NAME OF

ACTION/ SHAPE & COLOR OF

MEDICATION GENERIC NURSING IMPLICATIONS/
DOSAGE CONTRAINDICATION/ THE MEDICATION
(BRAND NAME NURSING RESPONSIBILITIES
SIDE EFFECTS CARD TO BE USED
NAME)
Lasix Furosemide 20 mg IV ACTIONS: Alert: Monitor weight, BP, and pulse rate
once a day • Inhibits sodium and chloride reabsorption at routinely with long-term use.
the proximal and distal tubules and the Drug is potent diuretic and can cause severe
ascending loop of Henle. diuresis with water and electrolyte
ONSET: Within 5 min depletion. Monitor patient closely and
PEAK; 30 min ER 108 adjust dose carefully.
DURATION: 2 hr.
10-23-2022 • If oliguria or azotemia develops or
CONTRAINDICATIONS: increases, drug may need to be stopped.

Furosemide 20 mg IV once a
• Contraindicated in patients hypersensitive to • Monitor fluid intake and output and

Mary Julianne O. Galvan

day with Bp Precaution
drug and in those with anuria. electrolyte, BUN, and carbon dioxide levels
• Use cautiously in patients with hepatic frequently.
cirrhosis and in those allergic to sulfonamides. • Watch for signs of hypokalemia, such as
Alert: Drug may cause tinnitus and reversible muscle weakness and cramps.
or irreversible hearing loss. Ototoxicity is • Consult prescriber and dietitian about a
associated with rapid injection, severe renal high-potassium diet or potassium
impairment, use of higher-than-recommended supplements.
doses, hypoproteinemia, • Monitor glucose level in diabetic patients.

8 AM
or use with other ototoxic drugs. • Drug may not be well absorbed orally in
• Drug may exacerbate or activate SLE. patient with severe HF. Drug may need to
• Premature infants may be at increased risk for be given IV even if
persistent patent ductus arteriosus with patient is taking other oral drugs.
furosemide treatment during first weeks of life. • Monitor uric acid level, especially in
Dialyzable drug: No. patients with a history of gout.

*Assume that the medication card’s front has

Overdose S&S: Dehydration, blood volume • Monitor elderly patients, who are
reduction, hypotension, electrolyte imbalance. especially susceptible to excessive diuresis,

signature of the student nurse

because circulatory
SIDE EFFECTS: collapse and thromboembolic

Mary Julianne O. Galvan

CNS: vertigo, headache, dizziness, paresthesia, complications are possible.
weakness, restlessness, fever. • Monitor patients with severe symptoms of

WUP SN’25
CV: orthostatic hypotension, thrombophlebitis urine retention due to bladder emptying

10-23-2022
with IV administration. disorders, prostate
EENT: blurred or yellowed vision, transient enlargement, or urethral narrowing or
deafness, tinnitus. worsening of symptoms, especially during
GI: abdominal discomfort and pain, diarrhea, initial treatment.
anorexia, nausea, vomiting, constipation,
pancreatitis. PATIENT TEACHING
GU: azotemia, nocturia, polyuria, frequent • Advise patient to take drug in morning to
urination, oliguria. prevent need to urinate at night. If a second
Hematologic: agranulocytosis, aplastic dose is needed, tell
anemia, leukopenia, thrombocytopenia, patient to take it in early afternoon, 6 to 8
anemia. hours after morning dose.
Hepatic: hepatic dysfunction, jaundice, • Inform patient of possible need for
increased liver enzyme levels. potassium or magnesium supplements.
Metabolic: volume depletion and dehydration, • Instruct patient to stand slowly to prevent
asymptomatic hyperuricemia, impaired dizziness and to limit alcohol intake and
glucose tolerance, hypokalemia, strenuous exercise in
hypochloremic alkalosis, hyperglycemia, hot weather to avoid worsening dizziness
dilutional hyponatremia, hypocalcemia, upon standing quickly.
hypomagnesemia. Musculoskeletal: muscle • Advise patient to report all adverse
spasm. reactions and to immediately report ringing
Skin: dermatitis, purpura, photosensitivity in ears, severe
reactions, transient pain at IM injection site, abdominal pain, or sore throat and fever;
toxic epidermal necrolysis, SJS, erythema these symptoms may indicate toxicity.
multiforme. Alert: Discourage patient from storing
Other: gout. different types of drugs in the same
container, increasing risk of
drug errors. (The most popular strengths of
furosemide and digoxin are white tablets
that are about equal
in size.)
• Tell patient to consult prescriber or
pharmacist before taking OTC drugs.
• Teach patient to avoid direct sunlight and
to use protective clothing and sunblock
because of risk of
photosensitivity reactions.
Unasyn Ampicillin 1 gram IV ACTIONS: • Dosage is expressed as total drug. Each
Sulbactam every 12 • Inhibits cell-wall synthesis during bacterial 1.5-g vial contains 1 g ampicillin sodium
hrs. multiplication and 0.5 g sulbactam
ONSET: Immediate sodium.
PEAK: 15 min • In patients with impaired renal function,
DURATION: Unknown decrease frequency of administration.
ER 108
• Monitor LFT results during therapy,
CONTRAINDICATIONS: 10-23-2022 especially in patients with impaired liver
• Contraindicated in patients hypersensitive to function.

Mary Julianne O. Galvan

Ampicillin Sulbactam 1
drug or other penicillins, in those with • If large doses are given or if therapy is

gram IV every 12 hrs

sensitivity to multiple allergens, and in those prolonged, bacterial or fungal
with mononucleosis because of high risk of superinfection may occur,
maculopapular rash. especially in elderly, debilitated, or
• Contraindicated in patients with a history of immunosuppressed patients.
cholestatic jaundice or hepatic dysfunction • Watch for signs and symptoms of

8AM-6PM
associated with ampicillin–sulbactam hypersensitivity, such as erythematous
injection. maculopapular rash, urticaria,
• Use cautiously in patients with other drug and anaphylaxis.
allergies (especially to cephalosporins) • Monitor for CDAD, which can be fatal.
because of possible cross-sensitivity and in Antibiotic may need to be stopped and other
those with renal impairment. treatment begun.

*Assume that the medication card’s front

Dialyzable drug: Yes.
Overdose S&S: Neuromuscular PATIENT TEACHING

has signature of the student nurse

hyperexcitability, seizures. • Tell patient to report all adverse reactions,
including rash, fever, or chills. A rash is the

Mary Julianne O. Galvan

SIDE EFFECTS: most common
CV: thrombophlebitis. allergic reaction.

WUP SN’25
10-23-2022
GI: diarrhea. • Warn patient that IM injection may cause
Hematologic: agranulocytosis, leukopenia, pain at injection site.
thrombocytopenia,
thrombocytopenic purpura.
Skin: pain at injection site, thrombophlebitis,
rash, urticaria. Other: hypersensitivity
reactions.

Aldomet Methyldopa 250 gram ACTIONS: • Monitor patient's BP regularly. Elderly

per Orem •May inhibit the central vasomotor centers, patients are more likely to experience
every 6 decreasing sympathetic outflow to the heart, hypotension, syncope, and
hrs. kidneys, and sedation.
peripheral vasculature. • Occasionally, tolerance may occur,
ONSET: 4 - 6 hr. usually between the second and third
PEAK: Unknown months of therapy. Adding a
DURATION:12 - 48 hr. diuretic or adjusting dosage may be needed.
If patient's response changes significantly,
CONTRAINDICATIONS: notify prescriber.
• Contraindicated in patients hypersensitive to
drug and in those with active hepatic disease
(such as acute hepatitis) or active cirrhosis.
• Contraindicated in those whose previous
methyldopa therapy caused liver problems and
in those taking MAO inhibitors.
• Use cautiously in patients with history of
impaired hepatic function or sulfite sensitivity.
Dialyzable drug: Yes.
Overdose S&S: Sedation, acute hypotension,
weakness, bradycardia, dizziness, constipation,
abdominal distention, flatus, diarrhea, nausea,
vomiting, light-headedness.
SIDE EFFECTS:
CNS: decreased mental acuity, sedation,
headache, weakness, dizziness, paresthesia,
parkinsonism,
involuntary choreoathetoid movements,
psychic disturbances, depression, nightmares.
CV: orthostatic hypotension, edema,
bradycardia, HF, myocarditis, aggravated
angina.
EENT: nasal congestion.
GI: dry mouth, pancreatitis, nausea, vomiting,
diarrhea, constipation, flatus, sore or “black”
tongue, abdominal distention, colitis.
GU: amenorrhea, breast enlargement,
impotence.
Hematologic: thrombocytopenia, leukopenia,
bone marrow depression, hemolytic anemia.
Hepatic: hepatic necrosis, hepatitis,
jaundice.
Metabolic: hyperprolactinemia, weight gain.
Musculoskeletal: arthralgia, myalgia.
Skin: rash.
Other: drug-induced fever.
• After dialysis, monitor patient for HTN
and notify prescriber, if needed. Patient
ER 108 may need an extra dose
10-23-2022 of drug.
• Monitor CBC with differential counts
before therapy and periodically thereafter.
• Patients who need blood transfusions
Methyldopa 250 mg per Orem
should have direct and indirect Coombs
Mary Julianne O. Galvan
tests to prevent crossmatching
problems.
• Monitor patient's Coombs test results. In
every 6 hrs.
patients who have received drug for several
months, positive
reaction to direct Coombs test may indicate
12MN-6AM
hemolytic anemia.
• Report involuntary choreoathetoid
movements. Drug may be stopped.
PATIENT TEACHING
• If unpleasant adverse reactions occur,
advise patient not to suddenly stop taking
drug but to notify
*Assume that the medication card’s front
prescriber.
• Instruct patient to report signs and
Mary Julianne O. Galvan
has signature of the student nurse
symptoms of infection, yellowing of the
skin, flulike symptoms, and
WUP SN’25
10-23-2022
muscle aches.
• Tell patient to check weight daily and to
notify prescriber for a weight gain of 900 g
in 1 day or 2.3 kg in
1 week. Sodium and water retention may
occur but can be relieved with diuretics.
• Warn patient that, particularly at the start
of therapy, drug may impair ability to
perform tasks that
require mental alertness. A once-daily dose
at bedtime minimizes daytime drowsiness.
• Inform patient that low BP and dizziness
upon rising can be minimized by rising
slowly and avoiding
sudden position changes and that dry mouth
can be relieved by chewing gum or sucking
on hard candy or
ice chips.
 • Tell patient that urine may turn dark if left
sitting in toilet bowl or if toilet bowl has
been treated with
bleach.
Decadron Dexamethasone 3 mg IM ACTIONS: Alert: Epidural corticosteroid injections to
12 hrs. x 2 • Unclear. Decreases inflammation, mainly by treat neck and back pain and radiating pain
doses stabilizing leukocyte lysosomal membranes; in the arms and
suppresses legs may result in rare but serious adverse
immune response; stimulates bone marrow; events (vision loss, stroke, paralysis, death).
and influences protein, fat, and carbohydrate ER 108 The use of
metabolism. epidural corticosteroid injections isn't
ONSET: 1 hr. 10-23-2022 approved by the FDA.
PEAK: 1hr. • Most adverse reactions to corticosteroids

Dexamethasone 3 mg IM every
DURATION: 6 days are dose- or duration-dependent.
• For better results and less toxicity, give

Mary Julianne O. Galvan

CONTRAINDICATIONS: once-daily dose in morning.

12 hrs. x doses
• Contraindicated in patients hypersensitive to • Always adjust to lowest effective dose.
drug or its ingredients, in those with systemic • Monitor patient's weight, BP, and
fungal infections, and in those receiving electrolyte levels.
immunosuppressive doses together with live- • Monitor patient for cushingoid effects,
virus vaccines. IM administration is including moon face, buffalo hump, central
contraindicated in patients with ITP. obesity, thinning hair,

8AM-6PM
• Use cautiously in patients with recent MI. HTN, and increased susceptibility to
• Use cautiously in patients with GI ulcer, renal infection.
disease, HTN, osteoporosis, diabetes mellitus, • Watch for depression or psychotic
hypothyroidism, cirrhosis, diverticulitis, episodes, especially in high-dose therapy.
nonspecific ulcerative colitis, recent intestinal • Diabetic patient may need increased
anastomoses, thromboembolic disorders, insulin; monitor glucose levels.
seizures, myasthenia gravis, HF, TB, active • Drug may mask or worsen infections,
hepatitis, ocular HSV infection, emotional including latent amebiasis.
instability, or psychotic tendencies. • Elderly patients may be more susceptible

*Assume that the medication card’s front

• Because some forms contain sulfite to osteoporosis with long-term use.

has signature of the student nurse

Mary Julianne O. Galvan
preservatives, also use cautiously in patients • Inspect patient's skin for petechiae.
sensitive to sulfites. • Gradually reduce dosage after long-term

WUP SN’25
Dialyzable drug: No. therapy.

10-23-2022
• Look alike–sound alike: Don't confuse
SIDE EFFECTS: dexamethasone with desoximetasone.
CNS: euphoria, insomnia, psychotic behavior,
pseudotumor cerebri, vertigo, headache, PATIENT TEACHING
paresthesia, seizures, depression. • Instruct patient to take drug with food or
CV: HF, HTN, edema, arrhythmias, milk.
thrombophlebitis, thromboembolism. Alert: Counsel patient receiving epidural
EENT: cataracts, glaucoma. corticosteroid injections to seek immediate
GI: peptic ulceration, GI irritation, increased medical attention
appetite, pancreatitis, nausea,
vomiting.
 GU: menstrual irregularities, increased urine for loss of vision or vision changes; tingling
glucose and calcium levels. in the arms or legs; sudden weakness or
Metabolic: hypokalemia, hyperglycemia, numbness of the
carbohydrate intolerance, face, arm, or leg on one or both sides of the
hypercholesterolemia, hypocalcemia, sodium body; dizziness; severe headache; or
retention, weight gain. seizures.
Musculoskeletal: growth suppression in • Tell patient not to stop drug abruptly or
children, muscle weakness, without prescriber's consent.
osteoporosis, tendon rupture, myopathy. • Teach patient signs and symptoms of early
Skin: hirsutism, delayed wound healing, acne, adrenal insufficiency: fatigue, muscle
various skin eruptions, atrophy at IM injection weakness, joint pain,
site, thin fragile skin. fever, anorexia, nausea, shortness of breath,
Other: cushingoid state, susceptibility to dizziness, and fainting.
infections, acute adrenal insufficiency after • Instruct patient to carry medical
increased stress or abrupt withdrawal after identification indicating the need for
long-term therapy, supplemental systemic
angioedema. glucocorticoids during stress, especially
After abrupt withdrawal: rebound when dosage is decreased. This card should
inflammation, fatigue, weakness, arthralgia, contain prescriber's
fever, dizziness, lethargy, fainting, orthostatic name, drug name, and drug dosage.
hypotension, dyspnea, anorexia, • Warn patient on long-term therapy about
hypoglycemia. After prolonged use, sudden cushingoid effects (moon face, buffalo
withdrawal may be fatal. hump) and the need to
notify prescriber about sudden weight gain
or swelling.
Warn patient about easy bruising.
• Advise patient receiving long-term
therapy to consider exercise or physical
therapy. Tell patient to ask
prescriber about vitamin D or calcium
supplement.
• Instruct patient receiving long-term
therapy to have periodic eye examinations.
• Advise patient to avoid exposure to
infections (such as measles and
chickenpox) and to notify prescriber
if such exposure occurs.
• Tell patient to avoid alcohol.
Alert: Counsel patient to discuss benefits
and risks along with other possible
treatments with health
care provider before undergoing epidural
corticosteroid injection.
Adalat Nifedipine 5 mg twice ACTIONS: • Monitor BP and HR regularly, especially
a day per in patients who take beta blockers or
Orem antihypertensives.
• Thought to inhibit calcium ion influx across • Watch for symptoms of HF.
cardiac and smooth muscle cells, decreasing • The most common adverse effect is
ER 108
contractility and peripheral edema, which occurs within 2 to
oxygen demand. Drug may also dilate coronary 10-23-2022 3 weeks of start of therapy.
arteries and arterioles • Don't give immediate-release capsules

Nifedipine 5 mg twice a day per Orem

ONSET: 20 min. within 1 week of acute MI or in ACS.
PEAK: 30 – 6o hr. • Look alike–sound alike: Don't confuse

Mary Julianne O. Galvan

DURATION: 4 – 8 hr. nifedipine with nimodipine, nisoldipine, or
nicardipine. Don't confuse Procardia XL
CONTRAINDICATIONS: with Cartia XT.
• Contraindicated in patients hypersensitive to
drug, in those taking strong CYP450 inducers PATIENT TEACHING
(rifampin), and in patients with cardiogenic • If patient is kept on nitrate therapy while
shock or ST-segment elevation MI. nifedipine dosage is being adjusted, urge
• Increased angina and MI have occurred at continued

8AM – 6PM
start of therapy or with dosage titration of compliance. Patient may take SL
dihydropyridine calcium channel blockers. nitroglycerin, as needed, for acute chest
Reflex tachycardia may occur, resulting in pain.
angina or MI in patients with obstructive • Tell patient that chest pain may worsen
coronary disease, especially in the absence of briefly as therapy starts or dosage increases.
concurrent beta blockade. • Instruct patient to swallow extended-
• BP must be lowered at a rate appropriate for release tablets without breaking, crushing,
patient's clinical condition to avoid or chewing them.
symptomatic hypotension with or without • Advise patient to avoid taking drug with

front has signature of the student nurse

syncope. The use of immediate release grapefruit juice.

*Assume that the medication card’s

Mary Julianne O. Galvan
nifedipine in hypertensive emergencies and • Tell patient not to abruptly stop drug
urgencies is neither safe nor effective. Serious unless directed by prescriber. Abrupt

WUP SN’25
adverse events (death, cerebrovascular withdrawal may cause

10-23-2022
ischemia, syncope, stroke, acute MI, fetal rebound angina in patients with CAD.
distress) have been reported. Don't use • Advise patient that Adalat CC tablets
immediate release nifedipine for acute BP contain lactose and shouldn't be used by
reduction or to manage primary HTN. patients with galactose
• Avoid use in patients with HF; drug may intolerance, Lapp lactase deficiency, or
worsen symptoms. glucose-galactose malabsorption.
• Use with extreme caution in patients with • Reassure patient taking the extended-
severe aortic stenosis. Drug may reduce release tablet that the wax mold may be
coronary perfusion, resulting in ischemia. passed in the stools.
• Use cautiously in patients with hypertrophic Assure patient that drug has already been
cardiomyopathy and outflow tract obstruction completely absorbed.
because reduction in afterload may worsen • Tell patient to protect capsules from direct
symptoms. light and moisture and to store at room
• Use cautiously before major surgery. temperature
Cardiopulmonary bypass, intraoperative blood
loss, or
vasodilating anesthesia may result in severe
hypotension or increased fluid requirements.
Consider withdrawing nifedipine more than 36
hours before surgery if possible.
• Rare reversible elevations in BUN and serum
creatinine levels have been reported in patients
with preexisting chronic renal insufficiency.
• Use cautiously in patients with hepatic
impairment. Clearance of nifedipine is reduced
in cirrhotic patients, leading to increased
systemic exposure and possibly increasing
toxicities; monitor patient and consider dosage
adjustments.
Alert: Immediate-release drug is considered a
high-risk drug for elderly patients because of
the potential for hypotension and increased risk
of precipitating myocardial ischemia in this
population. Avoid use.
Alert: Use extended-release form cautiously
because of an increased risk of serious GI
obstruction in patients both with and without
risk factors. (Risk factors for GI obstruction
include altered GI anatomy, GI hypomotility
related to GERD, colon cancer, ileus, obesity,
hypothyroidism, diabetes, and concomitant
use of H2 blockers, NSAIDs, laxatives,
anticholinergic agents, and levothyroxine.)
• Safety and effectiveness in children haven't
been established.
Dialyzable drug: Unlikely.
Overdose S&S: Hypotension, dizziness,
palpitations, flushing, nervousness.

SIDE EFFECTS:
CNS: dizziness, light-headedness, giddiness,
headache, weakness, nervousness, mood
changes, shakiness, sleep disturbances, fever.
CV: flushing, heat sensation, peripheral
edema, palpitations, transient hypotension.
EENT: nasal congestion, sore throat, blurred
vision.
GI: nausea, heartburn,
diarrhea, constipation, cramps, flatulence.
Musculoskeletal: muscle cramps, tremor,
inflammation, joint stiffness.
Respiratory: dyspnea, cough, wheezing, chest
congestion, shortness of breath.
Skin: dermatitis, pruritus, urticaria, sweating.
Other: difficulties in balance, chills, sexual
difficulties.
MARY JULIANNE O. GALVAN
BSN 2 - 4
ENDORSEMENT

DATE/ TIME NURSE’S NOTES

October 23, 2022 Received 27 years old primigravida patient,
7:00 am Ma. Magdalena Delacruz from the emergency
room. Due to having:
 Globular enlarged abdomen
 Associated with abdominal pain
radiating to the back
 Patient had edema on both legs
According to Patient her Last Menstrual Period
- October 10, 2021
Taking and recording Vital Signs
 Temperature: 36.7
 Pulse rate: 90/min
 Respiratory rate: 24/min
 SPo2: 98%
 BP: 190/90
 Weight: 67 kg

Diet: Nothing per Orem

7:30am Patient admitted under Dra. Blessie Hernandez
Consent was secured for a patient undergo
CBC, APC, Blood typing, covid rapid test U/A
in the hospital laboratory.
Medication is prescribed including:
 IVF: D5LRS 1L to run for 8hours
 Furosemide 20mg IV once a day with
BP precaution
 Ampicillin sulbactam 1gram IV every
12 hrs.
 Methyldopa 250mg per Orem every 6
hrs.
 Dexamethazone 3mg IM every 12 hrs x
2doses
 Nifedifine 5mg twice a day per Orem
8:00am Oxygen 3LPM/NC administered
Administering medications:
 Furosemide 20mg IV once a day with
BP precaution
 Ampicillin sulbactam 1gram IV every
12 hrs.
 Nifedifine 5mg twice a day per Orem
10:00 am Progress of labor FHT and vital signs were
monitored every 2hours. Effect of medication
reduces patient’s vital sign
 BP:130/80
 Temperature: 35.5
 Pulse rate:84/min
 Respiratory rate: 21/min
 SPo2: 96%
1:00 pm Taking and Recording of Vital Signs
 Progress of labor, FHT and vital sign
were still monitored.
IVF and medication are still ongoing.
4:00 pm Seen and examined by Dra. Blessie Hernandez
with order made and carried out.
Always kept the patient comfortable, seen at all
times. Continue the medication ordered. All
the calls and needs attended. So far, there are
minimal complaints. Endorsed for continuity
of care.

Mary Julianne O. Galvan, Student Nurse of

Wesleyan University - Philippines
Name of Client: Dela Cruz, Ma. Magdalena
Diagnosis: G1 PO with Globular Enlarged Abdomen
Age: 27 years old
NURSING
NURSING
INTERVENTION
DIAGNOSIS EVALUATION: assess
NURSING GOAL (indicate the type of RATIONALE
ASSESSMENT (Indicate the type of if the goals are met,
(indicate if short term or intervention used: (Support each
(Indicate the method Nursing Diagnosis include indicators that
long-term goal, use the Independent, intervention with
used: Used: Actual, Risk, or suggest goals are
acronym SMART) Dependent, or rationale)
Wellness Nursing achieved
Collaborative Nursing
Diagnosis)
Intervention
Subjective Data Acute pain associated SHORT TERM INDEPENDENT: SHORT TERM
"Dumadalas po ang with headache may be The patient should have • Monitor patient’s vital • Some people deny the The patient have seen a
pagsakit ng aking ulo na related to pregnancy as seen a decrease in pain signs experience of pain when decrease in pain from
may pagkasamang evidenced by facial from 9/10 to 3-4/10 after it is present. Attention to 9/10 to 3-4/10 after 2 to
paghilab ng aking tiyan grimace, verbalization of 2 to 4 hours of treatment associated signs may 4 hours of treatment
na ramdam ko hanggang abdominal pain with help the nurse in
likod" as verbalized by pain scale of 6/10 and LONG TERM evaluating pain. LONG TERM
patient. elevated blood pressure. The patient should have The patient has
discovered personal • Perform pain • This data can be used to discovered personal
Last Menstrual Period triggers after two to three assessment to evaluate identify the extent of the triggers after two to three
was on October 10,2022 days of treatment in characteristics of pain pain as well as serve as a days of treatment in
order to avoid migraine and note and investigate baseline information. order to avoid migraine
Abdominal pain attacks and be headache- changes. attacks and be headache-
radiating to back free. • Reduces abdominal free.
• Encourage patient to tension and promotes a
Method: Interview have bed rest. sense of control. Goal met. After 2 hours
nursing interventions,
Objective data: • Promotes relaxation, patient’s blood pressure
Edema in both legs • Place patient in a side refocuses attention, and decreased to 134/80
Globular enlarged lying position. Provide may enhance coping mmHg.
abdomen comfort measure abilities

Vital Signs taken as

follows:
 Temperature: DEPENDENT:
36.7 • Administer prescribed Important for controlling
 Pulse rate: medications as chronic conditions,
90/min instructed. treating temporary
 Respiratory rate: conditions, and overall
24/min • Administer IV fluids long-term health and
 SPo2: 98% as ordered well-being
  BP: 190/90 • Administer oxygen • Maternal oxygen
inhalation as ordered supplementation as an
Method: Physical and intrauterine resuscitation
Laboratory Assessment technique to help
manage fetal heart rate
during childbirth.

COLLABORATIVE:
• Request for further • For further monitoring
examinations/tests of results of the patient
as instructed. and as a representation
of patient’s
improvement about her
diagnosis

Name of Student: MARY JULIANNE O. GALVAN

Year and Block No.: BSN 2 –4

ASUNCION GASPAR, MAN, RN

Clinical Instructor