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CASE PRESENTATION

OPENING PRAYER:
Father almighty we praise and glorify your
name, we thank you for all the blessings
that you’ve given us each and everyday.
Enlighten us this day to acquire and have a
great body of knowledge, Give us strength to
surpass each problems and trials that comes
our way, lead us through the right path, and
guide us to your kingdom, this we ask
through Christ our Lord.

Amen...
St. Jude
Pray for us..
BLOCK - 3B
CASE
PRESENTATION
Nursing is an art :   and if it is to
be made an art ,
it requires an exclusive devotion
as hard a preparation ,
as any painter's or sculptor's
work ;
for what is the having to do with
dead canvas or dead marble ,
compared with having to do with the
living body ,
the 's spirit?  It is one of the
Fine Arts :
I had almost said , the finest of
Fine Arts .
~Florence Nightingale
Pregnancy - Induced Hypertension ( PIH )
Pregnancy-induced hypertension (PIH) is a form of high blood pressure in
pregnancy. It is also called toxemia or preeclampsia ..
Usually, there are three primary characteristics of this condition,
including the following:
•high blood pressure (a blood pressure reading higher than
140/90 mm Hg, or a significant increase in one or both pressures)
•protein in the urine (proteinuria)
•edema (swelling)
The cause of PIH is unknown. Some conditions may increase the risk of
developing PIH, including the following:
•pre-existing hypertension (high blood pressure)
•kidney disease
•diabetes
•PIH with a previous pregnancy
•mother's age younger than 20 or older than 40
•multiple fetuses (twins, triplets)
What is pregnancy-induced hypertension
(PIH)?
The cause of PIH is unknown. Some conditions may
increase the risk of developing PIH, including the
following:
•pre-existing hypertension (high blood pressure)
•kidney disease
•diabetes
•PIH with a previous pregnancy
•mother's age younger than 20 or older than 40
•multiple fetuses (twins, triplets)
What are the symptoms of pregnancy-
induced hypertension (PIH)?

The following are the most common symptoms of high blood pressure in
pregnancy. However, each woman may experience symptoms differently.
Symptoms may include:
•increased blood pressure
•protein in the urine
•edema (swelling)
•sudden weight gain
•visual changes such as blurred or double
vision
•nausea, vomiting
•right-sided upper abdominal pain or pain around the stomach
•urinating small amounts
•changes in liver or kidney function tests
Biographical
Data
Name : RH                                          
Age : 28 y/o
Address : Bulacan
                               Weight : 64 kg.
Date of Birth : September 21, 1980                                    Gender :
Female
Religion :
Islam                                                                        O
ccupation : Domestic Helper
 
Reason for Seeking Health Care or Chief Complaint
·        Headache
·        Blurred Vision
Perception of Health Status
·        Mrs. RH doesn’t bother about her health status because she believes that
her headache and blurred vision will subside after delivery.
Previous illness / Hospitalization / surgeries
·        Year 2000 she gave birth to a baby boy at Bulacan Medical Center
·        Year 2002 she gave birth to a baby boy at Bulacan Medical Center
Family Medical History
·        Her mother has a history of hypertension, diabetes mellitus and asthma
·        Her father has a family history of cancer
 
Immunization / Exposure to Communicable Disease
·        Completed the five shots of Tetanus Toxoid and she is
fully immunized.
Allergies
·        Mrs. RH doesn’t have any known allergies.
Home Medication / Alternative Medicine
•        She usually takes Paracetamol whenever she has a fever
or colds.
Psychosocial History
•        she occasionally drinks alcohol (San Mig Light, 330ml)
and can consumed 2 bottles.
•        she prefers softdrinks (coke) for merienda1-2 bottles 8
oz per week.
Obstetrical History
•        She had her menarche when she was 13 y/o
•        Last Menstrual Period- November 18, 2008
•       Date of confinement- August 28, 2009
•     G TPAL (32002)
GORDON ’ S FUNCTIONAL PATTERN
PATTERN BEFORE HOSPITALIZATION DURING ANALYSIS
HOSPITALIZATION
1.HEALTH PERCEPTION-she can manage her own -not bothering on her Needs more
health condition knowledge regarding
-when she got sick for up her health status
to 3 days, she consults the
health care provider
immediately
2. NUTRITIONAL- Breakfast – 1-2 red eggs, On low salt, low fat She has to maintain
METABOLIC 1 cup of noodles diet. low salt, low fat
Lunch – 1 serving of (half cup of rice, diet due to high
vegetable and meat and a vegetable, fish, fruits, blood pressure.
cup of rice fruit juice)
Snack – 1 sandwich and a
glass of water
Dinner – bread or
crackers
-consumes 8 or more glasses
3. ELIMINATION a day Movement : once a (+) bowel movement:
Bowel Digestive system is
day, (every morning) soft, small amount, black not well
black stool, colored stool – 1pm on functioning yet
Urine output: light Post-Partum Day 2 because of the
yellow, 6-8 times a day - has foley catheter systemic changes in
connected to urine bag the mother after
(dark yellow, delivery thus
80ml/4hour) elimination pattern
altered.
PATTERN BEFORE DURING ANALYSIS
HOSPITALIZATION HOSPITALIZATION

4. ACTIVITY/EXERCISE -working 10 hours a -eating, sitting, lying Decreased ability to


day as a domestic on bed, texting, do activities of daily
helper (all around). chatting with living due to pain at
-texting and phone roommates and episiotomy site
chatting with visitors, taking care
relatives in the of her baby girl,
Philippines after sleeping
work.
5. SLEEP AND REST -sleeps 6 hours/day -sleeps 3 hours Alteration of sleep
between 10pm-4am between 12am-4am pattern is due to pain
-rest time 12pm-1pm -nap time 1pm-1:30pm in the episiotomy site
(lunchbreak), 4pm-4:30pm (3o minutes) and humid and noisy
(merienda), and after -praying and drinking environment.
work. milk before sleeping
- praying before
sleeping

6.COGNITIVE AND -own decision making -own decision making Visual Disturbance is
PERCEPTUAL regarding health on health one of the symptom of
-all senses are -suffers visual pregnancy induced
functioning well disturbances (blurred hypertension.
vision)
- Left side lying to
manage the pain in her
episiotomy site
7. ROLE AND -close family -family relationships Close family
RELATIONSHIP relationship become closer relationship greatly
-doesn’t adopt -she is ready to face influence the patient
responsibilities yet as the responsibilities on facing current
an Islam being a mother of 3 situation.

8. SEXUALITY AND -doesn’t use - abstinence, husband Patient doesn’t want


REPRODUCTIVE contraceptive is out of the country to bear a child again
-sexually active after -planning to undergo because she fears of
marriage tubal ligation after complication might
a month brought by history of
hypertension during
pregnancy.

9. COPING AND STRESS -eats a lot and sleep -entertaining Coping strategies used
TOLERANCE to overcome stress visitors and talking effectively.
to her baby to manage
stress

10.VALUE/BELIEF -she strongly believe -Faith in God and Her strong belief to
to the power of prayer prayers are her Almighty God gives her
for whatever kind of companion in facing hope and strength.
obstacles she faces current condition
- doesn’t believe in
quack doctors
PHYSICAL ASSESSMENT
(Abnormal findings)

BODY PART FINDINGS ANALYSIS

Perineum
 Medio-lateral episiotomy Surgical incision of the
 Reddish color vaginal perineum is done to prevent
 discharge tearing and to release
 pressure on fetal head with
 birth.

 (lochia rubra) Vaginal discharge consisting


 almost entirely of blood with
 only small particles of
 decidua and mucus, occurring
Breast
 from 1-3 days of the post-
 Right breast is much bigger partal period.
than the left breast.
- miss several nursing about
3. Eyes breastfeeding technique:
Blurred vision 15 minutes on each breast
alternate
(both eyes)
Spasm of the arteries in the
retina leads to vision
changes and increase in blood
pressure.
BODY PART FINDINGS ANALYSIS


- Dark circles under the eyes Altered sleep patterns
 related to environmental
factor such as over populated
wards, inadequate ventilation
and decreased in fluid
4. Conjunctiva, face, lips, Pale intake.
palm  
Caused by excessive blood

Edema loss during delivery.
5. Feet (both feet)

Caused by reduced blood


circulation in the lower
extremities related to
decrease in mobility of the
Linea nigra (brownish streak client and due to fluid
6. Abdomen runs vertically along the retention.
midline of the abdomen from
the pubis to the xiphoid
process)
A pigmentation resulting from
increased production of the
pigment melanin thought to be
caused by increased estrogen.
Diagnostic and Laboratory Examinations
DATE : AUGUST 22 , 2009
TIME : 10 : 00 am BULACAN MEDICAL HOSPITAL
EXAMINATIONS Normal Values Findings Analysis
Urinalysis 1 . 006 and 1 . 030 1 . 020 NORMAL

CBC : 2.5 - 4.5 3.2 NORMAL


> RBC ( millions of
cells
> WBC /(cu mm / cu mm
cells 5 - 10x10 * 3 / ml * 3 10 . 9 NORMAL
Heterophil

Basophiles 20 - 50 % 50 % NORMAL

Serum protein 25 . 5-- 78. 5 55 . 1 NORMAL


ABNORMAL
Monocytes - decreased
protein level
Hematocrit F . 37 - 48 32 - 34 through
ABNORMAL urine
(- proteinuria
Enlargement) of
the extremities
Medical Diagnosis :
> G3 P2 ( 32002 ) Pregnancy Uterine 35
5 / 7 weeks AOG , CHUD with SITE
ANATOMY AND PHYSIOLOGY
( AFFECTED ORGAN )
HEART
ANATOMY AND PHYSIOLOGY
Cardiovascular System
 The heart is responsible for maintaining adequate
circulation of oxygenated blood around the vascular
network of the body. It is a four-chamber pump, with
the right side receiving deoxygenated blood from the
body at low pressure and pumping it to the lungs (the
pulmonary circulation) and the left side receiving
oxygenated blood from the lungs and pumping it at
high pressure around the body (the systemic
circulation).The myocardium (cardiac muscle) is a
specialized form of muscle, consisting of individual cells
joined by electrical connections. The contraction of
each cell is produced by a rise in intracellular calcium
concentration leading to spontaneous depolarization,
and as each cell is electrically connected to its
neighbor, contraction of one cell leads to a wave of
depolarization and contraction across the myocardium.
This depolarization and contraction of the heart is
controlled by a specialized group of cells localized in
the sino-atrial node in the right atrium- the
pacemaker cells
1.These cells generate a rhythmical depolarization,
which then spreads out over the atria to the
atrio-ventricular node.
2.The atria then contract, pushing blood into the
ventricles.
3.The electrical conduction passes via the Atrio-
ventricular node to the bundle of His, which
divides into right and left branches and then
spreads out from the base of the ventricles
across the myocardium.
4.This leads to a 'bottom-up' contraction of the
ventricles, forcing blood up and
out into the pulmonary artery (right) and aorta
(left).
5.The atria then re-fill as the myocardium relaxes.
The 'squeeze' is called systole and normally lasts for about
250ms. The relaxation period, when the atria and ventricles re-
fill, is called diastole; the time given for diastole depends on
the heart rate.
KIDNEY
Kidney Anatomy and Physiology
Kidneys
The kidneys regulate the volume and concentration of 
fluids in the body by producing urine. Urine is produced in a 
process called glomerular filtration, which is the removal of waste 
products, minerals, and water from the blood. The kidneys maintain 
the volume and concentration of urine by filtering waste products 
and reabsorbing useful substances and water from the blood.

The kidneys also perform the following functions:


    * Detoxify harmful substances (e.g., free radicals, drugs)
    * Increase the absorption of calcium by producing calcitriol 
(form  of vitamin D)
    * Produce erythropoietin (hormone that stimulates red blood cell 
production in the bone marrow)
    * Secrete renin (hormone that regulates blood pressure and 
electrolyte balance) 
The kidneys are a pair of bean-shaped organs located below the ribs near the middle of 
the back. They are protected by three layers of connective tissue: the renal fascia 
(fibrous membrane) surrounds the kidney and binds the organ to the abdominal wall; 
the adipose capsule (layer of fat) cushions the kidney; and the renal capsule (fibrous 
sac) surrounds the kidney and protects it from trauma and infection.
Formation and Elimination of Urine
The formation of urine occurs in the basic units of the kidney, called nephrons. Each 
human kidney contains over 1 million nephrons. Nephrons consist of a network of 
capillaries (called a glomerulus), a renal tubule, and a membrane that surrounds the 
glomerulus and functions as a filter (called Bowman's capsule). The glomeruli are 
where urine production begins. Urine formation occurs in the renal tubules, which 
travel from the outer tissue of the kidney (called the cortex), to the inner tissue (called 
the medulla), and return to the cortex.
Hormones
The hypothalamus in the brain detects the level of substances in the blood and controls 
the secretion of hormones. Antidiuretic hormone, aldosterone, and atrial natriuretic 
factor are hormones that change the permeability of the distal convoluted tubule and 
the collecting tubule, regulating urine volume and helping to maintain blood pressure.
PATHOPHYSIOLOGY
OF THE
DISEASE
Predisposing Precipitating

Increase Sodium intake during


Gender(F) 1st and 2nd trimester
STRESS
Family History (working 10
Maternal Side(HPN) hours/day)

obesit
y
VASOSPASM

VASCULAR EFFECT INTERSTITIAL EFFECT

KIDNEY EFFECT
VASOCONSTRICTION

DIFFUSION OF FLUID FROM BLOOD STREAM INTO INTERTIT

SE POOR ORGAN FILTRATION


GLUMERULI PERFUSION RATE AND INCREASED PERMEABILITY OF GLUMERULI MEMBRANE

EDEMA
INCREASED BP
DECREASED URINE OUTPUT AND PROTENURIA
NURSING DIAGNOSIS
IDENTIFIED BASED ON
PRIORITIES
4. Ineffective
breast feeding related

to breast engorgement

3.
Altered
2. tissue
Pain
perfusion
related to Medio-lateral: Renal

1.
Disturbed
sleep

Episiotomy
patterns
related

to
NURSING CARE PLAN
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

Subjective Scientific Short Term Independent Human Short Term


Patient Disturbed : Goal : -for Resources Goal
verbalized Sleep - Hand infectio Evaluation
, Pattern ( Kozier Within 2 - washed n Patient
“ Putol - related and Erb ’ s 3 hours before and control and After 3
putol ang to Fundament of after nurse ’ s hours of
tulog ko , Uncomfort als of nursing interventio To time and nursing
halos 3 able Nursing interven n . promote effort interventi
oras lang Environme pp . 1164 - tion , the good on , the
buong nt as 1165 ) patient - Advised to sleeping patient
araw .” manifeste Sleep has will establish pattern enumerated
Objective : d by come to enumerat regular conditions
- restlessn be e bedtime that
restlessne ess , considere conditio ( 11pm ) and promote
ss irritabil d an ns that wakeup time sleep .
- ity , pale altered promote ( 5am ) and a - to
irritabili conjuncti state of sleep . short promote
ty va , lips , conscious daytime nap comfort
- pale palm and ness in ( 30minutes ) and
conjunctiv skin which the comfortab
a , lips , and dark individua - Advised ly
palm and circles l’s to wear
skin under perceptio loose -to
- dark eyes . n of and - fitting promote
circles reaction nightwear comfort
under eyes to the and
environme easiness
nt are - Advised to
decreased take a warm
. bath before
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

- Advised to -milk contains


The cyclic Long Term drink 1 tryptophan, a Long Term
nature of sleep Goal : glass of precursor of Goal
is thought to warm low serotonin, Evaluation
be controlled Within 3 fat milk which is
days of After 3 days of
by centers before thought to
nursing
located in the nursing sleeping induce and
lower part of intervention, maintain intervention,
the brain. the client will sleep. the client was
Neurons able to able to sleep
within the sleep for at - to avoid for 7 hours
reticular least 6 hours interruption including
formation, and to daytime nap.
located in the promote
brain stem, -Assisted and/or comfort
encouraged to
void before to promote

bedtime ventilation

-Opened the -to promote


windows comfort and
relaxation
-Maintained
smooth, clean,
and dry bed
linen
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

integrate Independent
sensory
information -Instructed the -to reduce
from the roommates to noise
peripheral lower their voices distraction
nervous system and prevent noise
and relay the at
information to bedtime.
the cerebral
cortex.
The absence of
usual stimuli or
the presence of
unfamiliar
stimuli can
prevent people
from sleeping.
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions
Situational :
Inability to sleep
because of
humid, noisy and
not well
ventilated
environment.
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

Subjective : Pain related Scientific : Short Independent : HUMAN After 7


Patient to Term RESOURCE hours of
verbalized, “ Mediolateral Sensing the Goal : - Hand washing - For infection nursing
Sumasakit yong Episiotomy pain sensation before and after control - Patient and intervention,
tahi ko.” as begins in the -Within 8 the procedure nurse’s effort. the patient
-Pain Scale: 7 manifested peripheral hours of verbalized
out of 10 by Cues nerves when a nursing -Monitored decrease of
Objective : stimulus interventio Vital signs - to know the pain from 7
- BP = activates n, patient status of the to 4 out of
150/100mmHg nociceptors. A will patient 10 pain
-irritability number of verbalize scale.
-facial grimace neurotransmitt that pain is -Established a -to promote
-with ers are also reduced to trusting expression of
mediolateral stimulated and 4 out of 10. relationship by the patient’s
episiotomy involved in listening thoughts and
conducting attentively to feelings and
pain. what the patient enhances
says about the effectiveness
pain of pain
management
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

- Explained to the - to help


Pain patient that it is relieve strong
impulses normal to emotions
join CNS experience an capable of
fibers in the intense pain after amplifying
dorsal horn a major surgery pain
of the spinal because of injured
cord. The tissues.
impulses are
projected - Provided a
upward to distraction
the brain, technique: -to ignore pain
when they talking with her

will be baby
perceived as entertaining

pain. visitors
-talking and
texting with loved
ones over the cell
phone

Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

Situational : - Provided - to lessen


The intense pain perineal care irritability
experienced by the
patient is due to - to relieve
injured tissues - Encouraged to pain and
after the delivery take a warm promote
with a bath healing of
mediolateral injured
episiotomy. tissues
- Provided a - to promote
massage (back, physical and
neck, hands and mental
arms) relaxation

- to promote
-Positioned the comfort
client to side
lying position
- to lessen the
- Provided for a perception of
guided imagery: pain
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

- closing eyes
- slow deep
breathing
- imaging
- Attended to the
patient’s needs
promptly - to reduce
irritability

-Instructed the
roommates to - to promote a
lower their voices relaxed feeling
and prevent noise and permit the
at patient to focus
bedtime. on the relaxation
technique

Dependent :
- Administer
Mefenamic Acid - to relieve pain
500 mg PRN
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions
Independent :
Objective : Altered Scientific : Short - Hand washing - For HUMAN After 8 hours
RESOURCE
- BP = Tissue (Maternal and Term infection of nursing
- Patient and intervention,
150/100mmHg Perfusion: Chil Health Goal : control
nurse’s effort.the patient’s
-both feet RENAL Nursing by -Within 8 - Monitored
noticeably Pillitteri) hours of vital signs - to know the blood pressure
enlarged -Vasospasm in nursing And Monitored status of the decreased to
- proteinuria the kidney intervention, input and patient 130/90.
(+2) increases blood patient’s: output and
-urine output flow resistance. - blood weighed.
80ml every 4 Degenerative pressure will
hours changes develop reduce to -Promoted bed
in kidney 130/90 mmHg rest - aid to
glomeruli increase
because of back evacuation of
pressure that sodium and
leads to encouraging
increased diuresis
permeability of
the glomerular - instructed the - to prevent
membrane patient to take seizure
allowing the medication as
serum proteins prescribed
( calcibloc 10
mg. TID )
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions
albumin and -Emphasized diet - To
globulin to restriction, as compensate
escape into the indicated (high in for the
urine protein and protein she
(proteinuria). moderate in is losing in
The sodium) urine
degenerative
changes also - Followed up
result in laboratory
decreased examinations, as - to know
glomerular needed the status of
filtration, so the patient
there is - Provided
lowered urine emotional - to elicit
output and support anxiety
clearance of
creatinine.
Increased
kidney
tubular
reabsorption
of sodium
occurs.
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions
Because
sodium retains
fluid, edema
results.
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

Subjective : Ineffective Scientific : Short -Hand washing - to prevent Human After 4


Patient Breastfeeding Term the spread of Resource hours of
verbalized, related to (http://www.web Goal : microorganis s nursing
“Hirap sumuso Breast md.com/baby/tc) m intervention,
ang anak ko.” Engorgement The breasts Within 3-4 Patient and patient
Objective : as evidenced switch from hours of -To know the nurse’s time demonstrate
-enlarged; by the cues colostrums to nursing status of the and effort d effective
reddened, mature milk intervention, - Monitored vital client breastfeedin
throb, (often referred patient will signs g technique
moderate pain to as when the demonstrate -for infection as evidenced
of the right milk "comes effective control by:
breast in"), when an breastfeeding -10
-firm and imbalance technique as -Cleaned the breastfeedin
warm to touch between milk evidenced by: breast with g per day,
breast supply and cotton balls dip in every 2
infant milk lukewarm water hours
demand, before
breastfeeding
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

veins in the - 10-12 -Demonstrated -to promote - 15 minutes


mammary glands
breastfeeding effective proper feeding on the
expand per day, every breastfeeding: breastfeeding first side
and the 1.5-2 hours > infant’s body technique before offering
pressure - 15 minutes closed to the the second
of new feeding on the mother’s body breast
breast milk first side before > touched infant’s
contained offering the lips with her
within second breast. nipple
them.
-Advised -to prevent
breastfeeding blocked milk
every 1.5-2 hours, ducts
10-12 times a day
And nursed for 15
minutes on the
first side before
offering the
second breast
Assessment Nursing Analysis Expected Nursing Rationale Resources Evaluation
Diagnosis Outcomes Interventions

Situational : -Advised to wear-to reduce


Lactating supportive bra pain and
mother miss and applied cold swelling
several nursing compress
and not enough
milk is -Applied hot
expressed from compress and
the breasts encouraged to -to soften
because of massage breast breast before
infant’s poor gently and use feeding
sucking reflex. hands to let out
a small amount
of milk from
both breasts.
DRUG
STUDY
Name Of Drug Mechanism of  Dosage Indications Contraindicatio Adverse  Nursing 
Action ns Reactions Considerations
Ferrous Drug Right Dose: Prevention and -allergy to any  Possible -Give drug 
Sulfate Classification: Adult:  treatment of  ingredient;  Adverse with fruit juice 
Brand Name:  Hematologic  Men, 8-11  iron deficiency  sulfite allergy  Reaction: for better 
EDINSOL Drugs mg/day PO;  anemias -use cautiously  GI: Nausea,  absorption 
Elevates the  Women, 8- 18  Dietary  with normal  Vomiting,  -Warn patient 
serum iron  mg/day PO;  supplement for  iron balance,  Constipation,  that stool 
concentration,  Pregnant and  iron peptic ulcer,  Diarrhea, Black maybe dark or 
which then  Lactating  ulcerative  Stools, green.  
helps to form  Women, 10-27  colitis, and in  Actual
Hgh or trapped  mg/day   those receiving  Adverse
in the  Actual repeated blood  Reaction:
reticuloendothel Ordered Dose: transfusion. Black stools
ial cells for  10mg/day PO - Use cautiously 
storage and  in long term 
eventual  basis
conversion to a 
usable form of 
iron.
Name Of Drug Mechanism of Dosage Indication Contraindication Adverse Nursing
Action Reaction Considerati
on

Cephalexin Drug Right Dose: Respiratory  -Use cautiously in  Possible -Give drug 


BRAND NAME: Classification: ADULT: Tract, GI  Breast-Feeding  Adverse with Meals 
KEFLEX ANTIOBIOTIC 1-4 g/day in  tract, skin,  women and in  Reaction: to prevent 
Bactericidal  divided  soft tissue,  patient with history  CNS:  GI 
inhibits  doses  bone and  of Colitis or Renal  Dizziness,  disturbance.
synthesis of  250mg PO  joint  Insuffiency Headache,  -Check for 
bacteria cell  every 6hr  infections  -Contraindicated Fatigue,  the Allergy 
wall causing cell usual dose.  and otitis  with allergy of Confusion,  of the 
death. Actual media  cephalosporins and Hallucinations Patient to 
Ordered caused by  penicillin , penicillin 
Dose: Escherichia GI: Nausea,  and 
500mg q  coli and  Anorexia,  cephalospori
12hrs daily  other  Vomiting,  ns
for 7 days coliform  Diarrhea, 
bacteria Abdominal 
Pain, 
GU: Genital 
Pruritus, 
Vaginitis
Actual
Adverse
Reaction:
-Nausea
Name Of Mechanism Dosage Indicati Contraindicati Adverse Nursing
Drug of Action ons ons Reactions Consideration
s
MEFENAMIC  Drug Right Relief of  -Hypersensitivity to Possible Give mefenamic
ACID  Classification: Dosage: moderate  Mefenamic acid  Adverse acid after meal
   Antipyretic  Initially 500 pain -aspirin allergy  Reaction : because it may
Brand Name: Anti-  mg  -use cautiously with CNS:  cause GI
headache,  disturbance if
Dolsten inflammatory;  followed by  asthma, renal or  it takes with
analgesic; anti- 250mg  hepatic impairment, dizziness,  an empty
pyretic every  peptic ulcer disease, insomnia,  stomach.
6hours as  GI bleeding,  fatigue, 
needed.  hypertension, heart  tiredness, 
Actual failure, pregnancy,  ophthalmic 
Ordered lactation effects 
Dose:  Dermatologic:
ACUTE  rash, pruritus, 
PAIN: 500  sweating 
mg PO  GI: nausea, 
PRN dyspepsia, GI 
pain, Diarrhea, 
vomiting, 
constipation 
Name Of Mechanism Dosage Indicati Contraindicati Adverse Nursing
Drug of Action ons ons Reactions Consideration
s
Hematologic:
Bleeding 
Patient
Adverse
Effect:
 headache, 
dizziness

Actual
Reverse
Reaction :
-fatigue
Name Of Mechanism Dosage Indicatio Contraindicat Adverse Nursing
Drug of Action ns ions Reaction Consideratio
s ns
Calcibloc Drug Right Dose: - - Hypersensitivity  Possible *Tell patient she 
classification: Adults: 10 mg  Hypertension to drugs  Adverse may take 
(Nifedipine) Antihypertensive TID PO.        Reaction : immediate 
drug  Maintenance  -Vasospasm  -Use cautiously in  CNS:  release form with 
   range 10-20mg  angina  a patient with heart headache,  or without meals. 
Inhibit transport  TID. Higher  (variant  failure or  dizziness,  If GI upset is 
to myocardial  dose 20-30mg  angina)  hypotension and in  fatigue and  occurs, tell her to 
and vascular  (TID- QID)  classic  elderly patient. vertigo  take it with meals 
smooth muscle  may be  chronic     but never with 
cells,  required  stable angina  CV:  grapefruit or 
suppressing  depending on  pectoris.  peripheral  grape juice 
contraction.  patient    edema, chest because it can 
Dilate main  response.  pain,  interact the drug 
coronary arteries  Adjust over 7- hypotension. and may cause 
and anterior  14days. More     dangerous effect. 
inhibits coronary than  EENT:  *Inform the 
artery spasm,  180mg/day is  epistaxis,  patient that 
increasing  not  Rhinitis  angina attack 
oxygen delivery  recommended.    (choking pain)
to heart and
Name Of Mechanism of Dosage Indication Contraindicat Adverse Nursing
Drug Action s ions Reactio Consideration
ns s
decreasing  Actual      may occur 30 
frequency and  Ordered Actual minutes after a 
severity of angina  Dose: reverse dose
attack 10 mg. TID  reaction:
P.O.  -fatigue
(7-14 days)
Nurse’s Progress
Note
Low salt, Low Fat

DAY 1
>patient received lying on bed
>conscious and coherent
> with minimal vaginal bleeding
>firm and contracted uterus
>ongoing IVF of PLR 1L @ 500cc level, regulated @ 31-32 gtts/min
>v/s taken and recorded
>febrile
>with Foley Catheter
August 25,
2009 DAY 2
8:00pm >awake lying On bed,
BP: 150/90 >conscious and Coherent
mmhg > with minimal vaginal bleeding
T: 36.7 C >firm and contracted uterus
P: 78 bpm > On Going IVF PNSS@950cclevel , regulated at
R: 20 Bpm 31-32gtts/min
>v/s taken and Recorded
>afebrile
Low salt low fat
>maintained
Health Teaching as follows:
> emphasized breast feeding
>Emphasized deep breathing exercise
>Personal Hygiene advised
> encouraged to eat fruits and green leafy vegetables
>advised bed rest
>on oral medication
> v/s q 4 hours monitoring
> Needs more care
August 26, 2009
8:00pm
BP: 130/90 mmHg
T: 36.6 C
P: 81 bpm
R: 21 Bpm

DAY 3
>patient received awake, sitting on bed
>conscious and coherent
> with minimal vaginal bleeding
>firm and contracted uterus
>v/s taken and recorded
> afebrile
Low salt, low fat diet > maintained
DISCHARGE PLAN
OBJECTIVE HEALTH TEACHING/ RESOURCES EVALUATION PLAN
INTERVENTIONS
*patient’s blood -continue low salt, low HUMAN RESOURCES : After one week, is the
pressure within fat diet(green leafy Patient and nurses’ patient’s blood
acceptable vegetables and fruits) time and effort pressure reduced from
parameters(120/90mmHg -promote adequate 150/100mmHg to
after one week) sleep and exercise. 120/90mmHg?
-advised to continue
medications as
prescribed

*improved -clean first the HUMAN RESOURCES : After three days, has
breastfeeding nipple with water Patient and nurses’ the patient achieved
technique -advise the mother to time and effort an effective
breastfeed her baby breastfeeding?
every two
hours(fifteen minutes
on each breast
alternate)

HOME MEDICATIONS :
Calcibloc 10mg TID PO for 7-14 days
Cephalexin 500mg q12h daily for 7 days
FOLLOW - UP CARE
After one week, assess breastfeeding technique, episiorraphy, vaginal secretions and blood pressure
Date:
Place/Clinic:
THANK YOU