II.

General and Specific Objectives

A. General objectives
The student nurses should be able to apply the theoretical and
practical skills, to provide a systematic way of collecting information
and to provide assistance in rendering care and treatment for health
maintenance of the patient.
B. Specific objectives
To provide adequate physical assessment essential for

understanding the condition of the client

To be able to distinguish factors that affects clients health and

condition
To enrich the skills of the student nurses in nursing intervention
and to be able to apply their theoretical knowledge into practical

uses.
To enhance their ability in rendering assistance for health
teaching and promotion

IX. Diagnostic and Laboratory Results

Urine analysis
(September 5, 2010)
Color
Transparency

Yellow
Slightly turbid

Microscopic Exam

Test

Result

Normal Values

Pus cells

3-5 hpf

0-2 hpf

Red cell

0-1 hpf

0-1 hpf

Epithelial cell

Few

Interpretation :
Pus cells are dead white blood cells. Increase number of pus cell in
urine may indicate infection. The patient might experience pain when voiding
Chemical Exam
Protein : trace

Hematology Report ( September 05 ,2010)

Test

Result

Normal Values

HGB

12

12.00-15.00g/dl

HCT

36

36.00-46.00%

WBC

11.0

4.8- 10.8 x 109 cells/L

Lymphocytes

20

20.00-30.00%

Segmenters

80

60-70%

Interpretation
The increased level of white blood cell indicates normal compensatory
mechanism during the first 24 hours of post partum

Blood Chemistry ( September 5, 2010)

Test

Result

Normal Values

Blood Urea Nitrogen

2.9 mmol/L

3.0-7.2

Creatinin

53 umol/L

50-100

Uric acid

0.25nmol/L

0.17-0.41

SGPT

14 U/L

5-40

SGOT

14 U/L

5-40

Interpretation :
Blood urea nitrogen (BUN) measures the amount of urea nitrogen, a
waste product of protein Metabolism in the blood. Slightly decreased BUN
indicates bodys compensatory mechanism due to decreased fluid level.

X. Discharge Planning
Discharge planning is the development of an individualized discharge
plan for the patient prior to leaving the unit. Discharge plans ensure the
continuity of care because it is a process that includes identification ,
assessment, goal setting, planning, implementation, coordination and
evaluation.
Understanding patient and familys condition work setting, finances,
living arrangement etc. would help to determine needs and availability, other
factors affecting discharge decision include access to transportation,
prescription and over the countermedicines, as well as medical equipment
arrangement.
Nurse-patient communication and interaction is very important in order
to enhance further recovery and prevent re-occurrence of certain disease .
the following are plans for patient to have continuity of care:
Work

Instruct the client to avoid heavy works like lifting or straining for at
first three weeks following birth

Environment

Home environment must be free from slipping or accident hazard

Rest

Encourage the client to rest at least once a day and get a good night
sleep.

Exercise

Diet

Instruct the client to limit the stairs she climb to 1 flight a day for the
first week at home

Encourage the client to increase intake of fibers to avoid constipation

Instruct to increase fluid intake
Instruct to increase intake of nutritious foods such as fruits and
vegetables

Health teachings

Instruct the client to increase intake of protein rich foods to promote

faster wound healing
Instruct the client to promote breastfeeding

Follow up

Instruct the client to return for an examination four to six weeks after
birth.
Advice the client to make an appointment to take her baby to a
pediatrician, family physician or well-child clinic for the examination at
two to four weeks.