Bulacan State University

COLLEGE OF NURSING
City of Malolos, Bulacan

NURSING CARE PLAN

Patient’s Initial: ____MB_____ Age: ___26___ Gender: ___F____ Date Handled: _____ 03-22-18_______ Clinical Area: __OB Ward__

Clinacal Impression/Medical Diagnosis: G2P1 (1001) PU 39 6/7 wks AOG, GIL Chief Complaint: Labor pain

Assessment Nursing Diagnosis Planning Intervention Rationale Evaluation

Subjective: Short Term Goal: Dependent: Short Term Evaluation:

Acute pain related to After 30 minutes of Assess current Allows the nurse to
effects of labor and nursing intervention, the knowledge of obstetric develop an individual
Objective: Long term Evaluation:
delivery process patient’s pain will be pain control measures teaching plan for the
 Facial grimace relieved or controlled patient
 Irritability
 Vital Signs: Assess pain noting
Provides information to
BP: 110/70 location, intensity (scale
aid in determining
Temp: 36.5°C of 0-10), duration
choice or effectiveness of
PR: 68 bpm
interventions
RR: 16 cpm

Provide teaching The patient is more

between uterine attentive and can better
internalize information
 contractions when not in pain

Provide comfort Promotes relaxation,

measure like back rub, refocuses attention and
helping position of may enhace coping
comfort. Suggest use of abilities
relaxation technique and
deep breathing exercise

Changing position and

Provide massage and
using counterpressure
counter pressure and
may help alleviate
assist patient to find
discomfort caused by
position of maximum
pressure of presenting
comfort --- standing,
parts on bony structures,
sitting, squatting, side
ligaments, or tissues.
lying, hands and knees
Massage helps relieve
as needed
muscle tension and
provide a diversion to
inhibit pain sensations

Student’s Name: Aquino, Vince Troy N. Yr&Sec/Group No. : BSN 2A- Group 1
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

DRUG STUDY

Patient’s Initial: ____MB_____ Age: ___26___ Gender: ___F____ Date Handled: _____ 03-22-18_______ Clinical Area: __OB Ward__

Clinacal Impression/Medical Diagnosis: G2P1 (1001) PU 39 6/7 wks AOG, GIL Chief Complaint: Labor pain

Medications Date Route of Mechanism Indication Contraindication Client’s Nursing Responsibilities

Ordered/ Administration/ of Action Response
Given/ Dosage/
Taken Frequency
Generic: 500 mg BID for Bind to cell It is effective for the  Contraindicated in N/A Prior:
Cefuroxime 7 days wall treatment of patients  Determine history of
membrane, penicillinase- hypersensitive to hypersensitivity
Classification: causing cell producing Neisseria the drug. reactions to
Anti- death gonorrhea (PPNG).  Use cautiously in cephalosporins,
infectives Effectively treats bone patients penicllins, and
and joint infections, hypersensitive to history of allergies,
bronchitis. penicillin because particularly to drugs,
Meningitis,gonorrhea, of possibility to before theraphy is
otitis media, cross-sensitivity initiated
pharyngitis/tonsillitis, with other beta-  Lab tests: Perform
sinusitis, lower lactam anti-biotics culture and
respiratory tract  Use with caution in sensitivity test before
infections, skin and breast feeding initiation of therapy
soft tissue infection, women and in and periodically
urinary tract patient history during theraphy if
 infections and is used colitis or renal indicated. Theraphy
for surgical sufficiency may be instituted
prophylaxis, reducing pending test results.
or eliminating Monitor periodically
infection. BUN nad creatinine
clearance

During:

After:

Student’s Name: Aquino, Vince Troy N. Yr&Sec/Group No. : BSN 2A- Group 1
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

DRUG STUDY

Patient’s Initial: ____MB_____ Age: ___26___ Gender: ___F____ Date Handled: _____ 03-22-18_______ Clinical Area: __OB Ward__

Clinacal Impression/Medical Diagnosis: G2P1 (1001) PU 39 6/7 wks AOG, GIL Chief Complaint: Labor pain

Medications Date Route of Mechanism of Indication Contraindication Client’s Nursing Responsibilities

Ordered/ Administration/ Action Response
Given/ Dosage/
Taken Frequency
Generic: 200 mg BID Exhibits anti- Adjunctive  Hypersensitvity to N/A Prior:
Celecoxib p.r.n inflammatory, treatment to drug sulfonamides,  Assess patients history
analgesic and decrease the or other NSAIDs of allergic reaction to the
antipyretic number of  Severe hepatic drug
Classification: action due to adenomatous impairment  Monitor complete blood
Pharmacologic inhibition of colorectal  History of asthma count, electrolyte levels,
Class- the enzyme polyps in or urticarial creatinine clearance, and
Nonsteroidal COX-2 familial  Advanced renal occult fecal blood test
cyclooxygenase adenomatous disease and liver function test
e-2 (COX-2) polyposis.  Late pregnancy results every 6-12
inhibitor, anti-  Breastfeeding months
inflammatory
drug (NSAID) During:
 Instruct patient to take
Therapeutic drug with food or milk
Class-  Teach patient to avoid
 Antirheumatic aspirin and other
NSAIDs (such as
ibufprofen and
naproxen) during
theraphy

After:
 Advise patient to
immediately report
bloody stools, blood in
vomit, or signs and
symtoms of liver
damage (nausea, fatigue,
lethargy, pruritus,
yellowing of eyes or
skin, tenderness on
upper right side of
abdomen or flulike
symptoms)

Student’s Name: Aquino, Vince Troy N. Yr&Sec/Group No. : BSN 2A- Group 1
 Bulacan State University
COLLEGE OF NURSING
City of Malolos, Bulacan

DRUG STUDY

Patient’s Initial: ____MB_____ Age: ___26___ Gender: ___F____ Date Handled: _____ 03-22-18_______ Clinical Area: __OB Ward__

Clinacal Impression/Medical Diagnosis: G2P1 (1001) PU 39 6/7 wks AOG, GIL Chief Complaint: Labor pain

Medications Date Route of Mechanism of Indication Contraindication Client’s Nursing Responsibilities

Ordered/ Administration/ Action Response
Given/ Dosage/
Taken Frequency
Generic: An essential Prevention Hemochromatosis, N/A Prior:
FeSO4 mineral found and hemosiderosis, or  Monitor blood studies of
haemoglobin, treatment of other evidence of patient
myoglobin and iron iron overload;  Observe proper dosage of
Classification: many enzymes. deficiency anemia’s not due medication
Iron Enters the anemia due to iron deficiency  Note other drugs patient is
supplement bloodstream and to blood loss taking to avoid possible
is transported to during Precautions: interactions
the organs of the menstruation, Use cautiously in  Verify the patient’s identity
reticuloendothelial infections, peptic ulcer,
system (liver, surgery, ulcerative colitis During:
spleen, bone delivery, or regional  Most effectively absorbed if
marrow), where it intoxications, enteritis administered 1 or 2 hrs
is separated out parasitosis, or alcoholism, severe before meal
and becomes part other causes hepatic  Take with a full glass of
of iron stores. and anemia impairment, water/ juice
 during severe renal  Do not crush/chew enteric-
pregnancy impairment, coated tablets and do not
rheumatid open capsules
It is prescribe arthritis,  Encourage patient to avoid
for pregnancy or using antacids, coffee, yea,
postpartum lactation dairy products within 1 hr
patients to after
prevent the Interaction:  Inform patient about dark,
occurrence of Drug-drug: green or black stools to avoid
pregnancy- antacids that panic
induced contain calcium. After:
anemia. Tetracyclines,  Monitor patient’s blood
biphosphates, studies
proton-pump  Inform patients about what
inhibitors possible adverse effects that
may occur
Drug-food: iron  Assess bowel function for
absorption is constipation/diarrhea
decreased 33-50%  Document and record
by concurrent
administration of
food

Student’s Name: Aquino, Vince Troy N. Yr&Sec/Group No. : BSN 2A- Group 1