RAD RLE Guide -Written Requirements

Name of Students: __Montecalbo, Hanniel , Taladro, Debbie Mae G. , Yuson, Johanna Maye_ Section: __BSN 2 –
A10___
Concept: ___Maternal and Child Health Nursing__________________________
Name of Clinical Instructor: __Dr. Ronnell Dela Rosa_______

Patients Data:
Occupation: ___Teacher______
Name: ____Celeste E. Maraguinot_____
Nationality: __Filipino____________
Gender: ______Female______________
Religion: ____Roman Catholic__________
Birth Date: ____May 16, 1999__________
Source of Data: ______________________
Birth Place: ___ Cebu City ____________
Date & Time of Admission: _2/18/20 7:15am_
Age: ________21______________________
Attending Physician: __Dr. Seboa________
Address: ___Canduman, Mandaue City____________
Diagnosis: G1P0 PU 36 6/7 weeks AOG, LMP,
Educational Level: ________________________
Mild Preeclampsia
Marital Status: __Married____________

Chief Complaint: Headache 2 Days_____

LMP: 6/5/19 I: 28-30 days, regular

AOG: 36³/₇ D: 4-5 days
EDC: 3/8/20 A: Moderate
M: 15 years S: none

VITAL SIGNS: BP_150/90_ Temperature _37.1_ Pulse Rate _94_ RR _24_ O2

Saturation: __98%__ Weight: _66.5 kg_

Brief History Upon Admission: 2 days PTA patient felt mild headache, dizzy and light headed, she did not check
her blood pressure. No medication taken, condition tolerated, duration only in minutes.

1-day PTA patient was at work (elementary teacher) when she suddenly felt light headed, dizzy, with headache,
now more intense, she took her blood pressure and it was 140/90. Patient went home and had rest.

3H PTA sought consult with a private doctor, BP:150/90 and was advised for admission.

O: awake, alert, pink palpebral conjunctiva, clear breath sounds, equal chest expansion, dynamic precordium, no
murmur, gravida linea nigra, no contractions, FH: 33 cm, FHT 128 BPM

Admitting Diagnosis: G₁P₀ PU 36 ⁶/₇ weeks AOG, LMP, Mild Preeclampsia

 Anatomy & Physiology
(This will show a drawing of the organ affected related to the diagnosis of the patient.)

Placenta - an organ that develops in your uterus.

-responsible for producing hormones.
Decidua - forms the maternal part of the placenta and remains for the duration of the pregnancy.
Trophoblast - The membrane of cells that forms the wall of a blastocyst during early pregnancy, and also
provides nutrients to the embryo and later develops into part of the placenta.
Myometrium - the distinct muscular layer of the uterine wall, which is involved in contraction during
labour.
Spiral Artery - temporarily supply blood to the endometrium of the uterus during the luteal phase of the
menstrual cycle.
Arcuate Artery - supplies blood to the adjoining muscles, metatarsal bones and toes.

During normal pregnancy, the villous cytotrophoblast invades into the inner third of the
myometrium, and spiral arteries lose their endothelium and most of their muscle fibers. These structural
modifications are associated with functional alterations, such that spiral arteries become low-resistance
vessels, and thus less sensitive, or even insensitive, to vasoconstrictive substances.

Pre-eclampsia has a complex pathophysiology, the primary cause being abnormal placentation.
Defective invasion of the spiral arteries by cytotrophoblast cells is observed during pre-eclampsia. Recent
studies have shown that cytotrophoblast invasion of the uterus is actually a unique differentiation pathway
in which the fetal cells adopt certain attributes of the maternal endothelium they normally replace. In pre-
eclampsia, this differentiation process goes awry. The abnormalities may be related to the nitric oxide
pathway, which contributes substantially to the control of vascular tone. Moreover, inhibition of maternal
synthesis of nitric oxide prevents embryo implantation. Increased uterine arterial resistance induces higher
sensitivity to vasoconstriction and thus chronic placental ischemia and oxidative stress. This chronic
placental ischemia causes fetal complications, including intrauterine growth retardation and intrauterine
death. In parallel, oxidative stress induces release into the maternal circulation of substances such as free
radicals, oxidized lipids, cytokines, and serum soluble vascular endothelial growth factor 1. These
abnormalities are responsible for endothelial dysfunction with vascular hyperpermeability, thrombophilia,
and hypertension, so as to compensate for the decreased flow in the uterine arteries due to peripheral
vasoconstriction.

Pre-eclampsia can be perceived as an impairment of the maternal immune system that prevents it
from recognizing the fetoplacental unit. Excessive production of immune cells causes secretion of tumor
necrosis factor alpha which induces apoptosis of the extravillous cytotrophoblast. The human leukocyte
antigen (HLA) system also appears to play a role in the defective invasion of the spiral arteries, in that
women with pre-eclampsia show reduced levels of HLA-G and HLA-E. During normal pregnancies, the
interaction between these cells and the trophoblast is due to secretion of vascular endothelial growth
factor and placental growth factor by natural killer cells. High levels of soluble fms-like tyrosine kinase 1
(sFlt-1), an antagonist of vascular endothelial growth factor and placental growth factor, have been found
in women with pre-eclampsia.

Followed by:
Parts of the organ and functions of each part
Definition of the disease:
Clinical Manifestation/Signs & Symptoms

Laboratory Test:

Date Type of Patient’s Normal Significance / Interpretation

exam Result Values

2/18/20 CBC WBC: 13.3 4.4 – 11.0 High, an infection may be present
NEU: 74.9 37.0-80.0 NORMAL
LYM: 13.4 10.0-50.0 NORMAL
MON: 10.6 0.0-12.0 NORMAL
EOS: 0.7 0.0-7.0 NORMAL
BAS: 0.4 0.0-2.5 NORMAL
RBC: 4.04 4.5 – 5.1 Low, indicate anemia
HGB: 12.4 12.3 – 15.3 NORMAL
HCT: 38.3 35.9 – 44.6 NORMAL
MCV: 95 80 – 96 NORMAL
MCH: 30.8 27.5 – 33.2 NORMAL
MCHC: 32.4 32.0 – 36.0 NORMAL
RDW: 12.1 11.6 – 14.8 NORMAL
PLT: 188 150 – 450 NORMAL
MPV: 7.4 6.0 – 11.0 NORMAL

02/18/20 Urinalysis Color: yellow Pale NORMAL

Transparency: Hazy clear Sign of dehydration/infection
Specific gravity: 1.010 1.003-1.030 NORMAL
 Albumin: NEGATIVE NEGATIVE NORMAL
pH: 6.5 4.5-8.0 NORMAL
Ketone: 3+ NEGATIVE High, indicate diabetic ketoacidosis
Blood: NEGATIVE NEGATIVE NORMAL
Glucose NEGATIVE NEGATIVE NORMAL
Nitrite: NEGATIVE NEGATIVE NORMAL
Bilirubin: NEGATIVE NEGATIVE NORMAL
Urobilinogen: NORMAL NEGATIVE NORMAL
WBC: 2-4/ HPF 0-5/ HPF NORMAL
RBC: 0-2/ HPF 0-5/ HPF NORMAL
Epithelial cells: FEW FEW/ SMALL AMOUNT NORMAL
Mucus Thread: RARE FEW/ SMALL AMOUNT NORMAL
Bacteria: RARE NONE/FEW NORMAL

Diagnostic Test:

Date Type of test Patient’s result Significance/ interpretation

02/8/20 Blood Glucose HGTs: 103 mg/dL Normal

02/18/20 Immunology IgG Antibody: NEGATIVE Normal

IgM Antibody: NEGATIVE

Problem List

Number of Focus / Nursing Diagnosis

Priority
1 Decreased cardiac output related to increased systemic vascular resistance secondary to
mild preeclampsia, as evidenced by blood pressure of 150/90

2 Altered Tissue perfusion related to interruption of blood flow

3 Deficient Knowledge related to lack of exposure

4 Deficient Fluid Volume related to osmotic pressure as evidenced by headache

5
Ineffective tissue perfusion related to vasoconstriction of blood vessels

Drug Study
 Drug name Classification Mechanism Indication Contraindication Adverse Nursing
of action reaction responsibilities

o Generi Calcium Nifedipine blocks Treatment The use of Peripheral Before

c Channel the slow calcium of coronary nifedipine in edema, Assess history of
Name Blocker channels thus heart combination with hypotensio hypersensitivity to
Nifedipine
preventing the disease: rifampicin is n, nifedipine and its
flow of calcium Chronic therefore palpitations components.
o Brand
ions into the cell. stable contraindicated. ,
Name
Adalat Gits It produces angina tachycardia Assess VS, skin,
peripheral and pectoris , flushing, orientation
o Actual coronary (angina of dizziness,
dosage, vasodilatation, effort). headache, During
route, reduces afterload, Treatment nausea, Administer on an
frequency peripheral of increased empty stomach.
30 mg/tab 1 resistance and hypertensio micturition
tab OD P.O. x 1 BP, increases n. frequency, Ensure that
week coronary blood lethargy, patients do not
flow and causes eye pain, chew or divide
reflex mental sustained-release
tachycardia. It depression, tablets.
has little or no visual
effect on cardiac disturbance After
conduction and s, gingival Monitor patient
rarely has hyperplasia carefully (BP,
negative inotropic , myalgia, cardiac rhythm, and
activity. tremor, output) while drug
impotence, is being adjusted to
https://www.rnped fever, therapeutic dose
ia.com/nursing- paradoxical
notes/pharmacolo increase in Orient patient about
gy-drug-study- ischemic the possible side
notes/nifedipine/# chest pain effects of the drug.
:~:text=WARNIN during
G%3A%20Monito initiation of
r%20patient%20c treatment,
arefully%20(BP,o rashes,
r%20divide%20su abnormaliti
stained%2Drelea es in liver
se%20tablets. function
(including
cholestasis)
, GI
obstruction
in some
tablets
covered in
indigestabl
e
membrane.

Drug name Classification Mechanism Indication Contraindication Adverse Nursing

of action reaction responsibilities
Generic Name NSAID Produces anti- For relief of Contraindicated Cardiovasc Before:
Mefenamic inflammatory, with ular -Verify patient.
Acid analgesic, and mild to hypersensitivity to Thrombotic -Check the patient’s
antipyretic moderate mefenamic acid, Events chart.
Brand Name effects, possibly aspirin -Re-examine the
Almefen through pain in allergy, and as -GI medicine.
inhibition of patients ≥ treatment of Bleeding, -Verify the
Actual prostaglandin preoperative pain Ulceration medication
dosage, route, synthesis. 14 years of with and -Ask for history of
frequency Mefenamic acid age, when coronary artery Perforation allergy
500 mg q6h has analgesic, bypass -Checks physician’s
anti-inflammatory, therapy will grafting. - Order
and antipyretic Hepatotoxic
not exceed
properties. The ity During:
mechanism of one week -Observe if there’s
action of - any
(7 days).
mefenamic acid, Hypertensi changes.
like that of other For on -Assist the patient
NSAIDs, is not treatment of while experiencing
completely primary - Failure the
understood but dysmenorrh and Edema pain.
involves inhibition ea. Relief of
of moderate -Renal After:
cyclooxygenase pain Toxicity -Monitor Vital signs
(COX-1 and when and
COX-2). therapy will Hyperkale
Mefenamic acid is not mia
a potent inhibitor exceed one
of prostaglandin week. -
synthesis in vitro. Anaphylacti
c Reactions

-Serious
Skin
Reactions

-
Hematologi
c Toxicity

Drug name Classification Mechanism Indication Contraindication Adverse Nursing

of action reaction responsibilities

Generic Name Second- Cephalosporins Serious Contraindicated in CV: Generic Name

Cefuroxime generation exert bactericidal lower patients phlebitis, Cefuroxime
cephalosporin activity by respiratory, hypersensitive to thrombophl
Brand Name interfering with urinary cefuroxime or other ebitiswith Brand Name
Altoxime bacterial cell wall tract, skin, cephalosporins. I.V. Altoxime
synthesis and and skin- Use cautiously in injection.
Actual inhibiting cross- structure breast-feeding Actual dosage,
dosage, route, linking of the infections; women and in GI: route, frequency
frequency peptidoglycan. bone and patients with pseudome 500 mg, P.O, qd
500 mg, P.O, The joint impaired renal mbranous
qd cephalosporins infections; function or penicillin colitis,
are also thought septicemia; allergy. nausea,
to play a role in meningitis anorexia,
the activation of caused by vomiting,
bacterical cell susceptible diarrhea.
autolysins which organisms.
may contribute to Hematologi
bacterial cell Pharyngitis, c: transient
lysis. Binds to tonsillitis, neutropenia
bacterial cell lower ,
membranes, respiratory eosinophilia
inhibits cell tract , hemolytic
wall synthesis. infection, anemia,
urinary tract thrombocyt
infection. openia,
decreased
Otitis hemoglobin
media, and
impetigo. hematocrit.

Perioperativ Skin:
e maculopap
prophylaxis. ular and
erythemato
Gonorrhea us rash,
(urethral, urticaria,
endocervic pain,
al, rectal). induration,
sterile
abscesses,
temperatur
e elevation,
tissue
sloughingat
injection
site.

Other:
hypersensit
ivity
reactions
(serum
sickness,
anaphylaxis
).
 Drug name Classification Mechanism Indication Contraindication Adverse Nursing
of action reaction responsibilities

Generic Name: - is in a class of is a centrally - Moderate - History of head -Abdominal Before:

Tramadol medications acting to severe injury fullness Assess BP & RR
called opiate analgesic with a pain. -epilepsy or other -abnormal before and
(narcotic) multimode of - seizure or periodically during
Brand Name: analgesics. It action. It disorder decreased administration.
Ultram works by acts on -History of drug or touch Assess previous
changing the serotonergic alcohol sensation analgesic
way, the brain and addiction -blisters history. Tramadol is
Actual Dosage, and nervous noradrenergic -Metabolic disorder under the not
system nociception, while -Using certain skin recommended for
respond to its medicines to -blood in patients dependent
pain. metabolite treat migraine, urine on
route, Odesmethyltrama headaches, - opioids or who
frequency: dol muscle spasms, hypertensio have
Oral, acts depression, mental n previously receive
37.5mg/325 mg on the μ-opioid illness -blurred dopioids for more
tab 1 tab TID receptor. Its or nausea and vision than
as needed analgesic vomiting -change in 1 wk;may cause
potency is -severe asthma or walking and opioid
claimed to be breathing problems balance withdrawal
about one tenth -Blockage in -chest pain Symptoms.
that of stomach or -discomfort During:
morphine. intestines -chills or •Assess type,
-Recently used convulsions location,
alcohol, -difficult and
sedatives, urination intensity of pain
tranquilizers or -dizziness before
narcotic -light and 2-3 hr (peak)
headednes • Respiratory
s depression has not
- occurred with
tachycardia recommended
-loss of doses.
memory After:
-numbness • Assess bowel
-tingling of function
face, routinely.
fingers Prevention
or toes of constipation
Recurrent should
fever being instituted with
-visual and increased intakeof
auditory fluids
hallucinatio and bulk and with
ns laxatives to
-severe minimize
cramping constipating effects.
-severe
nausea
 Drug name Classification Mechanism Indication Contraindication Adverse Nursing
of action reaction responsibilities

Generic Name: Pharmacothera Bind to bacterial Treatment Hypersensitivity to Hypersensit Baseline

Ampicillin peutic: cell wall, causing of skin and ampicillin, any ivity to Assessment:
Penicillin cell death skin penicillins or ampicillin, Question for history
Brand Name: Clinical: (bacteriocidal). structure sulbactam. HX of any of allergies, esp.
Ampi, Omnipen Antibiotic Depending on infections, cholestatic penicillins penicillins,
, Penglobe, agent, drugs have otitis media, jaundice, hepatic or cephaloposporins;
and Principen. broad spectrum sinusitis, impairment sulbactam. renal impairment
and can kill respiratory associated with HX of Intervention/Evalu
resistant infections ampicillin/sulbacta cholestatic ation: Promptly
Dosage/Route: organisms. and m. jaundice, report rash
2 grams IVTT Inhibits cell wall genitourinar hepatic (although common
ANST q6g 1st synthesis in y infections. impairment with ampicillin, may
dose at 8 AM susceptible Prevention associated indicate
microorganisms. of with hypersensitivity) or
Therapeutic endocarditi ampicillin/s diarrhea (fever,
effect: s. Post ulbactam. abdominal pain,
Bactericidal in exposure mucus and blood in
susceptible inhalational stool may indicate
microorganism. anthrax antibiotic-
Treatment of prophylaxis. associated colitis).
susceptible Treatment Evaluate site for
infections due to of infections phlebitis. Check IM
streptococci, with injection site for
including GI, GU, resistant pain, induration.
respiratory organisms. Monitor I&O,
infections. urinalysis, renal
function tests. Be
alert for
superinfection:
fever, vomiting,
diarrhea, anal,
genital pruritus, oral
mucosal changes
(ulceration, pain,
erythema)

Drug name Classification Mechanism Indication Contraindication Adverse Nursing

of action reaction responsibilities

Generic Name: An Iron Iron is an Iron • Iron Common • Educate

Ferrous Sulfate supplement essential supplement metabolis adverse the patient
constituent of the s are used m disorder effects with what is the
causing medication
Brand Name: blood to treat this
increased is about.
Feosol, (hemoglobin) iron- iron medication • Tell the
Feostat, etc. where its chief deficiency storage are patient
function is to and blood • An diarrhea or what to do
Dosage: carry oxygen to loss overload of constipatio and
1 Cap OD the body tissue. especially iron in the n and contraindic
Iron is used by during and blood abdominal ations
• A type of when
 the body to after blood upset. taking in
produce pregnancy disorder Taking iron the
hemoglobin and where iron- where the after a meal medicine
red blood such as
to prevent deficiency will help
cells burst eating
decreased after called alleviate before
production of pregnancy hemolytic and taking iron
healthy red blood can last up anemia decrease supplemen
cells. to 6-12 • An ulcer the side ts but there
months. from too effects. The are other
Iron much stools may substances
stomach that can
supplement become
acid interact
s either • A type of black but it with it.
alone or stomach is • Always
with irritation completely encourage
combinatio called harmless. the patient
n of gastritis Ferrous to inform
medicines it • Ulcerative sulfate has and
colitis consult
is provided higher
• Diverticular health
for disease chance of provider if
postpartum • Excess occurrence complicatio
women iron due to of adverse ns and
repeated effects than signs
blood other kinds appear.
transfusion
of iron
s
• Problems supplement
with food s.
passing Overdose
through the can also
esophagus lead to
toxicity and
cause
death

Nursing Care Plan 1

Defining Nursing Scientific Goal of Care Intervention Rationale

Characteristics Diagnosis Analysis

Subjective: Decreased Blood pressure Short Term: Independent

-2 days PTA cardiac is the force of After two days 1. Assess vital signs, 1. Edema, headaches,
patient felt mild output your blood of nurse and conduct physical visual disturbances,
headache, dizzy related to pushing against client examination, and and epigastric pain are
and light headed, increased the walls of interaction, the commence daily associated with high
weight monitoring.
she did not check systemic your arteries as client will be blood pressure level.
her blood vascular your heart able to control Weight gain is an
pressure. No resistance pumps blood. blood pressure important symptom of
medication taken, secondary High blood levels. preeclampsia.
condition to mild pressure, or
tolerated, preeclamp hypertension, is 2. Instruct patient to 2. To lower blood
duration only in sia, as when this force Long Term: have bedrest and pressure levels,
minutes. evidenced against your Patient will have avoid improve cardiac rate
-1-day PTA by blood artery walls is an improved environmental and enhance renal-
patient was at pressure of too high. cardiac output stressors. placental perfusion.
work (elementary 150/90 Changes in the through well-
teacher) when volume of blood controlled blood 3. Prepare for birth of 3. If conservative
she suddenly felt within the pressure fetus by cesarean treatment is ineffective
light headed, cardiovascular throughout the delivery, labor and labor induction is
when severe
dizzy, with system will also remainder of PIH/eclamptic ruled out, then surgical
headache, now affect BP. If a her pregnancy condition is procedure is the only
more intense, she person was stabilised, but means of halting the
took her blood severely vaginal delivery is hypertensive
pressure and it dehydrated or not feasible. problems.
was 140/90. lost a large
Patient went quantity of
Collaborative
home and had blood through a 1. Administer hypertensive 1. To lower blood
rest. wound there as prescribed. pressure levels.
-3H PTA sought would be less
consult with a blood for the 2. Obtain blood cultures if 2. Detects and
private doctor, heart to pump, symptoms of sepsis are identifies causative
BP:150/90 and thereby present. organism(s).
was advised for reducing
admission. cardiac output
and BP.
Objective: Preeclampsia Reference: Reference:
O: awake, alert, happens when https://nurseslabs.com/preg 36 Labor Stages,
pink palpebral a woman who nancy-induced- Induced and
conjunctiva, clear previously had hypertension-nursing-care- Augmented Labor
breath sounds, normal blood plans/#:~:text=Early%20rec Nursing Care Plans
equal chest pressure ognition%20and%20prompt Paul Martin- By-Paul
expansion, suddenly %20treatment,Decreased% Martin
dynamic develops high 20Cardiac%20Output https://nurseslabs.com/
precordium, no blood pressure* labor-stages-labor-
murmur, and protein in induced-nursing-care-
gravida linea her urine or plan/#a4
nigra, no other problems
contractions after 20 weeks
FH: 33 cm of pregnancy.
FHT 128 BPM Women who
have chronic
VS: hypertension
BP – 150/90 can also get
PR – 94 preeclampsia.
RR – 24 https://www.cdc
Temp - 37.1 .gov/bloodpress
O2 Sat – 98% ure/pregnancy.
Weight – 66.5kg htm

Nursing Care Plan 2

 Defining Nursing Scientific Goal of Care Intervention Rationale
Characteristics Diagnosis Analysis

Subjective: Altered Blood is a SHORT TERM: Independent:

-2 days PTA Tissue connective Educate mother to have a Bed rest helps prevent
patient felt mild perfusion tissue After 3-4 hours complete bed rest. further complications
comprised of a
headache, dizzy related to of interventions, and helps limit oxygen
liquid
and light headed, interruption extracellular patient will consumption.
she did not check of blood matrix termed demonstrate
her blood flow as blood blood pressure, Assess and monitor Alterations of the vital
pressure. No plasma which pulse, arterial continuously the vital signs signs of the mother
medication taken, dissolves and blood gasses of the mother and the fetus. and fetus from the
condition suspends normal values may
(ABGs), and
multiple cells
tolerated, Hematocrit/hem indicate that there is
and cell
duration only in fragments. It oglobin level something wrong in the
minutes. carries oxygen within the body of the mother.
-1-day PTA from expected range.
patient was at the lungs and Check FHR manually or Helps evaluate fetal
work (elementary nutrients from electronically, as indicated. well-being. An elevated
teacher) when the LONG TERM: FHR may show a
gastrointestinal Patient
she suddenly felt compensatory
tract. The demonstrates
light headed, oxygen and response to hypoxia,
dizzy, with normal CNS prematurity, or abruptio
nutrients
headache, now subsequently reactivity on placentae
more intense, she diffuse from the nonstress test
took her blood blood into the (NST) Administer IV fluids, as For nutritional support
interstitial fluid
pressure and it indicated. to the mother and fetus
and then into
was 140/90. the body cells. and for fluid
Patient went Insufficient replacement, if vaginal
home and had arterial blood bleeding occurs.
rest. flow causes
-3H PTA sought decreased Provide safety measure To protect client from
consult with a nutrition and (e.g. raise side rails and injuries and to provide
oxygenation at
private doctor, keeping off things that are the patient comfort.
the cellular
BP:150/90 and level. sharp and edgy), and
was advised for Decreased promoting a clean and quiet
admission. tissue perfusion environment.
can be
Objective: temporary, with
O: awake, alert, few or minimal Collaborative: Corticosteroids are
consequences
pink palpebral Give corticosteroid thought to induce fetal
to the health of
conjunctiva, clear the patient, or it (dexamethasone, pulmonary maturity
breath sounds, can be more betamethasone) IM as (surfactant production)
equal chest acute or ordered. and prevent respiratory
expansion, protracted, with distress syndrome, at
dynamic potentially least in a fetus
destructive
precordium, no delivered prematurely
effects on the
murmur, patient. When because of condition or
gravida linea diminished inadequate placental
nigra, no tissue perfusion functioning.
contractions becomes
FH: 33 cm chronic, it can To help SOs
FHT 128 BPM result in tissue Prepare the patient and understand the critical
or organ
family members for the condition of the mother
damage or
VS: death. possibility of an emergency and have
BP – 150/90 Regular tissue CS delivery, the delivery of reassurances of the
PR – 94 perfusion allow a premature neonate and mother’s current
s the exchange
RR – 24 the changes to expect in condition.
of gases and
Temp - 37.1 nutrients the postpartum period.
O2 Sat – 98% between the To help the SOs and
Weight – 66.5kg blood and the Offer emotional support mother to prepare
body's cells. and an honest assessment physically and
When this of the situation. emotionally to the
exchange is situation.
disrupted due
to a problem at
the exchange Tactfully discuss the Tell the mother that the
point in the possibility of neonatal neonate’s survival
capillaries, it death. depends primarily on
causes oxygen gestational age, the
deprivation in amount of blood lost,
the cells and associated
and tissues,
hypertensive
called ineffectiv
e tissue disorders- assure her
perfusion. that frequent
https://nursesla monitoring and prompt
bs.com/ineffecti management greatly
ve-tissue- reduce the risk of
perfusion/
death.
Encourage the patient and
her family to verbalize their Allowing them to
feelings. understand clearly the
situation.
Help them to develop
effective coping strategies, Help the SOs and
referring them for mother cope with the
counselling if necessary. situation properly.

Reference:
https://nurseslabs.com
/preterm-labor-nursing-
care-plans/

FDAR
Date Focus Time DAR
2/18/20 Receiving assessment 9: 40 PM D: Received patient awake, alert, pink palpebral conjunctiva,
clear breath
Hypertension 10:00 sounds, equal chest expansion, dynamic precordium, no
PM murmur, gravida
linea nigra, no contractions, FH: 33 cm, FHT: 128 bpm.
V/S: BP: 150/90, HR: 94, RR: 24, Temp.: 37.1, O2 Sat:
98%.

D: Patient felt mild headache, dizzy and light headed, she did
not check
her blood pressure. No medication taken, condition tolerated,
duration
only in minutes
A: Establish rapport with the patient. The patient's general
condition was
assessed. Check the patient's test results to see if there were
any
contributing variables. Both hands should be used to monitor
and record
blood pressure. During pain bouts, the patient was
encouraged to rest
and limit movement.
R: Patient is at ease and states that she is feeling much
better.

Students RLE Guide

SY 21-22 Page 4
Discharge Planning (SAMPLE)

AMETHOD of discharge planning was developed and modified to provide a systematic method for
ensuring client’s needs during the termination phase of hospitalization. The AMETHOD represent areas the nurse
should consider before the client goes home. The Discharge plan follows the FDAR format. AMETHOD is placed
in the Implementation.

Date Focus Time DAR

2/22/20 Discharges 10:20am D: With discharge order from attending physician Dr. Seboa
instructions
A: Activity: The client is assisted in attaining his or her
highest level of mobility possible before discharge.
Medication:
Cefuroxime (Altoxime) 500 mg 1 tab BID PO/6 days, works by
stopping the growth of bacteria.
Nausea, vomiting, diarrhea, strange taste in the
mouth, or stomach pain may occur as side effects.
Should be taken orally or by mouth.
Mefenamic Acid (Alfemen) 500 mg 1cap q 6o, used to relieve mild
 to moderate pain. Side effect includes, diarrhea,
constipation, stomach pain, gas, heartburn, nausea,
vomiting, and dizziness. Taken orally.
Nifedipine (Adalat Gits) 30 mg/tab 1 tab OD P.O. x 1 week, works
by relaxing blood vessels so blood can flow more
easily. Side effect includes, constipation, nausea,
heartburn, flushing and dizziness. Taken orally.

Environment: Stress free, clean and free from infections

Treatment: Instruct the necessity of take home medications,

Instruct the client and SO to monitor blood pressure. Encourage
patient for complete bed rest.

Health Teaching: Teach the client in preventing high blood

pressure levels, necessity of complete bed rest,
pelvic rest, temperature monitoring, and healthy
diet.

Outpatient Referral: Follow-up at SWU-RH on 2/28/2020, BP

Monitoring BID c/o Local Health Center

Diet: Soft Diet; Balance and healthy meal: Transition to

regular DAT
R: Out of the room per wheelchair with improved
condition

Bibliography (a summary of all the resources used)

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3148420/
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-
notes/nifedipine/#:~:text=WARNING%3A%20Monitor%20patient%20carefully%20(BP,or%20divide%20sustained%
2Drelease%20tablets.
https://www.cdc.gov/bloodpressure/pregnancy.htm
https://nurseslabs.com/pregnancy-induced-hypertension-nursing-care-
plans/#:~:text=Early%20recognition%20and%20prompt%20treatment,Decreased%20Cardiac%20Output
https://nurseslabs.com/ineffective-tissue-perfusion/
https://nurseslabs.com/pregnancy-induced-hypertension-nursing-care-
plans/#:~:text=Early%20recognition%20and%20prompt%20treatment,Decreased%20Cardiac%20Output
https://nurseslabs.com/preterm-labor-nursing-care-plans/
https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/#a4
https://www.cdc.gov/bloodpressure/pregnancy.htm
https://www.rnpedia.com/nursing-notes/pharmacology-drug-study-
notes/nifedipine/#:~:text=WARNING%3A%20Monitor%20patient%20carefully%20(BP,or%20divide%20sustained%2Drelease%20tabl
ets.