RAD RLE Guide -Written Requirements

Name of Student : Angelo M. Lenejan Section : BSN2 A7

Concept : Maternal and Health Nursing (RLE)

Name of Clinical Instructor : Ms. Rhea Rica Monteflacon

Patients Data:
Name: Grace Marie Torres Renegado Nationality: Filipino
Gender: Female
Religion: Roman Catholic
Birth Date: January 8, 1994
Birth Place: Talisay City Source of Data:
Age: 26
Date & Time of Admission: 6/17/20,15:09 AM
Address: Talisay City
Educational Level : Attending Physician: Dr. Ubal
Marital Status: Married
Diagnosis:
Occupation: Businesswoman

Chief Complaint: Watery Vaginal Discharge

LMP : 9/13/19
AOG : 39 4/7 weeks
EDC :
VITAL SIGNS: BP= 130/80 mmHg Temperature= 37.1 Pulse Rate= 92 RR = 24
O2 Saturation= 98% Weight: 117 lbs

Brief History Upon Admission:

G1PO

LMP: 9/13/19

AOG: 39 ⁴/₇ weeks

EDC: 6/20/20

GDM- diet controlled Epilepsy

S: 5 hours PTA, Patient noted sudden onset of watery vaginal discharges, clear associated with intermittent hypogastric pain,
every 5-10 minutes thus consult.

Abdomen:

FH – 20 cm

FHT – 140

EFW – 2, 945 gms

6 cm dilated. 80% eff.

HPI: 5 hours PTA, patient noted to trace intermittent leaking hypogastric Pain radiating at the back.

P: Admit

Admitting Diagnosis: ___________________

SY 21-22 Page 1

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

INTRODUCTION:

Patient G, 26 years old, lives at Pook, Talisay City, Cebu. She is admitted due to labor pains, she is 6 cm dilated,
G₁P₁ PU 39 ⁴/₇ weeks AOG, Cephalic in labor, PROM. She reported increased of appetite and thirstiness, both are
indications of gestational diabetes. Aside from gestational diabetes our patient also had history of epileptic seizure,
and is currently taking maintenance medication for epilepsy. According to the cbc, lab results shows that she have
signs that indicates that she may have infection due to increase levels of WBCs count and decreased levels of RBC
count. Gestational diabetes is a type of diabetes that is first seen in a pregnant woman who did not have diabetes
before she was pregnant. Some women have more than one pregnancy affected by gestational diabetes.
Gestational diabetes usually shows up in the middle of pregnancy. Doctors most often test for it between 24 and 28
weeks of pregnancy. Often gestational diabetes can be controlled through eating healthy foods and regular
exercise. Sometimes a woman with gestational diabetes must also take insulin. Epilepsy is a central nervous
system (neurological) disorder in which brain activity becomes abnormal, causing seizures or periods of unusual
behavior, sensations, and sometimes loss of awareness. Anyone can develop epilepsy. Epilepsy affects both males
and females of all races, ethnic backgrounds and ages. Seizure symptoms can vary widely. Some people with
epilepsy simply stare blankly for a few seconds during a seizure, while others repeatedly twitch their arms or legs.
Having a single seizure doesn't mean you have epilepsy. At least two unprovoked seizures are generally required
for an epilepsy diagnosis.
SOURCES:
Gestational Diabetes. (2002, January 25). WebMD. https://www.webmd.com/diabetes/gestational-diabetes#:
%7E:text=Gestational%20 diabetes%20is%20a%20condition,two%20classes%20of%20gestational%20diabetes.
Epilepsy - Symptoms and causes. (2020, May 5).
Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/epilepsy/symptoms-causes/syc-203 50093#:
%7E:text=Epilepsy%20is%20a%20central%20nervous,and%20sometimes%20 loss%20of%20awareness.
Placenta - organ that develops in the uterus during pregnancy. It provides oxygen and nutrients to the
growing baby and removes waste products from the baby’s blood.

Umbilical Cord - conduit between the developing embryo of the fetus and the placenta. It is loaded with
stem cells, they can treat cancer and blood diseases like anemia and some immune system disorders
which disrupt the body’s ability to defend itself.

Uterus - it is an inverted pear-shaped muscular organ located between the bladder and the rectum. It
functions to nourish and house a fertilized egg until the fetus is ready to be delivered.

Amniotic Sac - it is also known as the bag of water, it is a thin but tough transparent pair of membranes
that hold a developing embryo until shortly before birth.
Amniotic Fluid - protective fluid contained by the amniotic sac of a gravid amniote. It serves as a cushion
for the growing fetus and also serves to facilitate the exchange of nutrients, water and biochemical
products between mother and the fetus.

Cervix - cylinder-shaped neck of tissue that connects the vagina and uterus. It acts as the door to the
uterus which sperm can travel through to fertilized eggs.

Vagina - it is a muscular canal lined with nerves and mucus membranes. It connects the uterus and cervix
to the outside of the body, allowing for menstruation, intercourse, and childbirth
Laboratory Test
Type of exam Patient’s Normal Significance /
Interpretation
Result Values

Urine COLOR: Yellow PALE YELLOW- NORMAL

Analysis TRANSPARENCY: Hazy YELLOW CLEAR- NORMAL
SPECIFIC GRAVITY: CLOUDY 1.005- NORMAL
1.010 pH: 6.5 1.025 pH 7.3-7.4 ACIDIC/LOW
ALBUMIN: Trace NEGATIVE
NORMAL
KETONE: 2+ BLOOD: NEGATIVE
POSITIVE
1+ GLUCOSE: Negative NEGATIVE
NEGATIVE POSITIVE
NITRITE: Negative
NEGATIVE NORMAL
BILIRUBIN: Negative
NEGATIVE NORMAL
UROBILINOGEN:
NEGATIVE NORMAL
Normal WBC: 1-4/HPF
0-3/HPF 0-4/HPF NORMAL
RBC: 1-3/HPF
FEW/SMALL NORMAL
EPITHELIAL CELLS:
AMOUNT NORMAL
FEW MUCUS FEW/SMALL
THREADS: RARE FEW
AMOUNT NONE
BACTERIA: MODERATE NORMAL
FEW

The urinalysis shows low levels of pH; thus the patient is currently having slightly acidic urine, this may signify
kidney problems. Also urine shows positive signs of ketone and blood which further support our claim that she
may be having kidney problems.
 Type of exam Patient’s Normal Significance /
Interpretation
Result Values

CBC WBC: 11.24 4.40-11.00 SLIGHTLY HIGH

NEU: 81.30 1.80-7.80 HIGH

LYMP: 11.80
1.00-4.80 HIGH
MON: 6.10
0.00-1.00
EOS: 0.50 HIGH

BAS: 0.30 0.00-0.40

HIGH
RBC: 3.62 0.00-0.20
HIGH
HGB: 11.50
4.50-5.10
HCT: 34.00 LOW
12.30-15.30
PLT: 132.00 LOW
35.90-44.60
MCV: 93.90
LOW
MCH: 31.70 150.00-400.00
LOW
MCHC: 80.00-96.00
33.80 NORMAL
27.50-33.20
RDW-CV:
NORMAL
32.00-36.00
14.30
11.60-14.80 NORMAL
MPV: 10.00

PDW: 17.30 6.00-11.00 NORMAL

PCT: 0.13 NORMAL

11.00-22.00

0.15-0.40 NORMAL

44.00-140.00 NORMAL

18.00-50.00 LOW

LOW

Base on the results, the patient shows high levels of WBC which indicates that she may having an infection; our patient also
shows low RBC count which supports our claim that she is having an infection.
Diagnostic Test
Date Type of Test Impression Interpretation

5/13/2020 Ultrasound -Single, live, Patient’s impression

intrauterine pregnancy shows generally non-
in cephalic alarming results
presentation with
average ultrasound age
of approximately 35
weeks and 3 days of
gestation. -placenta
posterior high lying.
Grade 2-3 -Amniotic
Fluid volume-
adequate.

Problem List

Number of Focus / Nursing Diagnosis

Priority

1 Imbalance nutrition: less than body requirments related to iron deficiency anemia

2 Risk of infection related to rapture of amniotic membrane as evidenced by watery vaginal discharge

3 Knowledge Deficit
Drug Study

Drug Mechanism of Indication Contraindica Side Effects Adverse Nursing

Action tion Effects Responsibiliti
es
Generic name: It modulate the Levetiraceta Levetiracetam •Behavioral •Proteinuri • Ensure
Levetiracetam synaptic m is is Abnormalitie s a•toxic patient is well
neurotransmitte indicated contraindicat and Psychotic epidermal hydrated
Brand name: r release with Partial ed in patients Symptoms •necrolysis before and
Spritam through binding onset with •Somnolenc e •Drug during
to the synaptic seizure, levetiracetam and Fatigue Reaction administration.
Classification: vesicle protein Myoclonic hypersensitivi •Anaphylaxis with •Monitor fluid
SV2A in the Seizures In ty. and Eosinophilia
Racetam balance
brain. Patients Anaphylaxis Angioedema and
anticonvulsant closely.
With and •Serious Systemic
Juvenile angioedema Dermatologic Symptoms •Assess and
Myoclonic have al Reactions (DRESS) document any
Dosage: - Epilepsy and occurred •Coordinatio n •Stevens-Jo signs of seizure
tablet 200 mg Primary during Difficulties hnson activity.
-oral solution Generalized treatment. •Hematologi c syndrome • •Unopened
100 mg/L - Tonic-Clonic Abnormalitie acute vials should be
injectable Seizures. s• Increase in generalized stored at room
solution 100 Blood exanthemat temperature
mg/L Pressure ous (25ºC) •Discard
pustulosis unused
(AGEP) portions of
•suicidal opened vials.
Route: PO, ideation •Monitor
IV, IM •erythema Renal function
multiforme
and Full Blood
•pancytope
Count •
nia
•agranuloc Monitor liver
ytosis function test if
•hepatic indicated
failure necessary.
•pancreatiti •Monitor &
s•anaphylac notify
toid reaction physician of
•angioede difficulty with
ma gait or
•anaphylac coordination.
tic shock •Monitor for
•rhabdomy changes in
olysis phenytoin
blood levels
with
coadministered
drugs. • Assess
for any suicidal
or any
psychotic
 thoughts and
document
properly.

Drug Mechanism of Indication Contraindica Side Effects Adverse Nursing

Action tion Effects Responsibilitie
s
Generic Folic acid, as it Folic acid, Folic acid, •Rash a•naphylactoid •Administer
name: Folic is USP is USP is •itching/s reactions orally if at all
Acid biochemically effective in contraindicate welling •bronchospas possible. With
inactive, is the d in patients (especiall y of m, erythema severe GI
converted to treatment of who have the face/tong •confusion malabsorption
Brand name: tetrahydrofolic megaloblasti shown ue/throat )•diz •depression or very severe
Folvite acid and c anemias previous ziness •excitability disease, give
methyltetrahyd due to a intolerance to •trouble •rash • pruritus IM, IV, or
r ofolate by deficiency of the drug. breathing •malaise subcutaneousl
Classification :
dihydrofolate folic acid, •dysgeusia y. •Test using
Vitamins reductase USP (as •anorexia Schilling test
(DHFR). may be •nausea, and serum
These folic seen in •flatulence vitamin B12
Dosage: acid tropical or •irritability levels to rule
Tablet congeners are nontropical out pernicious
800mcg transported sprue) and anemia.
across cells by in anemias Therapy may
receptor- of nutritional mask signs of
mediat ed origin, pernicious
Route: PO endocytosis pregnancy, anemia while
where they are infancy, or the neurologic
needed to childhood. deterioration
maintain continues.
normal •Use caution
erythropoiesis, when giving
synthesize the parenteral
purine and preparations
thymidylate to premature
nucleic acids, infants. These
interconvert preparations
amino acids, contain benzyl
methylate alcohol and
tRNA, and may produce
generate and a fatal gasping
use formate. syndrome in
Using vitamin premature
B12 as a infants.
cofactor, folic •Monitor
acid can patient for
normalize high hypersensitivit
homocysteine y reactions,
levels by especially if
remethylation drug
of previously
homocysteine taken. Keep
to methionine supportive
via methionine equipment
synthetase and
 emergency
drugs readily
available in
case of
serious
allergic
response

Drug Mechanism Indication Contraindic Side Adverse Nursing

of Action a tion Effects Effects Responsibilities
Generic Carboprost Failure of Acute pelvic •mild •Vomiting •Monitor frequency,
name: is a synthetic expulsion inflammator fever that •diarrhoea duration, and force
Carboprost prostaglandi of the fetus y disease; may come •nausea of contractions and
tromethamine n. It binds during the active and go •transient uterine resting tone.
the course of cardiac, •chills fever •flushing •Notify physician or
Brand name: prostaglandi treatment pulmonary, •numbnes •increased BP other health care
Hemabate n E2 by another renal or s •tingly •bronchospas professional if
receptor, method, hepatic •feeling m •dyspnoea contractions are
causing premature disease •nausea •pulmonary absent or last more
myometrial rupture of •diarrhea edema. than 1 min. •Monitor
Classification: contractions, membrane •cough temperature, pulse,
Prostaglandin causing the s, •headach and BP periodically
Analog induction of postpartum e •breast throughout course of
labour or the hemorrhag pain or therapy. Large dose
expulsion of e. tendernes may cause
Dosage: 250 the placenta. s hypertension.
mcg/mL •menstrua •Auscultate breath
l type pain sounds. Wheezing
•ringing in and sensation of
Route: IM your ears. chest tightness may
indicate
hypersensitivity
reaction. •Assess for
nausea, vomiting,
and diarrhea.
Vomiting and
diarrhea occur in
approximately two-
thirds of patients.
Premedication with
antiemetic and
antidiarrheal is
recommended.
•Monitor amount and
type of vaginal
discharge. Notify
physician or other
health care
professional
immediately if
symptoms of
hemorrhage
(increased bleeding,
hypotension, pallor,
 tachycardia) occur.

Nursing Care Plan

Assessmen Nursing Scientific Planning Intervention Rationale Evaluation

t Diagnosis Analysis
Subjective: Sudden During Short term: 1. Assess and 1. To help in Short term:
“Permi increase of pregnancy, After 8 hours record dietary evaluating After 8 hours of
nalang ko appetite some women of nursing pattern and client’s nursing
gigutom og and
gi-uhaw” as thirstiness develop high intervention caloric intake understanding intervention
verbalized related to blood sugar the patient using a 24-hour and/or the patient was
by the Gestational levels. This will be: • to recall. compliance to a able: • to attain
patient. Diabetes condition is attain 2. Assess strict dietary knowledge
“intermittent as known as knowledge understanding regimen. 2. It is about
hypogastric evidenced gestational about of the effect of proven that gestational
pain by “Permi diabetes gestational stress on stress can diabetes. •to
hydrating to nalang ko
mellitus (GDM) diabetes. • diabetes. Teach increase serum feel optimistic
the back gigutom og
or gestational able to feel patient about blood glucose after knowing
every 5-10 uhaw” as
minutes.” verbalized diabetes. optimistic stress levels, creating that gestational
as by the Gestational after management variations in diabetes will
verbalized patient. diabetes knowing and relaxation insulin later on
by the typically that measures. requirements. diminished
patient. develops gestational 3. Instruct 3. People with after
Objective: • between the diabetes will client to drink 4 diabetes have pregnancy. • to
Patient 24th and 28th later on liters of water an increased learn the
noted with weeks of diminished in a span of 6 risk of practices that
sudden pregnancy.Acc after hours. dehydration as helps on
onset o rding to the pregnancy. • 4. Weigh the high blood regulating
watery Centers for able to learn client every glucose levels blood sugar
vaginal Disease Control the practices prenatal visit. lead to levels while
discharges. and that helps Encourage the decreased being pregnant.
• Patient Prevention, it’s on client to hydration in the Long term:
positive for
estimated to regulating periodically body. 4. Weight After 4 days of
GDM. •
occur in 2 to 10 blood sugar monitor weight gain serves as nursing
Patient
positive for percent of levels while at home an indicator for intervention
epilepsy. pregnancies in being between visits determining the patient was
VS BP: the United pregnant. 5. Instruct the caloric able: •to
130/80 States. If you Long term: client to adjustments. maintain the
mmHg RR: develop After 4 days consurich in 5. High protein advised
24 bpm gestational of nursing protein such as foods are specified diet.
WBC: 11.24 diabetes while intervention milk, egg, and importantduring •to adjust how
RBC: 3.62 you’re the patient meat pregnancy, it many yads of
pregnant, it will be: • productsme helps with the walking she is
doesn’t mean able to food development of going to
that you had maintain the 6. Advise fetus in the dodepending
diabetes before advised patient to as womb. 6. Eating on the bodily
your pregnancy specified much as fruits and state she is in.
or will have it diet. possible get vegetables •to relax and
afterward. But •able to carbohydrates provide not only stay calm now
gestational adjust how in fruits and carbohydrate that she is
Short term: many yards vegetables such but also educated with
After 8 hours of of walking as apple, vitamins and her condition
nursing she is going oranges, minerals that regarding to
intervention to do grapes, help for the GDM.
the patient will depending watermelon, development of
be: • to attain on the pear and the fetus and
knowledge bodily state cucumber. mother.
about she is in. 7. Encourage
gestational •able to client to walk a 7. Constant
diabetes. • able relax and 20 yards back movement can
to feel stay calm and fort at least help regulate
optimistic after now that she 2 times a day blood glucose
knowing that is educated during 6:00 to levels, doing it
gestational with her 7:00 AM. in the morning
diabetes will condition 8. Advise client also exposes the
later on regarding to to eat filling client to light
diminished GDM. snacks such as sunlight that
after sandwiches and can help with
pregnancy. • fruits 3 hour vitamin D
able to learn post meal. production. 8.
the practices 9. Monitor Eating very
that helps on blood serum frequent small
regulating levels every meals improves
blood sugar morning until insulin function.
levels while discharge. 9. Detects
being pregnant. 10. Assess impending
Long term: client for ketoacidosis;
After 4 days of vaginal determines
nursing bleeding and times of the day
intervention abdominanl client prone to
the patient will tenderness. hyperglycemia
be: • able to 10. Vascular
maintain the changes
advised associated
specified diet. with diabetes
•able to adjust place client at
how 1. Assess risk for
and record abruption of
placenta
dietary pattern
and caloric
intake using a
24-hour recall.
2. Assess
understanding
of the effect of
stress on
diabetes. Teach
patient about
stress
management
and relaxation
measures. 3.
Instruct client
to drink 4 liters
of water in a
span of 6
hours. 4. Weigh
the client every
prenatal visit.
Encourage the
client to
periodically
monitor weight
at home
between visits.
5. Instruct the
client to
consume food
1. To help in
evaluating
client’s
understanding
and/or
compliance to
a strict dietary
regimen. 2. It is
proven that
stress can
increase serum
blood glucose
levels, creating
variations in
insulin
requirements.
3. People with
diabetes have
an increased
risk of
dehydration as
high blood
glucose levels
lead to
decreased
hydration in
the body. 4.
Weight gain
serves as an
indicator for
determining
caloric
adjustments. 5.
High protein
foods are
important
Short term:
After 8 hours of
nursing
intervention
the patient was
able: • to attain
knowledge
about
gestational
diabetes. •to
feel optimistic
 after knowing
that gestational
diabetes will
later on
diminished
after
pregnancy. • to
learn the
practices that
helps on
regulating
blood sugar
levels while
being pregnant.
Long term:
After 4 days of
nursing
intervention
the patient was
able: •to
maintain the
advised
specified diet.
•to adjust how
many yads of
walking she is
going to do
diabetes does
raise your risk
of developing
type 2 diabetes
in the future. If
poorly
managed, it
can also raise
your child’s risk
of developing
diabetes and
increase the
risk of
complications
for you and
your baby
during
pregnancy and
delivery.

NURSING SCIENTIFI NURSING

DEFINING PLAN OF
DIAGNOSI C INTERVENTIO RATIONALE
CHARACTERISTICS CARE
S NURSING CARE PLANNS2
ANALYSIS
SUBJECTIVE: Pain Preterm SHORT INDEPENDENT
Patient noted related to labor TERM: 1.Monitor 1. Reflects
soaked preterm occurs -After 4 maternal and effectivenes
underwear,hypogast labor during the hours of fetal vital s of
ric pain contraction end of interventio signs. intervention
radiating to s week 37 of n, the 2.Using nursing s.
lumbosacral area. gestation. patient comfort 2. Relieves
Women pain measures such muscle
having decreases. as changes of
tension and
persistent Was able linen and
fatigue.
uterine to take position, back
3. Nifedipine
OBJECTIVE: contraction action rubs, and
Increased vaginal regarding may be
s (four therapeutic
discharge the touch. irritating to
every 20
VS: underlying 3.Encourage the oral
minutes) is
BP: 110/70 considered problem on routine cavity in
HR: 80 to bein hypogastric inspection of which case
RR: 19 labor. pain. mucous it should be
TEMP: 36.8 Symptoms membranes for swallowed
02 SAT: 98% include ulceration or whole.
increased reaction to 4. Side-lying
vaginal LONG chewing of position
discharge; TERM: nifedipine, if improves
uterine -After 2 used. uterine
contraction days of 4. Expedite the blood flow
s; and interventio admission and may
intestinal n, the process and decrease
cramping. patient was initiate bedrest uterine
able to for client, using
recover irritability.
lateral 5. Helps client
and was recumbent
able to refocus,
position
relief pain. attention
5.Teach
decreases
relaxation
techniques muscle
(e.g., deep tension,
breathing reduces
exercises, perception
visualization, of
guided discomfort
imagery, soft and
music). promotes a
sense of
COLLABORATI control.
VE
Reference: 1.Emphasize 1.To prevent if
necessity of the patient is still
taking experiencing pain
antivirals or 2.To relieve pain
antibiotics, as 3.Provides
directed by the elements
doctor. necessary for
 2. Refer to the tissue
physician about regeneration or
the client if the healing
infection is still Reference:
severe after
the nursing
interventions
done
3. Refer to a
nutritionist
dietician to
encourage
patient to eat a
balanced diet.

Reference:

SCIENTIFIC
DEFINING NURSING NURSING PLAN
ANALYSIS CAREOFPLAN NURSING
1 RATIONALE
CHARACTERISTICS DIAGNOSIS CARE INTERVENTIONS
SUBJECTIVE: Risk for Vaginal SHORT INDEPENDENT 1.Aseptic
-Pt complains of maternal discharge TERM: 1.Monitoring for technique
having a watery infection ebbs and After 4 hrs. signs of infection, decreases the
vaginal discharge. related to flows of nursing such as fever, chances of
rupture of throughout a intervention pain, increased transmitting or
amniotic woman’s the patient
fetal heart rate, spreading
membranes menstrual will be able
as evidenced cycle due to to
and/or laboratory pathogens to
OBJECTIVE: tests.
by watery a fluctuation understand or between
BP: 110/70
vaginal in hormone the causative 2.Maintain strict patients.
HR: 85
RR: 19 discharge. level. Once factors and asepsis for Interrupting
T: 36.8 the woman appropriate dressing the chain of
02 Sat: 98% become interventions changes, wound infection (see
Weight: 117 lbs pregnant, care, intravenous image above)
hormones therapy, and is an effective
continue to LONG catheter handling way to
play a role in TERM: 3. Assess for the prevent the
the changes After 3 days:
to your
presence, spread of
vaginal existence of, and infection.
-Patient will be history of the 2.Taking of
discharge.
However,
able to common causes antivirals or
alongside verbalize of infection antibiotics, as
with normal understanding 4. Assess the directed may
vaginal of individual intactness of cure the
discharges causative or amniotic infection.
there are also risk factors membranes 3. These
some signs of
5. Assess factors
abnormal Identify
discharge immunization represent a
interventions status and break in the
like; yellow,
to prevent or history body’s normal
green or gray
color, strong reduce risk of first line of
and foul odor infection defense and
 accompanied COLLABORATIVE may indicate
by redness 1.Emphasize an infection.
and itching or necessity of 4. Prolonged
vulvar taking antivirals rupture of
smelling. or antibiotics, as amniotic
directed by the membranes
doctor. before delivery
2. Refer to the puts the
Reference:
physician about mother and
the client if the neonate at
infection is still increased risk
severe after the for infection.
nursing 5. People with
interventions incomplete
done immunizations
3. Refer to a may not have
nutritionist sufficient
dietician to acquired
encourage active
patient to eat a immunity.
balanced diet. 1. To prevent
if the client is
Reference: still having an
infection
2. To treat
bacterial
infections
3. To reduce
risk of
infection

Reference:

FDAR

Date Focus Time DAR

6/17/2 Receiving 5:09 D> Received Px awake and lying in bed. Patient shows restlessness and evidence of
0 Assessment am discomfort.

D> Patient noted soaked underwear, onset of watery vaginal discharges, associated with
hypogastric pain

Risk for Infection

related to vaginal A> Maintain strict asepsis for dressing changes, wound care, intravenous therapy, and
8:30
discharges catheter handling.
am
Emphasize necessity of taking antivirals or antibiotics, as directed

1:00 R> Patient identified interventions to prevent or reduce risk of infection

pm Patient in supine position, appears to be on a good mood.

Discharge Planning (SAMPLE)

DATE FOCUS TIME DAR

D: With discharge order from
attending physician Dr.Ubal

Patient shows improve well-being

Patient with epilepsy and GDM was
admitted because she was having a
watery discharge. Later on, she
delivered a healthy baby girl. No
complications was noted during the
labor but she is advised to take
medications as indicated.
● Patient’s vital signs: BP: 130/80,
HR: 92, RR: 24, Temp: 37.1, O2 Sat:
98%

A: •Stress importance of well-

balanced diet, such as protein-rich
foods, and adequate fluid intake.
•Instruct to increase fluid intake at
least three liters a day.
•Encourage patient to eat lactation
Medication:
•Cefuroxime (Altoxime) 500 mg 1
tablet twice a day orally must be taken
for 6 days.
•Tramadol + Paracetamol (Altotram)
37.5mg/325 mg tab 1 tab three times
a day as needed for pain.
•Multivitamins + Iron (OB CARE) 1 cap
once a day must be taken for 3
months.
•Calcium (OSTEO-D) I tab once a day
must be taken for 3 months.
•Lactulose 30 ml must be taken orally
once a day during bed time for 2
weeks.

Environment:

•Be in a setting with less stressors in

which she can relax properly to
recover energy lost during labor.
• Maintain a clean and healthy
environment. Stay away from
hazardous areas or discard things that
could be a hazard within the area.
• Have a supportive environment.

Treatment:
• Inform patient that she has to follow
up cureent status via call/viber to OB
department phone after 1 week. •
 Inform patient to report any side
effects and adverse reactions to the
take home medications as indicated
by the healthcare provider.

Health Teaching:
•All medications must be taken
accordingly to avoid nausea,
dizziness and other adverse side
effects that may lead to toxicity

Bibliography (a summary of all the resources used)

https://www.google.com/search?
q=anatomy+and+physiology+of+womb&rlz=1C1CHBF_enPH978PH978&oq=anatomy+&aqs=chrome.1.
69i57j69i59j46i131i433i512j0i131i433i512j0i433i512j0i512j69i60l2.3726j0j7&sourceid=chrome&ie=U
TF-8
https://www.google.com/search?
q=what+is+watery+vaginal+discharge&rlz=1C1CHBF_enPH978PH978&oq=what+is+watery+vaginal+dischar
ge&aqs=chrome..69i57.11324j0j7&sourceid=chrome&ie=UTF-8

https://www.google.com/search?
q=levetiracetam&rlz=1C1CHBF_enPH978PH978&oq=leverira&aqs=chrome.1.69i57j0i10i433j0i10i131i433j0
i10l4j0i10i433j0i10l2.6270j0j7&sourceid=chrome&ie=UTF-8

https://www.google.com/search?
q=levetiracetam+classification&rlz=1C1CHBF_enPH978PH978&ei=je86YsTvEpKM2roPsNaYsAE&ved=0ahUK
EwiE6pfO_Nv2AhUShlYBHTArBhYQ4dUDCA4&uact=5&oq=levetiracetam+classification&gs_lcp=Cgdnd3Mtd2
l6EANKBAhBGABKBAhGGABQAFgAYMcCaAFwAXgAgAEAiAEAkgEAmAEAwAEB&sclient=gws-wiz

https://www.google.com/search?
q=folic+acid+classification&rlz=1C1CHBF_enPH978PH978&ei=je86YsTvEpKM2roPsNaYsAE&oq=folic+
+classification&gs_lcp=Cgdnd3Mtd2l6EAEYADIGCAAQBxAeMgYIABAHEB4yBggAEAcQHjIGCAAQBxAeMgYIA
BAHEB4yBggAEAcQHjIGCAAQBxAeMgYIABAHEB4yBggAEAcQHjIGCAAQBxAeSgQIQRgASgQIRhgAUABYrAdgz
BJoAHABeACAAfcBiAGnCZIBBTAuMy4zmAEAoAEBwAEB&sclient=gws-wiz
 https://www.google.com/search?
q=carboprost+tromethamine+classification&rlz=1C1CHBF_enPH978PH978&ei=0u86Yp5Orc_aug_Wz4CoBg&
ved=0ahUKEwie__ju_Nv2AhWtp1YBHdYnAGUQ4dUDCA4&uact=5&oq=carboprost+tromethamine+classificati
on&gs_lcp=Cgdnd3Mtd2l6EANKBAhBGABKBAhGGABQAFgAYKEGaAFwAXgAgAEAiAEAkgEAmAEAwAEB&scli
ent=gws-wiz