RAD RLE Guide -Written Requirements

Name of students: Escaran, Eborda, Atun, Café, Diongzon, and Faelnar Section: BSN2-A8 Concept: Maternal and Child nursing

Name of Clinical Instructor: Leah Walesa Barcenas

Patients Data:

Name: Rachel S. Agapito Nationality: Filipino

Gender: Female Religion: Roman Catholic

Birth Date: October 27,1997 Source of Data: 4/26/20 @ 7:03 pm

Birth Place: Date & Time of Admission:

Age: 23-year-old Attending Physician: Dr. Yu

Address: 45 Lawaan, Talisay City Cebu Diagnosis: Premature Rupture of membranes

Educational Level: College

Marital Status: Single

Occupation: Sales Agent

Chief Complaint: Watery Vaginal Discharge

LMP: 7/28/29

AOG: 39 weeks

EDC: 5/5/20

VITAL SIGNS: BP 90/60 Temperature 36.5 Pulse Rate 96 RR 19 O2 Saturation: 98% Weight: 63kg Brief

History Upon Admission:

G1P0

LMP: 7/28/2019

AOG: 39 weeks
EDC: 5/5/20

37 6/7 weeks by 1st UTZ

S: 5 hours PTL, Patient noted soaked underwear, onset of watery vaginal discharges, associated with hypogastric pain

radiating to lumbosacral area, with uterine contraction every 30 minutes, condition persisted thus opted consult.

Abdomen: FH: 34 cm

EFW: 3565 grams

FHT; 145 bpm

SPE: (+) minimal whitish discharges at posterior fornix area, foul smell

IE: 1 cm, UE ST -5, Leaking BOW, Cephalic, posterior, firm, BISHOP score: 1

A: G1P0, 39 weeks AOG, Cephalic in latent phase of labor, PROM

P: Admit

Anatomy & Physiology

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

Signs and symptoms

o Hypogastric pain o
Minimal whitish discharge
o Foul smell o Watery
vagina

Parts and function of each organ

o Placenta- The placenta acts to provide oxygen and nutrients to the fetus.
o Umbilical cord- Is a tube that connects mother and baby during pregnancy. It delivers nutrients and oxygen to the baby and
removes the baby's waste products.
o Bag of water or amniotic sac - surrounds and protects the baby in the uterus and provides a protective barrier from the outside
environment.
 o Amniotic fluid- provides nutrition, maintains the temperature, helps baby to develop bone and muscle. o Cervix-
attaches the vagina to the uterus.

o Uterus- nourish the developing fetus prior to birth. o Vagina- connects the uterus and cervix to the outside of the body,
allows menstruation, pregnancy and sexual intercourse.

Definition of the disease: Premature Rupture of Membrane (PROM)

Premature rupture of membrane (PROM) is the rupture of the fetal membranes before the onset of labor. In most cases PROM occurs near
term. Premature rupture of membrane is caused by infection on the vagina, cervix and uterus of the mother due to lack of perineal hygiene
or care, but in most cases cause of Premature rupture of membrane is not identified.

o If the rupture occurs before 37 weeks of gestation it will be called preterm PROM.
o If the rupture of membranes lasting longer than 18-24 hours, between time of rupture and time of delivery it will be called
Prolonged PROM. o Previable preterm premature rupture of membranes (PPROM) between 14 and 24 weeks of gestation
complicates < 1% of pregnancies.

Laboratory Test
Date Type of exam Patient’s Result Normal Values Significance /
Interpretation
CBC WBC: 8.50 WBC: 4.4
▫ NEU: 63.5 ▫ NEU: 37.0-80.0 The hematocrit,
▫ LYM: 23.5 ▫ LYM: 10.0 – 50.0 hemoglobin, and red
▫ MON: 11.5 MON: 0.0-12.0 blood cells of the
▫
EOS: 1.3 BAS: EOS: 0.0-7.0 patient are below the
▫ ▫ BAS: 0.0 – 2.5
0.2
▫ normal range. All the
▫ RBC: 3.75 RBC: 4.50-5-10 other results are
HGB: 11.7 HGB: 12.3-15.3 normal.
▫ HCT: 34.7 ▫ HCT: 35.9-44.6
▫ MCV: 92 ▫ MCV: 80-96
▫ MCH: 31.1 ▫ MCH: 27.5-33.2
MCHC: 33.6 MCHC: 32.0-36.0
▫ RDW: 12.6 ▫ RDW: 11.6-14.8
PLT: 199 PLT: 150-450
▫ ▫
MPV: 7.9 MPV: 6.0-11.0
▫ ▫
▫ ▫
▫ ▫
 Urinalysis Macroscopic examination: Color: Yellow
▫ Color: Yellow ▫ (light/pale to dark The patient’s hazy
▫ Volume: 30mL deep amber) urine transparency
▫ Transparency: Clarity/Turbidity: may indicate infection.
Hazy All except the
Specific Gravity: ▫ Clear or Cloudy transparency of the
▫ Specific Gravity:
1.015 urine sample are
1.005-1.025 within the normal
▫
range.
al Examination: Albumin: Negative
Chemic
Albumin: Negative pH: 4.5 - 8
▫ pH: 7.5 ▫ Ketone: None
▫ Ketone: Negative ▫ Blood: ≤ 3
▫ Blood: Negative RBC Glucose: ≤
▫
▫ Glucose: Negative 130 mg/d
▫
▫ Nitrite: Negative Nitrite: Negative
▫
▫ Bilirubin: Negative Bilirubin: Negative
Urobilinogen:
▫ Urobilinogen: 0.5
Normal ▫
▫ -1 mg/dL
opic Examination: ▫
WBC: 0-3/HPF ▫ WBC: ≤ 2-5
Micros RBC: 0-2/ HPF WBCs/HPF
c Epithelial cell: Few RBC: ≤ 2
▫ Mucus thread: Few RBCs/HPF
▫ Bacteria: Few ▫
Epithelial Cells:
▫ ▫ Few to Moderate (≤
▫ ▫ 15-20 epithelial
▫ cells/HPF)
▫ Mucus Threads:
FEW
Bacteria: None-
Few
▫

Diagnostic Tests
Date Type of test Patient’s result Significance/
interpretation
9/18/19 Ultrasound scan 6 2/7 weeks of AOG First Trimester

Ultrasound scan ▫ BDP:8.81cm 35weeks 4-days AOG

▫ HC:31.3cm 35weeks 1-day AOG
▫ AC:32.3cm 36weeks 1-day AOG
FL:6.82cm 36weeks 0 days AOG
▫ Average Average= 35weeks 3day
AOG
 ▫ Placenta: Posterior high Conclusion:
lying grade 2-3 =Single, Live, Intrauterine
▫ Amniotic fluid: AFI-13.2 pregnancy in cephalic
▫ LMP:7/28/19 presentation with average
FHB:135bmp ultrasound age of
▫
EDD (based on today’s approximately 35 weeks
▫ measurement):05/05/20 and 3 days Age of
EDD (LMP):05/03/20 Gestation
▫ EFW:2756g =Placenta posterior high
▫ Lying, grade2-3
=Amniotic fluid volume-
Adequate

Problem List
Number of Priority Focus / Nursing Diagnosis

1 Risk for maternal infection in relation to rupture of

amniotic sac.

2 Patient shows leaking in vagina, smelly and foul odor also

the transparency of urine is cloudy which indicates
Urinary tract infection.

3 Have lower than normal levels of hemoglobin or

hematocrit and red blood count. Risk of having severe
iron deficiency anemia.

Drug Study
Drug name Classification Mechanism Indication Contraindica Adverse Nursing
of action tion reaction responsibiliti
es
Generic name: Antibiotic drug Exerts Treatment of Use cautiously Central Nervous Before: Culture
Ampicillin under bactericidal moderate to with renal System: Lethargy, infected area; skin
activity via severe infections disease, hallucinations, rashes, lesions; R,
Penicillin caused by sensitive pregnancy, seizures.
Brand name: inhibition of adventitious
organisms. lactation for it sounds; bowel
Ampi bacterial cell may cause Gastrointestinal: sounds, normal
wall synthesis by diarrhea or Glossitis, output; CBC, LFTs,
Route and binding one or candidiasis in the stomatitis, renal function
dosage: 2grams more of the infant. gastritis, sore tests,
IVTT, q6h penicillin mouth, furry serum
binding tongue, black electrolytes, Hct,
proteins. “hairy” tongue,
urinalysis; skin
nausea,
test with
vomiting,
diarrhea, benzylpenicilloyl
abdominal Pain. polylysine if
hypersensitivity
reactions have
occurred. Inform
patient about
the route and
dosage of the
drug and its
uses. During:
Check IV site
carefully for
signs of
thrombosis or
drug reaction.

After:
Ask patient if
there is any
abnormal
reaction.

Drug name Classificati Mechanism Indication Contraindi Adverse Nursing

on of action cation reaction responsibil
ities
o Generic Dinoprostone is Dinoprostone is Initiation and/or Asthmatic, High Upset stomach, Before:
Name: a naturally a natural continuation of blood and low vomiting, Ask patient for
Dinoprostone occurring substance cervical ripening blood pressure, any allergies
diarrhea, and and asthma.
o Brand Name: prostaglandin E2 (prostaglandin) in pregnant Inflammation
dizziness
Cervidil (PGE2). that your body women at or of the cervix, an
During:
Suppository o makes in near term in infection of the
Administer
Actual preparation for whom there is a female
drugs.
dosage, labor. It softens medical or reproductive
route, and widens the organs called
After:
Frequency: opening of the pelvic
0.5 mg gel womb and obstetrical inflammatory Check the vital
endocervically increases indication for the disease. signs of the
contractions. induction of patient and for
labor. any allergic
reaction.

Drug name Classificati Mechanism Indication Contraindi Adverse Nursing

on of action cation reaction responsibil
ities
o Generic Therapeutic Ketorolac, like It is in the In patients with Central Before:
Name: class: NSAID other NSAIDs, nonsteroidal renal disease or nervous Assess if
Ketoralac o blocks antiinflammatory renal failure, patient has
system: possible
Brand Name: cyclooxygenase drug (NSAID) ketorolac is
Pharmacologi headache, allergies to
Toradol o s (COX), which drug class. contraindicated
cal class: are enzymes Ketorolac is because it may
dizziness, NSAIDs.
Actual
NSAIDs that convert versatile, as it is increase fluid drowsiness,
dosage, During:
arachidonic acid available in retention and sedation.
route, Administer the
into multiple-dose worsen renal Cardiovascular
Frequency: medicine
prostaglandins, forms: oral, nasal function. : arrhythmias,
1-amp IVTT q8o through IV.
prostacyclin, spray, IV, or IM. It GIrelated edema, HTN
hr.
and is contraindicatio palpations.
thromboxane. commonly used ns for ketorolac After:
The inhibition of postoperatively include patients Advise patient
these for pain with active
Genitourinary to seek medical
renal failure attention
substances management. In peptic ulcer
Hematologic: immediately for
decreases pain, combination disease, recent
chest pain,
fever, and with opioids, GI bleed, or GI decreased shortness of
inflammation. Ketorolac perforations. platelet breath or trouble
results in a Extreme adhesion, breathing,
significant caution is prolonged weakness in
decrease in necessary when one part or side
bleeding time,
opioid administering of the body, or
requirement ketorolac in the purpura slurred speech.
and lowers the geriatric
incidence of population.
adverse effects
such as
vomiting and
decreased
gastrointestinal
motility.

Gillis JC, Brogden

RN. Ketorolac. A
reappraisal of its
pharmacodynamic
and pharmacokinetic
properties and
therapeutic use in
pain management.
Drugs. 1997
Jan;53(1):139-88.
 [PubMed]
[Reference list]

Drug name Classificati Mechanism Indication Contraindi Adverse Nursing

on of action cation reaction responsibil
ities
o Generic Name: Antibiotics The exact Metronidazole Known allergy to Adverse effects Before: Ask
Metronidazole mechanism of is indicated for TXA, intracranial include seizures, patient about all
action of the treatment bleeding, headaches, of the medicines
o Brand Name: metronidazole of confirmed known backache, they take
Flagly has not been trichomoniasis defective color abdominal pain, including
fully established, caused by vision, history nausea, prescription and
o Actual dosage, non-prescription
however, it is Trichomonas of venous or vomiting,
route, medicines,
possible that an vaginalis (except arterial diarrhea,
Frequency: vitamins and
500mg, IV drip q
intermediate in for in the first thromboemboli fatigue, herbal
8 hours, 2 dose the reduction of trimester of sm, or active pulmonary supplements and
metronidazole pregnancy) and thromboemboli embolism, deep past allergies.
which is only the patient's c disease. vein thrombosis,
made by sexual partners, Greater than 3 anaphylaxis, During: Tell
anaerobic bacterial hours from impaired color patient that
bacteria and vaginosis, traumatic injury. vision, and other urine may be a
protozoa, binds certain types of visual darker color than
deoxyribonuclei amebiasis, and disturbances. usual; this is
c acid and various expected.
electrontranspor anaerobic After:
t proteins of infections. Assess patient by
organisms, asking if there is
any abnormal
blocking nucleic https://go.drug
reaction like
acid synthesis. bank.com/drugs
pounding of the
/DB00916 headache,
stomach ache
and feeling sick.

Drug name Classification Mechanism Indication Contraindica Adverse Nursing

of action tion reaction responsibiliti
es
o Generic Name: Antifibrinolytic Tranexamic To reduce or Tranexamic acid Central Before: Monitor
Tranexamic s acid prevent is Nervous blood pressure,
competitively hemorrhage. contraindicated System:
o Brand Name in patients with pulse, and
:Lysteda and reversibly Dizziness
hypersensitivity respiratory
inhibits the to tranexamic
o Actual dosage, status as
activation of acid or any of Cardiovascular
route, plasminogen : Hypotension, indicated by
the ingredients,
Frequency: IVTT
via binding at acquired thrombosis, severity of
several distinct defective color and bleeding.
sites, including vision, since this thromboembo Monitor for
four or five prohibits lism
measuring one overt bleeding
lowaffinity
endpoint that every 15–30
sites and one should be
Eyes: Visual
high- impairments min.
followed as a
affinity site, measure of Notify physician
the latter of toxicity, Gastrointestin of positive
which is subarachnoid al: Diarrhea, Homans’ sign,
hemorrhage, leg pain
involved in its vomiting and
and active hemorrhage,
binding to nausea edema,
intravascular
fibrin. The hemoptysis,
clotting
binding of dyspnea, or
plasminogen chest pain.
to fibrin
induces
During:
fibrinolysis - by
occupying the Stabilize IV
necessary catheter to
binding sites minimize
tranexamic
acid prevents thrombophlebit
this is. Monitor site
dissolution of closely.
fibrin, thereby
stabilizing the
clot and
preventing
hemorrhage. After:
Instruct patient
Source: to notify the
https://go.dru
gbank.com/ nurse
drugs/DB0030 immediately if
2 bleeding recurs
or if
thromboemboli
c symptoms
develop.
Caution patient
to make position
 changes slowly
to avoid
orthostatic
hypotension.

Drug name Classificati Mechanism Indication Contraindi Adverse Nursing

on of action cation reaction responsibil
ities
o Generic Cephalosporin Cefuroxime is a ZINACEF is Cefuroxime is Respiratory Before:
Name: s, 2nd bactericidal indicated for the contraindicated tract: Obtain a history
Cefuroxime agent that acts treatment of in patients with Wheezing, to determine
generation
by inhibition of patients with cephalosporin difficulty of previous use of
o Brand bacterial cell infections hypersensitivity and reactions to
Name: Zinacef breathing, and
wall synthesis. caused by or cephamycin penicillin.
Cefuroxime has susceptible hypersensitivity swallowing,
o Actual activity in the strains of the . Cefuroxime swelling of Inform patient
dosage, presence of designated should be used throat, tongue that even with
route, some organisms in the cautiously in and lips negative history
Frequency: betalactamases, following patients with of penicillin
500mg/tab, both diseases like in hypersensitivity Integumentar sensitivity, they
thrice a day by penicillinases Lower to penicillin. y: Rash, might still have
mouth (TID and Respiratory Tract allergic
itching, hives,
PO) cephalosporinas Infection: response.
es, of Pneumonia swelling of the
Gramnegative Urinary tract face During:
and infection, Skin Administer drug
Gram-positive & EENT: as doctor’s order
bacteria. Skinstructure Swelling of the
infections, eyes After:
Septicemia, Observe patient
Gonorrhea, for signs and
Gastrointestin
bone and joint symptoms of
infection.
al tract: anaphylaxis
watery stool, (rash, pruritus,
stomach laryngeal
cramps, edema,
wheezing).
Instruct patient
to report
hypersensitivity
.

Drug name Classificati Mechanism Indication Contraindi Adverse Nursing

on of action cation reaction responsibil
ities
o Generic Pharmacology: 2complementar Management of Patients who Gastrointestin Before: Inform
Name: Dolcet Pharmacodyna y mechanisms moderate to have previously al: Nausea, patient about
mics appear severe pain. demonstrated the doctor's
vomiting, order.
applicable, hypersensitivity
o Brand diarrhea
Pharmacodyna binding of to tramadol,
Name: Zuellig mics: Tramadol parent and M1 paracetamol and During:
Skin: Rash Administer
metabolite to any other
medication as
μopioid component of
o Actual doctor’s
receptors and Dolcet or CNS:
dosage, prescribed
weak inhibition opioids. It is also Sleepiness,
route, of reuptake of contraindicated
Frequency: One
headache After: Instruct
norepinephrine in cases of acute patient to
tab, 3x a day by
and serotonin. intoxication with report any
mouth alcohol, adverse effect
hypnotics, of drug.
narcotics,
centrally-acting
analgesics,
opioids or
psychotropic
drugs.

Drug name Classificati Mechanism Indication Contraindi Adverse Nursing

on of action cation reaction responsibil
ities
o Generic Dulcolax tablets Dulcolax is used DULCOLAX is GI: Nausea, Before
Name: Laxative generally to treat contraindicated vomiting, During After:
Dolcolax produce a bowel constipation or in patients with diarrhea Tell your doctor
movement in 6 to empty the ileus, intestinal right away if any
to 12 hours. bowels before obstruction, of these unlikely
Muscle: Muscle but serious side
o Brand surgery, acute abdominal
Name: colonoscopy, conditions pain and effects occur:
xrays, or other including cramps/weakn persistent
Bisacodyl
intestinal appendicitis, ess nausea/vomitin
medical acute g/diarrhea,
o Actual procedure. inflammatory CNS: muscle
dosage, route, bowel diseases, Dizziness, cramps/weakne
Frequency: 2 and severe ss, irregular
fainting,
tabs if no bowel abdominal pain heartbeat,
associated with
mood/mental dizziness,
movement
nausea and changes fainting,
vomiting which decreased
may be Decreased urination,
indicative of the urination mental/mood
aforementioned changes (such as
severe confusion).
conditions.
Drug name Classificati Mechanism Indication Contraindi Adverse Nursing
on of action cation reaction responsibil
ities
o Generic Antiinflammator The mechanism Celebrex is a People who GIT: bloody or Before: Assess
Name: y drugs (NSAIDs). of action of prescription take tarry stool, the patient’s
Celecoxib celecoxib is due medicine used nonsteroidal upper right history of any
to selective to treat the antiinflammator medication.
side stomach
o Brand inhibition of symptoms of y drugs (NSAIDs)
cyclooxygenase acute pain or
pain During: Remind
Name: (other than
Celebrex -2 (COX-2), which inflammation. patient to take
aspirin) such as UT: dark urine,
is responsible for Celebrex may be the medicine.
celecoxib may little or
o Actual prostaglandin used alone or
have a higher
dosage, route, synthesis, an with other no urination After: Tell the
integral part of risk of having a doctor if you
Frequency: 200 medications.
the pain and heart attack or a have any side
mg 1 tab, IS: Pale skin,
inflammation stroke than effect that
people who do jaundice
pathway. bothers you or
not take these that does not go
medications. RS: shortness away.
of breath,

Nursing Care Plan

Defining Nursing Scientific Goal of Care Intervention Rationale

Characteristics Diagnosis Analysis
Subjective: Risk for maternal Premature Rupture Short-term After Independent: • To find out
Onset watery infection in of the Membranes 47 minutes of 1. Assess the
(PROM) is a vital signs
vaginal discharge, relation to complication
medical causative
2. Take note of
hypogastric pain rupture of occurring during intervention the agent of
the characteris
radiating to amniotic sac. pregnancy in which patient must: tics of the PROM.
lumbosacral area, the mother’s 1. Gain amniotic
membranes rupture • To have a
uterine knowled ge fluid
(this is commonly coming out safe
contraction every about
referred to as the from the delivery
30 minutes, “water breaking”) possible vagina. without
minimal whitish more than an hour infection. 3. Show any
discharges at before labor begins. emotional
PROM puts unborn infection
posterior fornix Long-term support to
area, foul smell,
babies at risk of not patient. • Promote
getting enough After 2 days of
leaking bag of good
oxygen because nurse to client
waters. Dependent wellbeing
their umbilical cord interaction the
becomes 1. Administer of the
client: drugs as
Objective: compressed, as well mother
as becoming
1. Will be free prescribed
Mother: infected and from .
infection
BP: 90/60 experiencing other 2. Safe and
HR: 96bpm dangerous delivery Collaborative: infant.
consequences. One 1. Review
RR:19 complication • To relief
Temp.:36.5 laboratory
associated with data with a
pain
O2 Sat: 98% PROM is the physician.
Weight: 63kgs maternal infection:
Without the
protection of the Source: Title of the
Fetal: amniotic sac,
FHT: 145bmp book, author, page
maternal infections no., edition, volume
FH: 34cm can be easily
EFW:3565 grams transmitted to the
baby, potential
leading to sepsis,
meningitis, and
permanent brain
damage.

Reference:
Premature Rupture
of Membranes: Birth
Injury and
Pregnancy Faqs
Jesse Reiter

Defining Nursing Scientific Goal of Care Intervention Rationale

Characteristi Diagnosis Analysis
cs
Subjective: Patient shows Urinary tract Short-term After Independent: Increase
Onset watery leaking in vagina, infection occurs in 30 minutes of hydration to
the bladder. 1. Teach the
vaginal discharge, smelly and foul nurse to pt flush bacteria
Premature rupture patient to
hypogastric pain odor also the interaction the pt empty away. Provide
of membrane
radiating to transparency of (PROM) and
verbalizes bladder or information to
lumbosacral area, urine is cloudy preterm PROM knowledge bowel at aid in
uterine which indicates relation of having regular determining
(PPROM) are
intervals.
contraction every Urinary tract commonly related UTI to premature choice or
30 minutes, infection. with poor maternal rupture of effectiveness of
2. Advice
minimal whitish and perinatal membrane. client to intervention.
discharges at outcomes. Urinary clean
tract infection (UTI) perineal
posterior fornix
has been known as often.
area, foul smell, one of its risk
leaking bag of factors. 3. Encourage
waters. use of sitz
bath and
Objective: warm soak
Mother: to the
perineum.
BP: 90/60
HR: 96bpm 4. Encourage
RR:19 increase of
Temp.:36.5 fluid intake.
O2 Sat: 98%
Weight: 63kgs
Collaborative:
Urinalysis results: Schnarr J, Smaill 1. Administer
F. Asymptomatic antibacteri
bacteriuria and
symptomatic
The patient’s urinary tract al as
hazy urine infections in prescribed
pregnancy. Eur J .
transparency Clin Invest2008;
may indicate 38(suppl 2):50-7.
infection. All
except the Source: Title of the
transparency of book, author, page
no., edition,
the urine sample volume
are within the
normal range.

Defining Nursing Scientific Goal of Care Intervention Rationale

Characteristic s Diagnosis Analysis
Subjective: Have lower than It's normal to have Short-term After Independent: To know the risk of
normal levels of mild anemia when one hour of 1. Observe anemia and its
pregnant. But it may vital signs
hemoglobin or nursing every 15
relation to mortality.
Objective: Mother: hematocrit and red have more severe intervention the minutes
anemia from low
BP: 90/60 blood count. Risk of iron or vitamin levels client will be able 2. Educate
HR: 96bpm having severe iron or from other to: client that
RR:19 deficiency anemia. reasons. having
1. Verbalize
anemia is
Temp.:36.5 Anemia can leave understa normal
O2 Sat: 98% pregnant woman nding during
Weight: 63kgs feeling tired and about the pregnanc
weak. If it is severe y.
causes and
but goes untreated, 3. Iron
▫ RBC: 3.75 ▫ effects of
it can increase risk deficiency is
HGB: of serious iron caused by
11.7 complications like deficienc y inadequat
▫ HCT: 34.7 preterm delivery. anemia e iron in the
Iron-deficiency before blood
anemia. This type of Dependent
Complete Blood and after
anemia occurs when pregnanc Collaborative
Count the body doesn't
The hematocrit, y. 1. Monitor
have enough iron to
hemoglobin, and laboratory
produce adequate
results of
red blood cells of amounts of
HB or
hemoglobin. That's a
the patient are HCT and
protein in red blood
below the normal RBC.
cells. It carries 2. Consultati
range. All the oxygen from the on to a
other results are lungs to the rest of dietitian for
the body. meal
normal.
In iron-deficiency planning
anemia, the blood which will
cannot carry enough include
oxygen to tissues nutritious
throughout the body. and high in
iron food.

Source: Title of the

book, author, page

Iron deficiency is no., edition,

the most common volume
cause of anemia in
pregnancy.

Source: Title of
the book, author,
page
no., edition,
volume

FDAR

It is a method of charting nurses use, along with other disciplines, to help focus on a specific patient
problem, concern, or event. It is geared to save time and decrease duplicate charting. It is a great charting
method for nurses who have a lot of patients and is easier read by other professionals. It gives other
professionals a snapshot of what went on during your shift in a concise manner.

F (Focus): This is the subject/purpose for the note. The focus can be:

Nursing diagnosis

Event (admission, transfer, discharge teaching etc.)

Patient Event or Concern (code blue, vomiting, coughing)

D (Data): This is written in the narrative and contains only subjective (what they patient says and things that
are not measurable) & objective data (what you assess/findings, vital signs and things that are measurable).
This lays the supporting evidence for why you are writing the note. You are letting the reader know “this is
what the patient is saying and what I’m seeing”.

A (Action): This is the “verb” area. In this section, you are going to write here what you did about the findings
you found in the data part of the note. This includes your nursing interventions (calling the
doctor, repositioning, administering pain medication etc.)

R (Response): This is where you write how the patient responded to your action. Sometimes, you won’t chart
the response for several minutes or hours later.
Date Focus Time DAR
4/26/20 Risk for 7:03 pm D: Patient was received conscious and speaking, G1P0, AOG 39weeks based on LMP,
maternal EDC/EDD 5/5/20, 37 6/7 weeks by 1st ultrasound.
infection in Complaints of having soaked underwear, onset of watery vaginal discharges, associated
with hypogastric pain radiating to lumbosacral area, with uterine contraction every 30
relation to minutes.
rupture of
amniotic sac. A: Assess the patient’s brief medical history. Monitor fetal activity. Request for laboratory
examination such as CBC, Urinalysis and Utz. Review the laboratory results to assess
signs of infection. Admit to a physician. Secure consent of care. Assess TPR q4h.
Administer antibiotic drug through IV, ampicillin as prescribed to treat moderate to
severe infection. Monitor progress of labor.

R: Pt and infant is safe from infection.

Date Focus Time DAR

4/27/20 Urinary tract 5:00 am D: Patient was ordered to go under Urinary Analysis. The laboratory results show
infection Transparency: Hazy, the patient’s hazy urine transparency may indicate infection.
A: Observe if patient show more severe signs and symptoms of having urinary infection.
Educate patient about staying hydrated and increased water consumption. Encourage
patient to not to restrain the feeling of urination and urinate regularly. Encourage
patient to do perineal care.

R: The patient shows negative sign and symptoms of having mild to severe urinary
infection.

Date Focus Time DAR

4/27/20 Iron 5:00 am D: Patient was ordered to go under Complete blood Count. The laboratory results show
deficiency that the hematocrit, hemoglobin, and red blood cells of the patient are below the
normal range RBC: 3.75, HGB: 11.7, HCT: 34.7
Anemia
A: Observe if patient show more severe signs and symptoms of having iron deficiency
anemia. Educate patient about the importance of having adequate dietary intake during
pregnancy and the importance of taking iron.

R: Patient verbalized understanding.

Date Focus Time DAR

4/27/20 Pain in 5:00 am D. – the patient comes to the ER with a complaint of watery vaginal discharge and
lumbosacral hypogastric pain radiating to a lumbosacral area with uterine contraction every 30
area minutes.

A. – check if the infection is present in the vagina which can be the cause of pain and
discharge. Provide medication to help relieve the pain. Advise the client to do perineal
exercise because it helps lessen the pain and teach the client how to properly do
perineal care.

R. – the client should know the reason and cause of the pain and discharge. The client
knows what is the purpose of the medication given to her. The client understands and
will follow the advice that is given to her

Date Focus Time DAR

4/26/20 Acute Pain 7:03

D: Subjective Data: pt is experiencing “hypogastric pain radiating to

lumbosacral area, with uterine contraction every 30 minutes” Objective data:
Vital Signs: BP: 90/60
HR: 96 RR: 19
Temp: 36.5
O2 Sat: 98% Weight: 63 kg
Abdomen: FH: 34 cm
EFW: 3565 grams
FHT; 145 bpm
SPE: (+) minimal whitish discharges at posterior fornix area, foul smell
IE: 1 cm, UE ST -5, Leaking BOW, Cephalic, posterior, firm,
BISHOP score: 1
A: G1P0, 39 weeks AOG, Cephalic in latent phase of labor, PROM P: Admit
A: letting the doctor know the current condition of the patient, repositioning
the pt for comfort, and giving pain reliever as ordered by the doctor.
R: after repositioning the client, the client said that “I feel comfortable, my
back pain is relieved.”

Date Focus Time DAR

4/29/20 Health 7:25 PM D: G1P0 - first time mother, insufficient knowledge about medication.
Teaching on
Home A: Patient instructed on the actions and side effects of the medication.
Medications Educate how, where, and when to administer drugs. Discusses when she
would call the physician about the medicine.

R: Patient demonstrated how to administer the medication, and verbalized

correctly the side effects and safety precautions.

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

4/29/21 Discharges instructions 7pm D: With discharge order
from attending physician
Dr. Yu.

A: Activity: Stick to healthy

diet and exercise regimen
Instruct the patient to practice
perineal hygiene daily and
refrain from excess
movements.

Medication:

Take Home Medications:

1. Celecoxib 200mg 1
cap BIDx1week
2. Cefuroxime 500mg
1 tab BID 7days
3.
T treatment: Continue the
use of prescribed
medication.

H health Teaching:
Instruct patient to follow
important guidelines and
never discontinue the use
of medicine given.
Get back at APS clinic on
May 6, 2020

D diet: Increase
consumption of fruits and
vegetable to sustain the
nutrients body need
naturally.

R: Out of the room per

wheelchair with improved
condition