TOXIC skin rash frequently
200 mg 1 cap  Severe hepatic EPIDERMAL during therapy.
dysfunction NECROLYSIS, rash Discontinue at first sign
Frequency:  Coronary artery of rash.
BID x 1 week bypass graft (CABG)  F and E:
surgery hyperkalemia 5. Instruct patient to
take celecoxib exactly
 GI: GI BLEEDING, as directed. Do not take
abdominal pain, more than prescribed
diarrhea, dyspepsia, dose. Increasing doses
flatulence, nausea does not appear to
increase effectiveness.
notify health care
professional promptly if
signs or symptoms of GI
toxicity (abdominal
pain, black stools),
cardiovascular effects
(chest pain, shortness
of breath, weakness,
slurring of speech), skin
rash, unexplained
weight gain, or edema
occurs.
7. Instruct patient in
correct technique for
monitoring BP and to
notify health care
professional if
significant changes
occur.

DRUG STUDY

PRECAUTION
Generic Name: Binds to bacterial  Chronic obstructive  Hypersensitivity to  CNS: Seizures (high 1. Check physician’s
Cefuroxime cell wall membrane, pulmonary disease, cephalosporins doses). orders.
causing cell death. acute exacerbation.  Serious  GI:
Brand name: Bactericidal action  Lyme disease (early) hypersensitivity pseudomembranous 2. Observe 10 rights of
Zoltac against susceptible  Otitis media, acute to penicillins. colitis, diarrhea, drug administration.
bacteria.  Pharyngitis/ nausea, vomiting,
Classification: tonsillitis cramps. 3. Determine history of
Anti-infective agent  Skin and skin-  Derm: rashes, hypersensitivity
structure infections urticaria, diaper reactions to
Route: (impetigo) dermatitis. cephalosphorins,
Oral  Hemat: bleeding, penicillins and history
eosinophilia, of allergies particularly
Dosage: hemolytic anemia, to drugs before therapy
500 mg 1 tab leukopenia. is initiated
 Misc: allergic
Frequency: reactions including
BID x 7 days ANAPHYLAXIS, super
take oral drug with
infection.
food to decrease GI
upset and enhance
absorption. Tablets can
be administered on full
or empty
stomach.
5.Instruct the patient to

swallow whole tablets,
not crushed; crushed
tablets have a strong,
persistent bitter taste.
Shake well each time
before using. Tablets
and suspension
are not
interchangeable.
6. Inform patient to
store the tablet in
refrigerator for up to
10 days
7. Advise the patient to

have vitamin K
available in case
hypoprothrombinemia
occurs. Discontinue if
hypersensitivity
reaction occurs.
take medication around
the clock at evenly
spaced times and to
finish the medication
completely, even if
feeling better. Missed
doses should be
taken as soon as
possible unless almost
time for next dose; do
not double doses.
report signs of
superinfection (furry
overgrowth on the
tongue,
vaginal itching or
discharge, loose or
foul-smelling stools)and
allergy.

notify health care
professional if fever
and diarrhea
develop, especially if
stool contains blood,
pus, or mucus. Advise
patient
not to treat diarrhea
without consulting
health care
professional.

CEPHALOCAUDAL ASSESSMENT
HEAD AND FACE FINDINGS

Skin, Head and Face, Eyes, Ears, Nose Skin: The patient’s skin is uniformly brown in color except in areas
exposed to the sun, has no lesions, edema or abrasions,
Head: Patient’s head is symmetrically round. Patient’s hair is thick
brownish-black medium straight hair.
Eyes: Pupils are equally round, reactive to light and accommodation. No
visual disturbances.
Ears: Bilaterally symmetrical in both sides, tympanic membranes clear,
cartilage is firm in texture and movable.
Nose: Narrow, rounded nose tip symmetric along midline. Nares are paten
without septal deviation. Nasal turbinates are intact without
deformities and presence of nodules.
NECK FINDINGS
Neck, Thyroid Gland The trachea is on central placement in the midline of the neck, spaces are
equal on both sides. Thyroid gland is not visible in inspection, gland
ascends during swallowing, no palpable masses.
CHEST FINDINGS
Anterior: Breathing pattern is quiet, rhythmic. Chest is symmetric upon
Anterior Thorax, Posterior and Lateral expansion, has flat sound on the part with heavy muscles and
bony prominences, bronchovesicular and vesicular sounds
observed.
Posterior: Posterior thorax is asymmetric, muscle development is equal.
Chest is symmetric upon expansion.
ABDOMEN FINDINGS
Abdominal movements, Auscultation of bowel sounds The patient’s abdomen skin color is uniform, no lesions, no scars.
Intermittent gurgling sounds observed. Guarding movements
observed. Patient reports hypogastric pain radiating to lumbosacral
area. PS: 6/10, 10 being the highest and 1 being the lowest.
UPPER EXTREMITIES FINDINGS
Muscles, Bones and Joints, The patient’s muscles are bilaterally symmetric, has no contractures and
tremors. The bones are uniform in structure, no deformities, tenderness
or edema. Joints are not tender, has smooth movement and no nodules.
LOWER EXTREMITIES FINDINGS
Both extremities are equal in size, have the same contour with
prominences of joints, slight edema observed. Color is even,
temperature is warm and even.
MENTAL STATUS / GROSS MOTOR FUNCTION FINDINGS

Patient is awake, conscious and coherent.
Language, Orientation, Attention span, Level of Consciousness,
Walking gait,
ANATOMY AND PHYSIOLOGY
VAGINA
The part of the female genitals behind the bladder and in front of the rectum that forms a canal. This extends from the uterus to the vulva.
CERVIX
The lower part of the uterus that extends into the vagina. The cervix is made up of mostly fibrous tissue and muscle. It is circular in shape.
UTERUS
The uterus, or womb, is a hollow, pear-shaped organ ln a woman's lower stomach between the bladder and the rectum. It sheds its lining each
month during menstruation. A fertilized egg (ovum) becomes implanted in the uterus, and the fetus develops. The inner layer, called the
endometrium, is the most active layer and responds to cyclic ovarian hormone changes. The middle layer, or myometrium, makes up most of the
uterine volume and is the muscular layer. The outer layer of the uterus, the serosa or perimetrium, is a thin layer of tissue that envelop the
uterus.
OVARIES
The ovaries are the female pelvic reproductive organs that house the ova and are also responsible for the production of sex hormones. They are
paired organs located on either side of the uterus within the broad ligament below the uterine (fallopian) tubes.
FALLOPIAN TUBES
Also called oviduct or uterine tube, either of a pair of long narrow ducts located in the human female abdominal cavity that transport male
sperm cells to the egg, provide a suitable environment for fertilization. Varies from 8-14 cm in length. Ovaries produced during puberty are
about 400,000 egg cells.
ANATOMY AND PHYSIOLOGY DURING PREGNANCY
UTERUS
 The uterus leaves the pelvic and ascends to the abdominal cavity and the abdominal content
displaced in response to the increased size of the uterus which is 5 times more than normal
this increases in the size of uterus associated with an increase of blood supply to the uterus
and uterine muscle activity.
 Increases in size till the 38 weeks after that the funds level starts to descend preparing for
delivery.
 Its weight increases from 50mg to 1000mg after that it doesn't get heavier any more and
only stretches to accommodate the fetus size, and associated with an increase in the
thickness and length of the fundus.
CERVIX
 The enlarged mucus glands of the cervix during pregnancy secretes a mucus plug called
“operculum”, act as a seal for the uterus and protect it from ascending infection, and act as a
barrier between the vagina and cervix. Later in pregnancy before delivery, there is a softening
of the cervix in response to the increasing uterine contractions.
VAGINA
 During pregnancy there is an increase in the blood supply to the vagina, its color change from
pink to purple, and becomes more elastic in the second trimester.
VAGINAL DISCHARGE
 During pregnancy, leukorrhea production increases due to increased estrogen and blood
flow to the vaginal area.
 However, this increase doesn't typically become noticeable until the 8 th week—after other,
more definitive signs of early pregnancy, such as a missed period.
 In first trimester of pregnancy, vaginal discharge increases in an effort to remove dead cells
and bacteria from the uterus and vagina to help prevent infections.
Non pregnant woman vs. Pregnant woman
WHAT IS PRETERM LABOR?
 A typical pregnancy lasts about 40 weeks. Preterm labor is labor that starts before 37 weeks of pregnancy.
 Babies born prematurely are more likely to have health problems than babies born on time.
RISK FACTORS:
 Infections. It includes sexually transmitted infections (also called STIs) and infections of the uterus, urinary tract or vagina.
 High blood pressure and preeclampsia. High blood pressure (also called hypertension) is when the force of blood against the walls of the
blood vessels is too high. This can stress your heart and cause problems during pregnancy. Preeclampsia is a kind of high blood pressure
some women during or right after pregnancy.
 Preterm premature rupture of the membranes (also called PPROM). Premature rupture of membranes (also called PROM) is when the
amniotic sac around your baby breaks (your water breaks) before labor starts. PPROM is when this happens before 37 weeks of
pregnancy.
PATHOPHYSIOLOGY DURING PRETERM LABOR
The 3 main components that contribute to labor are: cervical changes, persistent uterine contractions, and activation of the decidua and
membranes. Labor occurs via a normal physiologic process and the preterm labor is pathological. Some processes are acute, and some can take
several weeks leading up to preterm labor. It has been shown to be influenced by such factors as prostaglandin synthesis, oxytocin release,
hormonal ratios (decline in progesterone level, rise in estradiol level), mechanical stretch of the uterine tissues, and changes in uterine blood
flow.
References:
https://emedicine.medscape.com/article/1949215-overview#a1
https://www.physio-pedia.com/Physiological_changes_during_pregnancy
https://emedicine.medscape.com/article/1949171-overview#:~:text=The%20ovaries%20are%20the%20female,the%20uterine%20(fallopian)
%20tubes.
https://www.britannica.com/science/fallopian-tube#:~:text=Fallopian%20tube%2C%20also%20called%20oviduct,to%20the%20central
%20channel%20(lumen)
https://www.medscape.com/viewarticle/408936_7
https://www.marchofdimes.org/complications/preterm-labor-and-premature-birth-are-you-at-risk.aspx#:~:text=Preterm%20and%20premature
%20mean%20the,can%20lead%20to%20premature%20birth.

Case Study 10 NCP

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Case Study 10 NCP

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Nursing Care Plan NCP

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

Assessment Nursing Scientific Analysis Goal and Nursing Rationale Evaluation

7. Maintain sterile 7. To prevent

8. Educate the 8. Having

9. Discuss the 9. Knowledge of

10. Discuss the 10. To make sure

Nursing Care Plan NCP

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

Assessment Nursing Scientific Goal and Outcomes Nursing Rationale Evaluation

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DATE AND TIME FOCUS DATA, ACTION AND RESPONSE

0830 -Performed initial vaginal examination to the patient.

1150 -Instructed the patient of practicing good hygiene.

0510 R: Patient verbalized 5 signs and symptoms and identified

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DATE AND TIME FOCUS DATA, ACTION AND RESPONSE

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

6. Introduce gel with

9. Monitor vital signs of

10. Explain the purpose

11. Instruct patient to

12. Provide emotional

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

9. Give direct IV doses

10. For IV infusion, give

11. Caution patient to

12. Advise patient to

13. Inform patient of

14. Advise patient to

15. Document that the

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

5. Monitor intake and

8. Inform patient that

10. Document that the

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

8. Check the patency of

10. Document that the

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

5. Monitor patient for

7. Watch and take note

8. Document that the

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

9. Document that the

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

5. Monitor for S&S of

6. Monitor for fluid

10. Advise patient to

11. Advise patient to

12. Document that

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

10. Caution patient to

11. Document that the