FATALLA, JESSIE RAINNE C.

2BSN6 GROUP 24

A. PERSONAL DATA AOG: 39 weeks

NAME: Rhonalien Bautista GP: G3P3003
AGE: 34 years old LMP: February 13, 2023
DATE OF BIRTH: September 7, 1989 EDD: 11/20/2023
DATE ADMITTED: November 13, 2023

B. CHIEF COMPLAINT
● The client verbalize, “Masakit pa din yung tahi ko kaya nahihirapan pa ako makatulog” as a I observe she keep guarding her lower belly and doing
just a small range of movement.
C. NURSING HEALTH HISTORY
1. PRESENT ILLNESS
● Acute pain in her abdomen after the C-section
2. PAST ILLNESS
● NONE
3. FAMILY ILLNESS
● NONE
4. SOCIAL ILLNESS
● NONE
D. PHYSICAL ASSESSMENT
HEAD TO TOE EXTREMITIES: Normal
SKIN: Normal BREAST: No lumps or masses
HEAD: Generally round, prominences in the frontal and occipital UTERUS: In pain due to C-sectionl
area BOWEL: Normal, dark color and in form consistency
E.E.N.T: Eyes placed evenly and inline with each other, none BLADDER: In pain when urinating with bleeding
protruding, ears are parallel and symmetrical, nose are midline LOCHIA: Lochia robea in urine
NECK: Symmetrical, no visible mass or lumps WOUND: Pain scale of 8/10
BREAST: No lumps or masses SPIRITUAL: Catholic
CHEST: No presences of muscle accessories HOMAN SIGN: No presence
BACK: No lump or masses EMOTION: Good
ABDOMEN: With striae and vertical cut due to c section
GENETALIA/ANUS: Normal
E. LABORATORY RECORDS

URINALYSIS CHEMICAL
COLOR YELLOW
TRANSPARENCY SL. TURBID
RBC >50 HPF
PVS 1-2 HPF
EPITHELIAL CELL MODERATE
BACTERIA FEW
AMORPHOUS URATES FEW
 F. DRUG STUDY

DRUG CLASSIFICATION/ DOSE ROUTE & MECHANISM OF CONTRADICTION SIDE EFFECTS NURSING
IDENTIFICATION FREQUENCY ACTION RESPONSIBILITI
ES
GENERIC PHARMACOLOGIC ROUTE: Oral Blocks Active peptic ulcer Aseptic meningitis BEFORE:
NAME: CLASS: cyclooxygenase, an disease or recent GI Hemorrhage Advise patient not to
Ketorolac NSAID DOSE: 30mg enzyme needed to bleeding or Dizziness, take aspirin, other
synthesize perforation; Drowsiness, NSAIDs, or other
BRAND NAME: THERAPEUTIC FREQUENCY: 3x prostaglandins. advanced renal Headache, salicylates while
CLASS: a day Prostaglandins impairment or risk of Edema, taking ketorolac
Analgesic mediate renal impairment due Hypertension without
inflammatory to volume depletion; Hyperglycemia consulting
To treat moderate to response and cause cerebrovascular Nausea/vomiting prescriber. Urge
severe pain that local vasodilation, bleeding, Worsening of patient to limit use
requires analgesia at pain, and swelling. hemorrhagic inflammatory bowel of acetaminophen to
the opioid level They also promote diathesis, incomplete disease only a few days
pain transmission hemostatsis, or high during ketorolac
from periphery to risk of therapy and to notify
spinal cord. By bleeding; history of prescriber of use.
blocking asthma, urticaria, or
cyclooxygenase and other allergic-type
inhibiting reactions after taking DURING:
prostaglandins, this aspirin or other Caution patient not
NSAID reduces NSAIDs; to use ketorolac for
inflammation and hypersensitivity to more than 5 days, as
relieves pain. ketorolac serious adverse
tromethamine or its effects may occur.
components; labor
and delivery;
postoperative pain
after coronary artery AFTER:
bypass Instruct him to
graft (CABG) immediately report
surgery; use as a blood in urine, easy
prophylactic bruising, itching,
analgesic before any rash, swelling, or
major surgery yellow
eyes or skin.
DRUGS CLASSIFICATION/ DOSE, ROUTE & MECHANISM OF CONTRADICTION SIDE EFFECT NURSING
INDICATION FREQUENCY ACTION RESPONSIBILITI
ES
GENERIC PHARMACOLOGIC ROUTE: Oral Have the role as a Contradicted to the Dizziness BEFORE:
NAME: CLASS: major mediator of patient with Headache Assess the patient’s
Mefenamic NSAID DOSE: 500mg inflammation and pre-existing kidney Nausea/Vomiting pain scale.
BRAND NAME: the role for disease, should not Diarrhea
THERAPEUTIC FREQUENCY: prostanoid signaling be used for pain Stomach pain DURING:
CLASS: QID x8 dose in management for Increased blood Give the drug with
Anti inflammatory activity-dependent coronary artery pressure food, milk, or
plasticity, the bypass graff surgery. antacids.
For the treatment of symptoms of pain
the inflammation, to are temporarily Do not increase the
decrease the pain from reduce. dose, follow the
mild to moderate prescribed dosage.

AFTER:
Monitor for the
adverse reaction.

DRUGS CLASSIFICATION/ DOSE, ROUTE & MECHANISM OF CONTRADICTION SIDE EFFECT NURSING
INDICATION FREQUENCY ACTION RESPONSIBILITI
ES
GENERIC PHARMACOLOGIC ROUTE: Oral Kills bacteria by Hypersensitivity Nausea/vomiting BEFORE:
NAME: CLASS: binding to and including severe Diarrhea Use drugs cautiously
Amoxicillin Aminopenicillin DOSAGE: 500mg inactivating reactions Abdominal pain in patient with
penicillin-binding (anaphylaxis or Rash hepatic impairment.
BRAND NAME: THERAPEUTIC FREQUENCY: proteins on the inner Stevens-Johnson s Allergic reactions
CLASS: TID x6 dose bacterial cell wall. syndrome) to (itching, hives, DURING:
Antibiotic weakening the amoxicillin, other swelling) Administer the
bacterial cell wall beta-lactam Oral thrush amoxicillin as
and causing lysis antibiotics, or their (candidiasis) prescribed by the
components. Headache physician.

AFTER:
Document
accordingly.