RAD RLE

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

Concept : Maternal and Health Nursing II

Name of Clinical Instructor : Ms. Rhea Rica Montefalcon

Patients Data:
Name: Rachel Chiong Mendez Occupation: NA
Gender: Female
Nationality: Filipino
Birth Date: February 23, 1992
Birth Place: 51 Mendez Compound Labangon Street Cebu Religion: Roman Catholic
City
Source of Data:
Age: 28
Address: 51 Mendez Compound Labangon Street Cebu City Date & Time of Admission: 6/17/20, 5:09 AM
Educational Level :
Attending Physician: Dr. Jumao-as
Marital Status: Single
Diagnosis:

Chief Complaint: Watery Vaginal Discharge

AOG :
EDC :
VITAL SIGNS: BP= 120/80 Temperature= 36.4 Pulse Rate= 83 RR 20
O2 Saturation= 98% Weight: 109 lbs

Brief History Upon Admission:

Chief Complaint: : Watery Vaginal Discharge

DDR- Direct to Delivery Room

V/S: BP: 120/80, HR: 83, RR: 20, Temp: 36.4, O2 Sat: 98%

P: Admit

Admitting Diagnosis: ___________________

 Anatomy & Physiology
(This will show a drawing of the organ affected related to the diagnosis of the patient.)
INTRODUCTION:
Patient R is 28 year old patient, she lives on 51 Mendez Compound Labangon St., Cebu City. Patient R went to SWU MC with a
complain of watery vaginal discharge. The patient suffers from watery vaginal discharge. Watery discharge is a totally ordinary
part of pregnancy, and it normally gets heavier as the pregnancy advances. Truth be told, weighty discharge towards the
finish of the third trimester could be an indication that a lady's body is getting ready to start giving birth or getting into labor.
At the point when a lady is expecting, more significant levels of the pregnancy chemical estrogen cause more blood to stream
to the pelvic territory. This expanded blood stream animates the body's mucous layers, which thus causes the additional
discharge. Yet, watery release during pregnancy isn't only a good for nothing manifestation. Leukorrhea gets out dead cells in
the vagina, which keeps up sound microscopic organisms in the birth channel and shield you and your child from disease
numerous women have an expansion in vaginal discharge during pregnancy. Watery release is generally harmless, yet
different kinds of release can be an indication of disease. A call to a specialist is expected in the event that one may encounter
any of the accompanying indications (Taylor M., 2020):

• pain or itchiness in your vulva or vagina

• a green or yellow discharge

• a foul-smelling discharge

• white, cottage cheese discharge

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.

Clinical Manifestations/ Signs and Symptoms:

● Hypogastric pain
● Minimal Whitish Discharge
● Fouls Smell
● Watery Vagina

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 /

Result Values Interpretation

Urine COLOR: YELLOW PALE NORMAL

Analysis TRANSPARENCY:
CLOUDY YELLOW-YELLOW
SPECIFIC NORMAL
GRAVITY: 1.020 CLEAR- CLOUDY
pH: 6.5
ALBUMIN: 1+ 1.005-1.025 NORMAL
KETONE: 1+
BLOOD: 4+ pH 7.3-7.4
LOW
GLUCOSE: 4+
NITRITE: NEGATIVE
NEGATIVE HIGH
BILIRUBIN: NEGATIVE HIGH
NEGATIVE HIGH
UROBILINOGEN: NEGATIVE HIGH
NORMAL NORMAL
WBC: 1-3/HPF NEGATIVE NORMAL
RBC: TNTC/HPF NORMAL
EPITHELIAL NEGATIVE NORMAL
CELLS: FEW HIGH
MUCUS NEGATIVE NORMAL
THREADS: RARE NORMAL
BACTERIA: FEW NORMAL

0-3/HPF NORMAL
 0-4/HPF

FEW/SMALL

AMOUNT

FEW/SMALL

AMOUNT
NONE

COMPLETE WBC: 20.70 4.40-11.00 HIGH

BLOOD COUNT
NEU: 85.2 37.00-80.00 HIGH
LYMP: 8.70 LOW
MON: 4.50 10.00-50.00 NORMAL
EOS: 1.10 NORMAL
BAS: 0.50 0.00-12.00 LOW

RBC: 4.10 0.00-7.00

HGB: 13.30
HCT: 38.90 0.00-2.50
PLT: 220.00

MCV: 95.00 LOW

4.50-5.10
MCH: 32.40 NORMAL
MCHC: 34.10 NORMAL
12.30-15.30
MPV: 7.30
NORMAL
35.90-44.60

150.00-450.00
HIGH
80.00-96.00 NORMAL
NORMAL
27.50-33.20 NORMAL

32.00-36.00
6.00-11.00

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
Name of the Indication/s Side Nursing
Drug Classificati Mechanism Effects/Adverse Responsibilities
on of action Reactions

Before:
Anti- Bind to Treatment of GI: Diarrhea, Determine history
Generic infectives bacterial cell It is effective nausea, antibiotic of hypersensitivity
Name: wall for the associated colitis. reactions to
Cefuroxime membrane, treatment of cephalosporins,
causing cell penicillinase Skin: Rash, pruritus, penicillin’s, and
death. producing urticaria history
Brand Name: Neisseria of allergies,
Altoxime Therapeutic gonorrhea(PP Urogenital: particularly
Effects: NG). Increased serum to drugs, before
Bactericidal Effectively creatinine and BUN, therapy
action treats bone decreased creatinine is initiated.
and joint clearance. Lab tests: Perform
infections, culture and sensitivity
bronchitis, Hemat: Hemolytic tests before initiation
Dosage: meningitis, of
anemia MISC:
500mg/cap gonorrhea, therapy and
Anaphylaxis
otitis media, periodically
pharyngitis/to during therapy if
nsillitis s, indicated. Therapy
Route: P.O sinusitis, may
lower be instituted pending
respiratory test results. Monitor
tract periodically BUN and
infections, creatinine clearance.
Frequency:
BID skin and soft
tissue During:
infections,
urinary tract Inspect IM and IV
infections, and injection sites
Timing: After is used for frequently for signs of
meal surgical phlebitis
prophylaxis,
reducing or
eliminating After:
infection.
Monitor for
manifestations of
hypersensitivity
 Contraindica
tion/s

Hypersensitivit
y to
cephalosporins
and related
antibiotics;
pregnancy
(category B),
lactation
Name of the Mechanism Indication/s Side Nursing
Drug Classification Of Effects/Adverse Responsibilities
Action Reactions
Generic Anti-pyretic Before:
Name: Tramadol is Moderate to Postural
Tramadol + a centrally severe pain. hypotension, resp -Assess for level of
Paracetamol acting opioid depression, pain relief and
analgesic hepatotoxicity, administer prn dose
which binds
Stevens-Johnson as needed but not to
Brand Name: to mu-opioid
syndrome, toxic exceed the
Altotram receptors
and weakly Contraindica epidermal recommended total
tion/s necrolysis, daily dose.
inhibits the
Dosage: reuptake of bradycardia,
norepinephri Acute collapse, allergic -Monitor vital signs
1 tab
ne and intoxication reactions w/ resp and assess for
Route: serotonin. w/ alcohol, symptoms (e.g. orthostatic
PO Paracetamol, hypnotics, dyspnoea, hypotension or signs
a para- centrally- bronchospasm, of CNS depression.
aminophenol acting wheezing,
derivative, analgesics,
Frequency: has
angioneurotic
opioids, or oedema), changes During:
analgesic,
antipyretic
psychotropic in appetite, motor
and weak drugs; weakness, changes -Identify patient
Timing: anti- uncontrolled in mood, activity, -Assess in
q 8 hours inflammator epilepsy. cognitive and administering
y activity. Severe sensorial capacity; the medication o the
Together, hepatic exacerbation of patient
tramadol impairment. asthma, withdrawal -Position client
and Concurrent symptoms (e.g. in comfortable
paracetamol use or w/in 2 agitation, anxiety), position
has faster
wk of skin rash, blood
onset of
discontinuati dyscrasias,
action
compared to on from hypoprothrombinem After:
tramadol MAOIs. ia.
alone and -Document
longer administration on
duration of medication
action -Assess patient 30-
compared to 60 minutes
paracetamol
after administration
alone.
and document
 the patient’s
response to
medication

Name of the Classification Mechanism Indication/s Side Nursing

Drug Of Action Effects/Adverse Responsibilitie
Reactions s
Generic Name: Before:
Multivitamins Vitamins and Treatment of It is GI: Diarrhea, Determine
+ Iron Minerals Multivitamins effective for the nausea, antibiotic history
with iron are treatment of associated colitis. of
Brand Name: used to penicillinase hypersensitivity
OB CARE provide producing Skin: Rash, reactions to
vitamins and Neisseria pruritus, urticaria cephalosporins,
iron that are gonorrhea(PPNG). penicillin’s, and
Dosage: not taken in Effectively treats Urogenital: history
1 cap through the bone and joint Increased serum of allergies,
diet. They are infections, creatinine and particularly
Route: also used to bronchitis, BUN, decreased to drugs, before
treat iron or meningitis, creatinine therapy
PO
vitamin gonorrhea, otitis clearance. is initiated.
deficiencies media, Lab tests:
caused by pharyngitis/tonsillit Hemat: Hemolytic Perform
Frequency: is s, sinusitis, culture and
illness, anemia MISC:
OD lower respiratory sensitivity
pregnancy, Anaphylaxis
poor nutrition, tract infections, tests before
digestive skin and soft initiation of
disorders, and tissue infections, therapy and
Timing: many other urinary tract periodically
conditions infections, and is during therapy if
used for surgical indicated.
prophylaxis, Therapy may
reducing or be instituted
eliminating pending
infection. test results.
Monitor
periodically BUN
and
Contraindication creatinine
/s clearance.

During:
Hypersensitivity to
cephalosporins and Inspect IM and
related antibiotics; IV injection sites
frequently for
 pregnancy signs of phlebitis
(category B),
lactation
After:

Monitor for
manifestations of
hypersensitivity

Nursing Care Plan

DEFINING NURSING SCIENTIFIC NURSING

CHARACTER DIAGNOSI ANALYSIS PLAN OF CARE INTERVENTIO RATIONALE
ISTICS S NS
SUBJECTIVE Risk for Watery Vaginal SHORT TERM: INDEPENDENT
: infection Discharge is usually Patient will be able 1.Monitoring 1.Aseptic technique
N/A related to a clear or to verbaliize for signs of decreases the
vaginal translucent fluid. understanding of infection, such chances of
discharges Glands inside your individual as fever, pain, transmitting or
vagina and cervical causative/ risk
increased fetal spreading
create vagina factors.
discharge to carry
heart rate, pathogens to or
away dead cells and and/or between patients.
bacteria. Healthy, laboratory Interrupting the
OBJECTIVE: normal discharge tests. chain of infection
BP: 120/80 provides (see image above)
HR: 83 lubricantion and is an effective way
RR: 20 prevents your
T: 36.4
to prevent the
vagina and urinary spread of infection.
02 Sat: 98% tract.

LONG TERM:
2.Maintain 2.Taking of
Patient will achieve strict asepsis antivirals or
timely healing, for dressing antibiotics, as
free of changes, directed may cure
complications. wound care, the infection.
intravenous
therapy, and
catheter
handling

3. Assess for 3. These factors

the presence, represent a break
Reference:
existence of, in the body’s
https://www.webm
d.com/women/guide
and history of normal first line of
/vaginal-discharge- the common defense and may
whats-abnormal causes of indicate an
infection infection.

4. Assess the 4. Prolonged

intactness of rupture of amniotic
amniotic membranes before
membranes delivery puts the
mother and
neonate at
increased risk for
infection.

5. Assess 5. People with

immunization incomplete
status and immunizations may
history not have sufficient
acquired active
COLLABORATI immunity.
VE
1. Maintain
strict asepsis for 1. Aseptic technique
dressing decreases the
changes, wound chances of
care, transmitting or
intravenous spreading pathogens
therapy, and to or between
catheter patients. Interrupting
handling. the chain of infection
(see image above) is
2. Ensure that an effective way to
any articles prevent the spread of
used are infection.
properly
disinfected or 2. This reduces or
sterilized before eliminates germs.
use.
3. Knowledge of
3. Educate ways to reduce or
clients and SO eliminate germs
about reduces the
appropriate likelihood of
methods for transmission.
cleaning,
disinfecting, and
Reference:
sterilizing items.
https://nurseslabs.co
m/risk-for-infection/
Reference:
https://nursesla
bs.com/risk-for-
infection/
 DEFINING NURSING NURSING
CHARACTERI DIAGNOSIS NURSING CAREPLAN
SCIENTIFIC PLAN
OF CARE INTERVENTI RATIONALE
ANALYSIS
STICS ONS
SUBJECTIVE: Risk for Bleeding is the SHORT TERM: INDEPENDEN
N/A bleeding loss of blood. It After 6 hrs. of T 1.Information
related to can be external, nursing 1. Educate the about
vaginal or outside the intervention, the at-risk patient precautionary
discharges body, like when client will be able about measures lessens
you get a cut or to identify precautionary the risk for
wound. It can individual risks measures to bleeding.
also be internal, and engage in prevent tissue
or inside the appropriate trauma or 2. These invasive
OBJECTIVE: body, like when behaviors or disruption of devices or
BP: 120/80 you have an lifestyle changes the normal medications may
HR: 83 injury to an to prevent clotting cause trauma to
RR: 20 internal organ. bleeding mechanisms. the mucous
T: 36.4
membranes that
02 Sat: 98% 2. Avoid rectal line the rectum or
suppositories, vagina.
thermometers,
LONG TERM: enemas, 3. These activities
After discharge vaginal may cause trauma
the patient will douches, and to the mucosal
be able to report tampons. linings in the
improvement rectum, nasal
Reference: 3. Limit
about her passages, or upper
https://medlinepl
condition straining with airways.
us.gov/bleeding.h bowel
tml movements, 4. The patient
forceful nose needs to avoid
blowing, situations that may
coughing, or cause tissue
sneezing. trauma and
increase the risk
4. Be careful for bleeding.
when using
sharp objects 5. This helps in
like scissors patient’s assurance
and knives. and calming.
Use an electric
razor for
shaving (not
razor blades).
1. Early evaluation
5. Provide and treatment of
psychological bleeding by a
and emotional health care
support to the provider reduce the
patient. risk for
complications from
COLLABORAT blood loss.
IVE
2. Most herbal
1. Educate the preparations
patient and interfere with
family platelet
members aggregation
about signs of through inhibition
bleeding that of serotonin release
need to be from the platelet.
reported to a Other herbs
health care increase the effect
provider. of antiplatelet and
anticoagulant
2. Educate the medications, thus
patient and increasing the risk
family for bleeding.
members
about limiting 3. Active
the use of participation
herbal encourages fuller
remedies that understanding of
are linked with the rationale and
an increased compliance with
risk for the treatment.
bleeding like
dongquai, Reference:
feverfew, https://nurseslabs.
ginger, ginkgo com/risk-for-
biloba, and bleeding/
chamomile.

3. Tell the
family
members to be
active in
decision-
making about
the treatment
of the patient
at risk for
bleeding.

Reference:
https://nursesl
abs.com/risk-
for-bleeding/
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
ograstic 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.

FDAR

DATE SHIFT FOCUS TIME DATA/ACTION/RESPONSE

 PM Receiving 1:00 pm D>Received Px in a supine position
02/22/2020 assessment awake, afebrile, conscious. VS: BP:
120/80, HR: 83, RR: 20, T: 36.4,
O2sat: 98%. Grimace face noted
on pt. face
A> Established rapport c the pt.
assessed the overall health status
2:50 pm
of the patient; monitored v/s taken
Vaginal and charted
discharge A>Instruct patient on health
teaching regarding proper hygiene.
Advice patient to drink a lot of
water and take a shower
Pain A> encourage the patient
6:00 pm comfortable positioning. Instruct
the patient to a side lying position.
Assess patient to do simple
exercise by standing, walking, and
sitting. Educate patient on
performing breathing technique
during labor
R> Px demonstrate the proper
comfort measure and different
techniques in reducing pain. Patient
is less risk of infection. Relieved
face is noted in pt. face. Verbalize
“I feel relieved and pain free”.

Discharge Planning (SAMPLE)

Date Focus Time DAR

2/24/20 Discharges 6:30 D: With discharge order from attending physician Dr. Dr. Jumao-as
instructions AM

Patient shows improve well-being

● Patient exhibited relevant Low levels of laboratory value such as RBC,

 Patient exhibited relevant normal value HBC, and HCT.

● No signs and symptoms of infection of vagina

● Patient’s vital signs: BP: 120/80, HR: 83, RR: 20, Temp: 36.4, O2 Sat: 98%

A: Stick to healthy diet and exercise regimen

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

Medication: Cefuroxime (Altoxime) 500 mg 1 tab BID x 6 days

Multivitamins + Iron (OB CARE) 1 cap OD x 3 months

Calcium (Osteo-D) 1 tab OD x 3 months

Tramadol + Paracetamol ( Alto-Tram) 1 tab, TID PRN for pain

Methylergometrine Maleate 200 mg 1 amp IM now

Methylergometrine Maleate 125 mcg 1 tab q 4 hours x 6 doses

Environment: Availability of good environmental resources and appropriate

area to recover

Treatment: Continue prescribed medication

Health Teaching: Get regular sleep

Instruct the patient to follow the doctor's prescription and avoid

from heavy workload until fully recovered.

Outpatient Referral: Follow up at RHU on March 3, 2020

Diet: The patient should continue taking prenatal iron and vitamin pills until
postpartum visit. It is important to eat a well-balanced diet and drink plenty of
fluids

R: Out of the room per wheelchair with improved condition

Bibliography (a summary of all the resources used)

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