University of Pangasinan

PHINMA Education Network College of Health

Sciences

Situation:

Jenny, a 34-year-old pregnant client who is 35 weeks pregnant, visited the RHU of Brgy. Maliwanag. During the assessment, it was found out that she has persistent,
dull low backache, persistent uterine contractions, low abdominal cramping, and cervical dilatation of 2 cm. The physician has concluded that she is experiencing
premature labor.

ASSESSMENT EXPLANATION OF THE PLANNING INTERVENTIONS RATIONALE EVALUATION

PROBLEM
Subjective: A 34-year-old patient has a 2 cm Short term: Position the client in a lateral Position changes may Short term:
Low abdominal dilated cervix and is concluded to After 1 hour of recumbent position. promote comfort and After 1 hour of
cramping have premature labor. Acute pain nursing increase venous return. A nursing
is an unpleasant sensory and interventions: lateral recumbent position interventions:
Persistent contraction emotional experience associated enhances placental
with acute or potential tissue The patient will circulation and helps the The patient
Dull low backache damage, or described as sudden or verbalize the pain fetus adapt to the size and verbalized that
slow onset of any intensity from is relieved or shape of the client’s pelvis. the pain is
Objective: mild to severe with an anticipated controlled. relieved or
Cervical dilatation of or predictable end. Moreover, the Teach relaxation techniques (e.g., Uterine contraction severity controlled.
2 cm patient is having an acute pain as deep breathing exercises, may decrease if the stress and
manifested by the patient’s The patient will visualization, guided imagery, soft anxiety level of the client can The patient
persistent, dull low backache, demonstrate use of music). be decreased by using demonstrated use
 persistent uterine contractions, relaxation skills relaxation-focused nursing of relaxation skills
and low abdominal cramping. and diversional care, causing an increase in and diversional
activities. gestational weeks. Thus, both activities.
maternal and fetal health can
The patient will benefit from this. The patient
verbalize a sense of verbalized a sense
control of response Every patient experiences of control of
to acute situations Determine the intensity of the pain differently, it varies response to acute
and a positive patient’s pain and discomfort depending on their physical, situations and a
outlook for the psychological, and cultural positive outlook
future. circumstances. The effects of for the future.
hormonal and chemical
changes before, during and
Long term: after birth may have an Long term:
After impact on a woman’s ability After
hospitalization: to tolerate pain. hospitalization:

NURSING The patient will A baseline for comparisons The patient

DIAGNOSIS follow a Monitor for fetal and maternal vital in the future is provided by followed a
pharmacological signs an assessment. Monitoring of pharmacological
Acute pain as regimen. the uterus and developing regimen.
evidenced by backache, fetus provides proof of fetal
uterine contractions, health.
and low abdominal
cramping secondary to Mild analgesics reduce
premature labor. Administer analgesics as ordered discomfort and muscle strain.
An epidural is recommended
if the patient wants
medication for labor pain
relief.

Painkillers are absorbed and

 Monitor the patient for
effectiveness of medication and for
any indication and symptoms of
adverse effects.
digested differently
depending on the patient,
medication’s effectiveness
must be assessed
individually.

DRUG STUDY
NAME OF DRUG MECHANISM OF ACTION CONTRAINDICATIONS SIDE ADVERSE NURSING RESPONSIBILITIES
EFFECTS EFFECTS
GENERIC NAME Inhibits the synthesis of Acetaminophen is Breathing Hives NURSING ASSESSMENT:
prostaglandins in the central contraindicated in: problems Assess for an allergy to
nervous system and Difficulty breathing acetaminophen.
Acetaminophen (IV) peripherally blocks pain Patients with known Nausea
impulse generation; produces hypersensitivity to Swelling in the
Assess the patient for pain by
antipyresis from inhibition of Acetaminophen or to any of Vomiting face, lips, tongue,
asking the patient to rate on a
BRAND NAME hypothalamic heat-regulating the excipients in the or throat
scale of 1-10, and describe pain
center; binds to opiate intravenous formulation Constipation
characteristic, duration, and
receptors in the CNS, causing Skin redness
frequency.
Ofirmev inhibition of ascending pain Patients with renal or Agitation
pathways, altering the hepatic impairment Rash that spreads
If given as an antipyretic, assess
perception of and response to Itching and causes
pain; causes cough Elderly, pregnant or blistering and temperature.
CLASSIFICATION
suppression by direct central breastfeeding patients Headache peeling
action in the medulla;
produces generalized CNS Children under age 2 Insomnia Chest pain Assess for pregnancy or lactation.
Analgesics
depression. Acetaminophen is a category B
Upper stomach risk meaning the risk of fetal
 INDICATION
Acetaminophen is one of the
most commonly used drugs
among pregnant women, and it
is usually the first-choice
analgesic and antipyretic. For
the reason that the intensity of
pain experienced by women
during labor has been shown to
influence labor progress, fetal
well-being, and maternal
psychology. Intravenous
acetaminophen is an effective
non-opioid pain reliever that has
no significant maternal or fetal
side effects.
DOSAGE & FREQUENCY
Dosage for Adult and pediatric:
● 500mg/50mL
● 1000mg/100mL
FOR PAIN AND FEVER:
Adult dosage
● Weighing less than 50kg:
12.5 mg/kg IV every 4
hours or 15 mg/kg IV
every 6 hours; not to
A: Acetaminophen has 88%
oral bioavailability and
reaches its highest plasma
concentration 90 minutes
after ingestion.
D: Acetaminophen appears to
be widely distributed
throughout most body tissues
except in fat.
M: Acetaminophen is mainly
metabolized in the liver by
first-order kinetics and its
metabolism of comprised of 3
pathways: conjugation with
glucuronide, conjugation with
sulfate, and oxidation through
the cytochrome P450 enzyme
pathway, mainly CYP2E1, to
produce a reactive metabolite
(N-acetyl-p-benzoquinone
imine or NAPQI).
E: Acetaminophen
metabolites are mainly
excreted in the urine. Less
than 5% is excreted in the
urine as free (unconjugated)
acetaminophen and at least
90% of the administered dose
is excreted within 24 hours.
DRUG INTERACTIONS:
Activated charcoal and
cholestyramine decrease the
absorption of
acetaminophen.
Barbiturates,
carbamazepine, isoniazid,
rifampin, and more can
increase the risk of
hepatotoxicity.
Hormonal contraceptives
can decrease the
effectiveness of
acetaminophen.
Oral anticoagulants may
have an increased
anticoagulant effect.
FOOD INTERACTIONS:
Alcohol may increase risk
of hepatotoxicity.
pain harm is possible but unlikely.
Administration is safe under the
Loss of appetite prescription and supervision of a
healthcare provider.
Dark urine
Assess for acetaminophen
Clay-colored stools
toxicity: nausea, vomiting,
abdominal pain, elevated bilirubin
Jaundice
and liver enzymes.
NURSING INTERVENTION:
Routinely monitor the
effectiveness of acetaminophen by
assessing pain levels and fever
reduction.
IV acetaminophen should be
infused over 15 minutes.
For patients who are at risk for
hepatotoxicity or renal toxicity,
the nurse should closely monitor
AST and ALT levels and BUN and
creatinine.
Acetaminophen can cause
hematologic reactions. The nurse
should monitor for anemia and
decreased red and white blood
counts.
 exceed 750 mg/dose or
3.75 g/day The antidote for acetaminophen
overdose is N-acetylcysteine given
● Weighing over 50 kg: 650
either orally or IV.
mg IV every 4 hours or
1000 mg IV every 6 PATIENT TEACHING:
hours; not to exceed 4 Instruct patients to never take
g/day more than 4,000 mg of
acetaminophen per 24 hours. This
● Infuse IV over at least 15
includes all forms of
minutes
acetaminophen and
acetaminophen-containing
products.
Pediatric dosage

Do not take acetaminophen with

● Children younger than 2
alcohol due to the risk of liver
years of age: Safety and
toxicity.
efficacy not established

● Children 2-12 years of Educate that acetaminophen can

age: 12.5 mg/kg IV every increase anticoagulant effects. If
4 hours or 15 mg/kg IV the patient is taking warfarin,
every 6 hours; not to acetaminophen can increase the
risk of bleeding. Teach the patient
exceed 75 mg/kg/day
to monitor for bruising and signs
● Children 13 years or of bleeding, and to prevent the
older: risk of injury.

● Weighing less than 50 kg:

Acetaminophen may not be safe
12.5 mg/kg IV every 4
for children under the age of 2.
hours or 15 mg/kg IV Always discuss with a healthcare
every 6 hours; not to provider first. Acetaminophen
exceed 750 mg/dose or comes in preparations and doses
3.75 g/day. for children such as Children’s
Tylenol liquid. Always use the
appropriate dropper or measuring
cup provided when administering
to children.

Keep out of reach of children to

prevent poisoning.

Store at room temperature.

Suppositories should be stored in
the refrigerator.

Acetaminophen may be taken

with or without food.

Group 1
Esquibal, Shanthal
Estac, Cyra
Escosio, Irish
Espiritu, Sheena
Estigoy, Mary Ruth
Estrada, Princess Joy
Fabia, Ginia
Ferrer, Hannah Grace