RAD RLE Guide -Written Requirements

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

Concept : MCN2 RLE

Name of Clinical Instructor : Ms. Rhea Rica Montefalcon

Patients Data:
Name: Kaille Abad Santos Nationality: Filipino
Gender: Female
Religion: Roman Catholic
Birth Date: May 16, 1992
Birth Place: Source of Data: ______________________ Date &
Age: 28 Time of Admission: 4/13/20- (1:29 PM
Address: 96 F Llamas St. Cebu City
Attending Physician: Dr. Coja
Educational Level : College Graduate
Marital Status: Married Diagnosis:
Occupation: Teacher

Chief Complaint: Watery Vaginal Discharge

LMP : July 08,2019

AOG : 37 ²/₇/ Utz
EDC : April 15,2020
VITAL SIGNS: BP= 90/60 Temperature= 36.5 Pulse Rate= 96 RR = 19 O2 Saturation: 98 %
Weight:63kg

Brief History Upon Admission:

G₂P₁ (1101)

37 ²/₇ weeks AOG

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

Admitting Diagnosis: ___________________

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

The watery discharge is a typical pregnancy side effect and is once in a while a reason for concern. So, focus on
what's normal for you and watch for any changes. In the event that your release begins to look or smell changed, or
on the off chance that you presume that it very well maybe your water breaking, let your doctor know

PLACENTA- it provides oxygen and nutrients to your growing baby and removes waste products from your
baby’s blood.

UMBILICAL CORD- this allows structure allows for the transfer of oxygen and nutrients from the maternal
circulation into fetal circulation.

FETUS- it obtains oxygen and nutrients from the mother through the placenta and the umbilical cord.

UTERUS- where the implantation and nourishment of the fertilized ovum takes place. It helps pushing out the
baby during birth through muscle contraction.

AMNIOTIC SAC- kit hold the developing embryo (and later fetus) until shortly before birth.
CERVIX- it is to allow the flow of menstrual blood from the uterus into the vagina, and direct the sperms into
the uterus during intercourse.
BLADDER-it can contract or relax depending autonomic function of bladder(internal) that can prevent the urine
to urine out.

VAGINA- provides a passageway for blood and mucosal tissue from the uterus during a woman’s montly
period; receives the penis during sexual intercourse and holds the sperm until they pass the uterus; provides
passageway to childbirth.

ANUS- the lining of the upper anus is able to detect rectal contents and let to know whether the contents are
liquid, gas, or solid
Laboratory Test
Date and Results Normal Values Interpretation
Examination

 Urinalysis Color: Yellow PALE YELLOW/YELLOW  The result is with normal

Clarity: Cloudy CLEAR/TRANSPARENT range. The Px is not at risk
Specific 1.005-1.025 4.5-8.0 acquiring infections.
Gravity: 1.010 NEGATIVE NEGATIVE
pH: 7.0 NEGATIVE NEGATIVE
Albumin: NEGATIVE NEGATIVE
NEGATIVE NEGATIVE 0.5-1 mg/dl
Ketone: ≤2-5 HPF ≤2 Few/Small
NEGATIVE amount Few/Small
Blood: 4+ amount
Glucose:
NEGATIVE
Nitrite:
NEGATIVE
Bilirubin:
NEGATIVE
Urobilinogen:
NORMAL
WBC: 0-2
/HPF RBC:
TNTC/HPF
Epithelial Cells:
FEW Mucus
Threads:
RARE
Bacteria: FEW

WBC:9.0
 hematology NEU:66.8/5.99  4.4-11.0 The result is with normal range.
LYM:23.9/2.14  37.0-80.0/1.8-7.8 The Px is not at risk acquiring
MON:8.1/0.73  10.0-50.0/1.0-4.8 infections.
EOS:0.9/0.08  0.0-12.0/0.0-1.0
BAS:0.3/0.03  0.0-7.0/0.0-0.4
RBC:4.11  0.0-2.5/0.0-0.2
HGB:12.3  4.5-5.1
HCT:12.3  12.3-15.3
MCV:87  35.9-44.6
MCH:30.1  80-96
MCHC:34.4  27.5-33.2
RDW:12.5  32.0-36.0
PLT:293  11.6-14.8
MPV:7.9
 Problem List

Number of Focus / Nursing Diagnosis

Priority

1 Imbalance nutrition: less than body requirements 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

Name of Drug Mechanism of Indication Contraindication Adverse Nursing Responsibilities

Action Reaction
Brand Name: A NSAID agent The drug is used The medication is For the symptoms Before:
Almefen with analgesic, for the treatment contraindicated to of overdose, it Medication should be given
antiinflammator of: Rheumatoid patient with may include: with meals, food or milk to
Generic Name: y and Arthritis, hypersensitivity GI Tract: Severe minimize GI adverse
Mefenamic antipyretic Osteoarthritis, to the drug and its Stomach Pain, GI effects.
Acid properties. It is Dysmenorrhea formula or active ulcers, Bleeding
an inhibitor in Inflammation, ingredients. It also Respiratory: During:
Classification: the action of Fever, Mild to includes patients Dyspnea, Asthma •Assess patients who
Nonsteroidal prostaglandi n Moderate Pain with: and Broncho- develop severe diarrhea, &
anti- synthetase in from various •High Blood constriction vomiting for dehydration
inflammatory which the conditions, and pressure Urinary Tract: and electrolyte balance
drugs (NSAID) symptoms of Gastro-intestina l •An increased risk Change in amount •Monitor outcomes/side
pain are cramps. It is also of bleeding of urine, renal effects after administering
Dosage: 500 temporarily used to decrease •Liver problems impairment. medication
mg/cap reduced. It pain and blood •Chronic Kidney Cardiovascular:
reduces loss from Disease Unusually fast or
After:
hormones that menstrual Monitor blood glucose for
•Pregnancy slow heartbeat.
caused periods. It is (category c) & loss of glycemic control if
Route: Oral CNS Toxicity:
inflammatio n used short term Lactation diabetic.
Administration Convulsions,
and pain in the (7 days or less) •Increased •Educate patient not to
Insomnia,
body. to treat pain in cardiovascular breastfeed while taking
Confusion SIDE
adults and event risk medication.
EFFECTS:
children who are •Tobacco Headaches,
at least 14 years smoking •Long Dizziness, Nausea
old. term use & Vomiting,
increase risk of
serious adverse
events.

Name of Mechanism of Indication Contraindication Adverse Reaction Nursing

Drug Action Responsibilities
Brand Name: Ergonovine This medication is The medication is SIDE EFFECTS: Before:
Ergotrate directly an ergot alkaloid. contraindicated to Gastrointestinal Medication blood
stimulates the It is used to patient with •Nausea pressure, pulse,
Generic uterine muscle prescribed for hypersensitivity to •Vomiting and uterine
Name: to increase post-partum and the drug and its •Abdominal pain response while
Ergometrine force and uterine bleeding. allergic reactions •Diarrhea CNS: taking
Maleate frequency of It helps the uterus to ergot •Headache medication.
contractions. contract back and preparations. •Dizziness •Should be
Contraction of prevents bleeding Contraindicated to ADVERSE administered with
Classification: the uterine wall after childbirth. patients with: EFFECTS care to patients
Ergot around For the •Vascular Disease Cardiovascular: under general
Alkaloids bleeding prevention or •Psychosis •Chest pain anesthesia
vessels at the treatment of During:
•The 1st and 2nd •Palpitation
placental site postpartum or •Assess for history
stage of labor. •Shock &
produces post-abortal of hypersensitivity
Dosage: •High Blood Abnormal Heart
hemostasis. hemorrhage due and allergy
0.2 mg Pressure •During Rhythm
Ergonovine to uterine atony. reactions.
Pregnancy •High Blood
also induces •Avoid prolonged
Route: IM •Spontaneous Pressure ENT:
cervical administration or
Labor •Ringing in the
contractions. concomitant use
•Induction of ears Skin:
The sensitivity of other
Labor •Rashes
of the uterus to vasoconstrictors.
the oxytocic
effect is much After:
greater toward •Monitor amount
the end of and type of
pregnancy. vaginal
The oxytocic discharge.
actions of •Advise patient
ergonovine are not to engage in
greater than its potentially
vascular hazardous
effects. activities until
response to drug
is known

Name of Drug Mechanism of Indication Contraindication Adverse Reaction Nursing

Action Responsibilities
Brand Name: Ferrous sulfate This medication Contraindicated to SIDE EFFECTS: Before:
OB Care facilitates is a multivitamin patients with Gastrointestinal Advise patient to
oxygen and iron product hypersensitivity •Nausea take medicine as
Generic Name: transport via used to treat or to the medication •Vomiting prescribed.
Ferrous SO4 + Hb. It is used prevent vitamin and its active •Constipation •Caution patient
MV as iron source deficiency due to ingredients. •Diarrhea to make position
as it replaces poor diet, certain Contraindicated to •Blackening of changes slowly to
Classification: iron found in illnesses, or patients with: stool ADVERSE minimize
Vitamins and Hb, myoglobin during •Hemo- EFFECTS orthostatic
Minerals/ and other pregnancy. chromatosis Gastrointestinal hypotension.
Anti-anemics enzymes. Vitamins and iron •Iron overload •GI Irritation During:
Hematologic are important syndromes •Epigastric Pain •Instruct patient
Dosage: 1 cap response: building blocks of •Blood Disorders •Abdominal to avoid
Approx. 3-10 the body and (e.g., Hemolytic Discomfort concurrent use of
Route: Oral days (oral). help keep you in anemia) Immune System alcohol or OTC
Administration Peak effect: good health. This •Active peptic Disorders medicine without
Reticulocytotic: medication is ulcer •Regional •Hypersensitivity consulting the
5-10 days; best taken on an enteritis physician.
CNS •Depression
increased Hb: empty stomac h •Ulcerative colitis ranging from
Within 2-4 1 hour before or •Patient receiving lethargy to coma
After:
weeks. 2 hours after •Advise patient to
frequent blood
Majority binds meals consult physician
transfusions
to transferrin if irregular
•Concomitant
and heartbeat,
parental iron
transported to dyspnea, swelling
therapy SPECIAL
the bone of hands and feet
PRECAUTIONS
marrow. and hypotension
Iron storage, Iron
Absorbed occurs.
absorption & GI
mainly in the disease,
duodenum and pregnancy and
upper jejunum. lactation

Nursing Care Plan

ASSESSME NT NURSING SCIENTIFI C PLANNING INTERVENTIO RATIONALE EVALUATION
DIAGNOS IS ANALYSIS N
Subjective :“Hyp Premature Premature Short term: 1. Provide 1. Providing Short term: After
ogastic pain Rupture of rupture of After 8 reassurance to reassurance hours of nursing
every 5 to 10 membrane s membranes hours of the mother by and talking to intervention the
mins” as related to (PROM) is a nursing talking about 8 the mother patient was able:
verbalized by Latent rupture intervention out of 10 will reduce to attain
the patient phase of (breaking open) the patient pregnant maternal knowledge about
Objective: - labor as of the will be: • to women anxiety and premature
Patient noted evidenced membranes attain experiences help the rupture of
with sudden by sudden (amniotic sac) knowledge POM. mother relax. membranes. (Goa
onset of watery onset of before labor about was met) • to feel
discharge. - A: watery begins. If PROM premature 2. Establish 2. Facilitates a sign of relief now
G1P1 (1101) - discharge. occurs before 37 rupture of rapport and cooperation; that she is aware
AOG: 37 2 7 weeks of membranes. accept behavior provides an that premature
weeks - pregnancy, it is • able to feel without opportunity rupture of
potassium level called preterm a sign of judgment. Make for the client membranes is
of 2.88 mmol/L premature relief now verbal contract to leave the common among
rupture of that she is about expected experience pregnant women.
membranes aware that behaviors of with positive Long term: After 4
(PPROM). premature client and nurse. feelings and days of nursing
Rupture of the rupture of enhanced self- intervention the
membranes near membranes 3. Notify the esteem. patient was able:
the end of is common primary care to maintain
pregnancy among provider 3. Sudden proper perineal
(term) may be pregnant assigned if the spike of care and hygiene.
caused by a women. • to temperature temperature is (Goal was met) •
natural learn the goes greater one of the to walk without
weakening of the proper than 38°C indication of assistance of the
membranes or technique (100°C). infection. nurse and
from the force of and ways to Report to S/O. (Goal was
contractions. do a proper 4. Instruct the primary care met) • to adjust
Before term, perineal patient to drink provider her behavior to
PPROM is often care and 4 liters of water immediately. her healing
due to an hygiene. in a span of 8 perineal area by
infection in the Long term: hours. 4. Hydration moving slowly bu
uterus. PROM is a After 4 days plays an constantly. (Goal
complicating of nursing 5. Assess the important role was met)
factor in as many intervention patient from any in keeping
as one third of the patient signs and electrolyte
premature will be: • to symptoms of balances in
births. A maintain infection such as our body
significant risk of proper fever, chills,
PPROM is that perineal vaginal spotting 5. Rupture of
the baby is very care and rapid heart rate membranes
likely to be born hygiene. • to etc. every 4 occurring 24
within a few days walk hours hours before
of the membrane without the surgery
rupture. Another assistance 6. Assess may result in
major risk of of the nurse cervical dilation, chorioamnion
PROM is and S/O. • effacement, and itis prior
development of a to adjust her station every 30 surgical
serious infection behavior to mins. 7. Provide intervention.
of the placental her healing oral and
 tissues called perineal parenteral
chorioamnionitis, area by fluids, as
which can be moving indicated. 8.
very dangerous slowly but Obtain blood
for mother and constantly. cultures if
baby. symptoms of
sepsis are
present.

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

Reference:

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

Reference:
FDAR

DATE/TIME FOCUS DATA, ACTION AND RESPONSE

D: Received patient c̅ an anxious look,

4/03/2020 Vaginal Discharge complaining about the sudden onset watery
vaginal discharge c̅ VS, BP:90/60,RR:19,T:
36.5,SPO2:98%,37 2/7 AOG

A: Health teaching: Advised patient the

watery discharges are normal in pregnancy
especially noticeable in the end of the
pregnancy.

R:Relieved face noted from the Px.

Discharge Planning
5/16/20 Discharges instructions 9:13 am D: With discharge order from attending physician
Dr. Coja

A: S: 5 hours PTA, Patient noted sudden onset of

watery vaginal discharges, clear associated with
intermittent hypogastric pain, every 5-10 minutes
thus consult. BP: 90/60,HR: 96,RR: 19, Temp: 36.5,
O2 Sat: 98%
.

Medication:

 Cefuroxime (Altoxime) 500 mg /cap/ 1

cap BID x 5 days
 Mefenamic Acid (Almefen) 500 mg/cap 1
cap q 6 hours, PRN for pain
 Ferrous SO₄ + MV (OB-CARE) 1 cap OD x
2 months
 Calcium + Vitamin D (OSTEO-D) 1 tab
BID x 2 months
 Vitamin C (Altocee) 1 cap OD x 2 months

Environment: Maintain a clean and healthy

environment. Stay away from hazardous areas or
discard things that could be a hazard within the area.

Treatment: Continue prescribed medication

Bibliography

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.rxlist.com/mefenamic-acid-drug.htm
https://www.drugs.com/cons/ergotrate.html

https://www.google.com/search?
q=ergotrate+classification&rlz=1C1CHBF_enPH978PH978&ei=lHM6YpHOD-eC4-
EP7Yit2A4&oq=ergotrate+clas&gs_lcp=Cgdnd3Mtd2l6EAEYADIGCAAQFhAeMgYIABAWEB4yBggAEBYQHjIGC
AAQFhAeMgYIABAWEB46BQgAEJECOgUIABCABEoECEEYAEoECEYYAFDlAVjrDWDYFmgBcAB4AIABeIgBowS
 SAQMwLjWYAQCgAQHAAQE&sclient=gws-wiz

https://www.tabletwise.net/philippines/ob-care-capsule