Case Study 203

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Liceo de Cagyaan University

R.N. Pealez Blvd., Kauswagan

Cagayan de Oro City

College of Nursing

DR CARE STUDY

In Partial Fulfillment of the course Requirements

In

NCM501203: Related Learning Experience

Submitted by:

Baran, Jayzel G.

Emong, Reyner Wayne

Galanza, Lorelyn T.

Piquero, Maria Seiko O.

Taganas, Jessah V.

Group D2 sub group 2

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Introduction

Pregnancy is defined as a gestational process of growth and development of anew individual within a woman. It begins with a process called fertilization. By which out

of millions of sperm cells ejaculated by a man only one has the chance to fertilize a

females egg cell.

Pregnancy is an integral component of human reproduction. For approximately

40 weeks, the still developing human being survives the fragile environment of the

uterus. The growth of the fetus requires utmost care on the part of the mother. Any

physical and emotional disturbance that affects the mother can have a great impact in

intrauterine development. Intrauterine development, therefore, is a dependent process.

Anything that affects the mother may adversely affect the development of the fetus.

In a country where fertility rate is higher compared to developed countries, it is

expected that the government cannot afford to deliver quality health services to majority

of its people who cannot pay for private health care. This is reflected in the policies of

state-run health care institutions. Mothers expected to deliver NSVD are confined to

birthing homes and those with complications are encouraged to deliver in the hospitals.

This strategy aims to manage the use of resources and to curb down mortality

rates. People are left with few options to choose from. With this problem in mind, it is

the duty of the nurse to be flexible at all times. In order to suit clients needs, the nurse

has to master the concepts of maternal and child health care so that by the hive

problems arise, the best solution is always chosen.

As future nurses, it is the responsibility of the proponents to acquaint themselves

in this field of nursing practice in order to function competently. In order to suit clients

needs, the nurse has to master the concepts of maternal and child health care so that

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II. Patients Profile

Name :Mrs. B

Address :Malaybalay City Bukidnon

Sex : Female

Age :25 years old

Birthday :June 13, 1974

Religion :Roman Catholic

Height : 53

Weight

:51kgs

Civil Status :Single

Admitting Diagnosis : PUFT on Labor Pains, G2P2

Initial Assessment:

Gravida 2, Para 2, Term 2, Premature 0, Abortion 0, Living 2

Temperature : 36.8rC

Pulse Rate : 91 bpm

Respiratory Rate : 19 cpm

Blood Pressure : 120/80mmHg

Fetal Heart Beat : 135 bpm

Last Menstrual Period : April 5 2010

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Labor is a series of events by which uterine contractions and abdominal pressure

expel a fetus and placenta from a pregnant woman. During pregnancy, the uterus

consists of a large number of greatly hypertrophied smooth cells. Each cell is activated

by a series of chemical reaction to begin regular contractions in a highly coordinated

manner and with such force that the cervix is dilated and the expulsion of the baby and

placenta occur. Several mechanisms are involved in initiating and maintaining the labor.

However the precise trigger of labor is unknown.

1. First Stage (Dilatation stage)

From the onset of first contraction through labor contractions to full cervical

dilatation. This stage averages about thirteen hours for a primipara and about eight

hours for multipara. It composed of 3 Phases: Latent Phase , Active Phase andTransition Phase.

2. Second Stage (Delivery stage)

The period from fully dilated cervix to the delivery or expulsion of the baby

3. Third Stage (Placental stage)

Begins in the delivery of the placenta

3 signs of placental expulsion:

1. Calkins sign

2. Sudden gush of the blood

3. Lengthening of the cord

4. Fourth Stage (Recovery stage)

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When progesterone (uterine muscle relaxant) decrease in late pregnancy with

corresponding increase in estrogen (uterine muscle stimulant), labor starts.

2. Oxytocin Theory

The pressure of the fetal head on the cervix in late pregnancy stimulates the

posterior pituitary gland to secrete oxytocin which causes uterine contractions.

3. Estrogenic, Fetal Hormone and Prostaglandin Theory

All these have stimulating effect on uterine musculature causing uterine

motility.

4. Theory of the Aging Placenta

As the pressure matures, more and more pressure is exerted on the fundal

portion, the usual placental site and the most contractile portion of the uterus. It is

believed that the resultant diminished blood supply to the area causes contraction.

5. Uterine Stretch Theory

The most acceptable theory. As the uterine muscles get stretched with fetalgrowth and increasing amniotic fluid, irritability and contraction to empty the contents of

the uterus are likely results.

B. Components of Labor

1. Passageway refers to the adequacy of the womans pelvis and birth canal in

allowing fetal descent.

2. Passengerrefers to the fetus and its ability to move through the passageway.

3 Powers refers to frequency duration and strength of uterine contractions to

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Mechanisms of Labor

1. Engagement

Refers to the setting of the presenting part of the fetus far enough into the pelvis

to be at the level of the ischial spine, a midpoint of the pelvis.

2. Descent

Is the downward movement of the biparietal diameter of the fetal head to withinthe pelvic inlet. Full descent occurs when the fetal head extrude beyond the dilated

cervix and touches the posterior vaginal floor. The pressure of the fetus on the sacral

nerves causes the mother to experience a pushing sensation. Descent occurs because

of the pressure on the fetus by the uterine fundus.

3. Flexion

As descent occurs, pressure form the pelvic floor causes the fetal head to bend

forward onto the chest. The smaller anteropostreior diameter (the suboccipitobregmatic

diameter) is the one presented to the birth canal in this flexed position. Flexion is aided

by abdominal muscle contraction during pushing.

4. Internal Rotation

During descent, the head enters the pelvis with the fetal anteroposterior head

diameter in a diagonal or transverse position the head flexes as it touches the pelvic

floor, and the occiput rotates until it is superior, or just below the symphysis pubis,

bringing the head into the best diameter for the outlet of the pelvis.

5. Extension

As the occiput is born, the back of the neck stops beneath the pubic arch and acts as a

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after coming shoulders are thus brought into anteroposterior position, which is best for

entering the outlet. The anterior shoulder is born first, assisted perhaps by downward

flexion of infants head.

7. Expulsion

Once the shoulders are born, the rest of the baby is born easily and smoothly

because of its smaller size. This is expulsion and is the end of the pelvic division of

labor.

True Labor versus False Labor

False Contractions True Contractions

1. Began and remain irregular

2. First abdominally and

remain confined to the

abdomen and groin

3. Often disappear withambulation and sleep

4. Do not increase in duration,

frequency or intensity

5. Do not achieve cervical

dilatation

1. Begin irregularly but

become regular and

predictable

2. Felt first in lower back and

sweep around to theabdomen in a wave

3.Continue no matter what

womans level of activity

4. Increase in duration,

frequency and intensity5. Achieve cervical dilatation

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IV. Ideal Nursing Care Plan for the mother

Name of patient:Irish Balacuit

CUES NURSING

DIAGNOSIS

OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:

``Sakit kaayo

akong tahi,`` as

verbalized by the

patient.

Objective:

- Facial

grimace

- Pain scale

of 8/10

- Presence of

episiotomy

Acute pain

related to

episiotomy

secondary to

childbirth

At the end of 30

minutes of nursing

interventions,

patients pain will

be lessened from a

pain scale of 8 to 6.

INDEPENDENT:

1. Reposition as indicated

e.g., semi-fowlers.

2. Provide additional

comfort measures, e.g.,

back rub heat/coldapplications.

3. Encourage use of

relaxation techniques

e.g., deep breathing

exercises, guided

imagery.

1. May relieve pain and

enhance circulation.

2. Improves circulation,

reduces muscle tension

and anxiety associatedwith pain. Enhances sense

of well being.

3. Relieves muscle and

emotional tension;

enhances sense of control

and may improve coping

abilities.

After 3

minutes of

nursing

interventions,

patients pain

was lessenedfrom 8 to 6.

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4. Respond immediately

to complaints of pain.

Dependent:

1. Administer Mefenamic

acid 500mg 1 cap PRNas ordered by the

physician.

4. In the midst of painful

experiences, patients

perception of time may

become distorted. Prompt

responses to complaints

decreased anxiety in

patient.

1. It has an anti-

inflammatory and analgesiceffect that could relieve

pain and decrease

stimulation of the

sympathetic nervous

system.

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CUES NURSING

DIAGNOSIS


Subjective:

daghan-daghan

pa akong dugo,

gikan sa pag

panganak as

verbalized by the

patient.

Objective:Postpart

um

wound

weak

Risk for

infection related

to postpartum

wound.

At the end of 1 hour

of nursing

interventions,

patient will be able

to prevent from

getting an infection.

INDEPENDENT:

1. Monitor vital sign

especially Temperature.

2. Encourage intake of

protein and calorie rich

foods

3.Wash hands and teach

other care giver to wash

hands, before contact

with patient and betweenprocedures with the

patient

4. Maintain or teach

asepsis for dressing

changes and wound care.

Dependent:

1. Administer Co-

1. To indicate present of

infection

2. This maintain optimal

nutritional status

3. To remove

microorganism from the

hands.

4. Use of aseptic

technique decreases the

chances of transmitting or

spreading pathogens to the

patient

1. A combination of a

After 1 hour of

nursing

intervention,

patient was

able to prevent

getting an

infection.

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amoxiclav 500mg 1 tab

BID as ordered by the

physician.

penicillin and a substance

called clavulanic acid. It

kills bacteria by interfering

their ability to form cell

walls. The bacteria

therefore breakdown and

die.

CUES NURSING

DIAGNOSIS


Subjective:

``Dili pa nako kaya

maglihok-lihok kay

sakit akung tahi,``

as verbalized by

the patient.

Objective:

-Weakness

-Body malaise

Activity

intolerance

related to

generalized

weakness

secondary to

postpartum

wound


nursing

interventions,


to ambulate and

regain strength.

INDEPENDENT:

1. Assess patient's ability

to perform normal

tasks/ADLs, noting

reports of weakness,

fatigue and difficulty

accomplishing tasks.

2. Assist patient to

prioritize ADLs/desired

activities. Alternate rest

1. Influences choice of

interventions/needed

assistance.

2. Promotes adequate rest,

maintains energy level, and

alleviates strain on the

After 1 hour of

nursing

intervention,

was able to

regain strength

and ambulate.

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-Inability to

ambulate

periods with activity

periods. Write out

schedule for patient to

refer to.

3. Recommend quiet

atmosphere; bed rest if

indicated.

4.Provide/recommend

assistance with

activities/ambulation asnecessary, allowing

patient to do as much as

possible.

5. Note changes in

balance/gait disturbance,

muscle weakness.

cardiac and respiratory

systems

3. Enhances rest to lower

body's oxygen

requirements, and reducesstrain on the heart and

lungs.

4. Although help may be

necessary, self esteem is

enhanced when patientdoes something for self.

5. May indicate

neurological changes

associated with vitamin

b12 deficiency, affecting

patient safety/risk of injury.

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CUES NURSING

DIAGNOSIS


Subjective:

`` Wala koy gana

mukaon kay luya

pa akong lawas ``as verbalized by

the patient.

Objective:

-

restless-weak in

appearance

Risk for imbalance

nutrition: less than

body requirements

related to changesin digestive

process/absorption

of nutrients

secondary to

fatigue

At the end of 1

hour, the patient will

be able to eat and

regain strength.

INDEPENDENT:

1. Provide oral

hygiene on regular,

frequent basis,

including petroleumjelly for lips.

2. Encourage the

patient to eat food

with high calories

and increaseadequate fluid

intake.

3. Explain the

importance of having

a good nutrition.

4. Encourage the

patient to eat foods

1. Prevents discomfort of

dry mouth and help to

have desired in ingesting

foods.

2. To provide nutrients

and give strength to

patient.

3. This is to let the

patient realize that her

nutrition will have a great

influence in taking care

of her baby.

4. This will make the

patient eat since it is her

After 1 hour of

nursing

interventions, the

patient was able toeat and regain

strength.

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of her choice.

5. Provide a quiet

environment, limit

visitors as needed

foods.

favorite

5. It promotes rest and

relaxation, thus, will

allow the patient to

regain strength.

CUES NURSING

DI

AGNOSI

S


Subjective:

`` lisod kog tulog

kay saba ang

palibot `` as

verbalized by the

patient.

Sleep pattern

disturbance

related to ambient

noise

At the end of 1

hour, the patient will

be able to have

comfort and

manage to rest and

fall asleep.

INDEPENDENT:

1. Encouraged the

patient to limit the

visitors.

2. Encourage to

drink warm milk

before bedtime.

1. This will promote

comfort at the same time

rest and relaxation.

2. To have comfort and

help to promote sleep.

After 1 hour of

nursing

interventions, the

patient was able to

eat

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Objective:

-fatigue

-weakness

-noisy and crowded

3. Instruct to limit or

provide linens to

have comfort and

promote sleep.

4. Provide comfortsuch as back

rubbing.

5. Instruct to limit

fluid intake in

evening.

3. This is to let the

patient realize that her

nutrition will have a great

influence in taking care

of her baby.

4. This will enhancerelaxation thus, makes

the patient fall asleep.

5. To reduce the need

for nighttime elimination.

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Ideal Nursing Care Plan for the newborn

Name: Baby boy Balacuit

CUES NURSING

DIAGNOSIS


Subjective:

- not

applicable

Objective:

- fresh cut

umbilical

cord

Risk for

infection related

to exposed

umbilical cord


of nursing

interventions,


to prevent from

getting an infection.

INDEPENDENT:

1. Monitor vital sign

especially Temperature.

2. Wash hands before

and after contact to the

patient.

3. Assess immunization

status.

4. Instruct mother to

maintain asepsis fordressing changes and

wound care.

5. Limit visitors.

1. To indicate present of

infection

2. To prevent transmission

of microorganism.

3. Young age is prone in

getting an infection, thus,

the baby is at higher risk.

4. Use of aseptic technique

decreases the chances oftransmitting or spreading

pathogens to the patient.

5. To reduce number of

microorganism in the

After 1 hour of

nursing

interventions,

patient was

able to protect

from getting an

infection.

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patient that is present in

the environment.

CUES NURSING

DIAGNOSIS


Subjective:

- not

applicable

Objective:

- Abnormal

breath

sounds

- crackles

Risk for

aspiration

related to

presence of

secretions

At the end of 30

minutes of nursing

interventions,


to experience no

aspiration as

evidence by

noiseless

respiration

INDEPENDENT:

1. Elevate head of

bed at 30 degreesand infant proppedon right side afterfeeding.

2. Breastfeed babyfrom time to time

3. Assist posturaldrainage

4. Suction secretions

5. Maintain proper

position

1. To avoid aspiration

2. To avoid discomfort andaspiration3. To mobilize secretions

4. It prevents secretionsfrom obstructing airway

5. To facilitate drainage of

secretions

At the end of

30 minutes

nursing

intervention,

patient was

able to

experience no

aspiration as

evidence by

noiseless

respiration

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CUES NURSING

DIAGNOSIS


Subjective:

- notapplicable

Objective:

- cool skin

Hypothermia

related to coldenvironment

At the end of 30

minutes of nursinginterventions, the

baby will be able to

prevent from having

hypothermia.

INDEPENDENT:

1. Note underlying cause

(e.g., cold environment).

2. Remove wet clothing.

Wrap in warm blankets,

extra clothing, as

appropriate.

3. Place knit cap on

infants head.

4. Avoid use of heat

lamps or hot water

bottles.

5. Measure core

temperature.

1. To assess

causative/contributingfactors

2. To prevent further

decrease in body

temperature.

3. Prevent further decrease

in body temperature.

4. Surface rewarming can

result in rewarming shock

due to surface vasodilation.

5. To evaluate effects of

hypothermia.

After 3

minutes ofnursing

interventions,

baby was able

to display core

temperature

within normal

range.

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CUES NURSING

DIAGNOSIS


Subjective:

- not

applicable

Objective:

- the baby is

place in the

bed

Risk for Injury

related to the

weakness of the

mother to

provide care for

the baby.


of nursing

interventions, the

baby will be

provided care and

safety by the

mother.

INDEPENDENT:

1. Maintain a safe

environment e.g. keeping

all necessary objects out

of babys reach.

2. Ascertain knowledge

of needs/injury prevention

and motivation to prevent

injury.

3. Handle infant gently.

Limit use/release

restraints periodically.

4. Initiate safety

1. To reduce accidental

injury to the baby.

2. Indicator for need of

information, assistance

with making positive

changes, thus, promoting

safety and security.

3. Skin /tissues are more

fragile and at greater risk

for damage.

4. Preventing injuries and

After 1 hour of

nursing

interventions,

the baby was

provided care

and safety by

the mother.

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precautions as

individually appropriate

e.g. bed in low position,

padded side rails,

infection precautions, and

medications in child

proof.

5. Instruct the mother to

place the baby nearer to

her.

complications is a prime

responsibility of parents

and care givers.

5. This is to guard the baby

from any falls.

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CUES NURSING

DIAGNOSIS


Subjective:

- not

applicable

Objective:

- thin in

appearance

Risk for

imbalance

Nutrition: less

than bodyrequirements

related to the

weakness of the

mother in

breastfeeding

the baby

At the end of 2

hours of nursing

interventions, the

baby will be able tobe breastfeed and

provided good

nutrition by the

mother.

INDEPENDENT:

1. Identify the infants risk

for malnutrition.

2. Determine whether

the infant is breastfeed orformula feed and typical

pattern of feedings during

a 24 hour period.

3. Emphasize the

importance of well-

balanced nutritious

intake.

4. Consult dietitian.

5. Refer to home care

1. Provide opportunity for

timely intervention.

2. Providing usual and

typical feedings isimportant to infant well

being and early growth.

3. Providing age

appropriate guidelines to

children as well as to

parents/care providers may

help them in making

healthy choices.

4. Useful in determining

individual nutritional needs

and therapeutic

diet/feedings.

5. To asses with initiation

After 2 hours of

nursing

interventions,

the baby wasable to be

breastfed by

the mother.

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resources unless

indicated by specific

condition or illness.

of home nutrition therapy

when used.

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V. Actual Nursing Management (SOAPIE) for the mother

SSakit kaayo akong tahi, as verbalized by the patient.

O

-Facial grimace

- pain scale of 8/10

- Presence of episiotomy

AAcute pain related to episiotomy secondary to childbirth

P

At the end of 30 minutes of nursing intervention, the patients pain

will be lessened from pain scale of 8 to 6.

I

Independent:

1. Positioned the patient in a side lying.

2. Provided comfort measures such as back rubs.

3. Encouraged to take the medication on the right amount/dose

and time as ordered by the physician.

4. Demonstrated and encouraged use of relaxation technique

such as deep breathing exercises.

5. Encouraged to verbalize the intensity of pain.

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S

daghan-daghan pa ang akong dugo gikan panganak, as

verbalized by the patient.

O

-postpartum wound

-weak

A

Risk for infection related to postpartum wound

P

At the end of 1 hour of nursing interventions, patient will be able to

prevent from getting an infection.

I

Independent:

1. Instructed to always wash hands before and after in contact to

wound.

2. Encouraged intake of protein and calorie rich foods.

3. Instructed to do perineal care.

4. Maintain or teach asepsis for dressing changes and wound care.

5. Instructed to take the medication Co-amoxiclav 500mg 1 tab BID

as ordered by the physician.

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S

dili pa na ko kaya ang maglihok-lihok kay sakit pa ako tahi, as

verbalized by the patient.

O

-body malaise

-presence of episiotomy

-inability to ambulate

A

Activity intolerance related to generalized weakness secondary to

postpartum wound

P


ambulate and regain strength.

I

Independent:

1. Encouraged to take the prescribed medication as ordered by the

physician.

2. Recommended to maintain bed rest.

3. Instructed the patient about proper positioning (e.g. side lying).

4. Encouraged to eat nutritious food for faster recovery.

5. Instructed to change position every two hours.

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SWala koy gana mukaon kay luya pa akong lawas `` as verbalized by

the patient.

O

--restless

-weak in appearance

A

Risk for imbalance nutrition: less than body requirements related to

changes in digestive process/absorption of nutrients secondary to

fatigue

P

At the end of 1 hour of nursing interventions, the patient will be able

to eat and regain strength.

I

Independent:

1. Encouraged to do oral hygiene on regular basis.

2. Encouraged the patient to eat food with high calories and

increase adequate fluid intake.

3. Explained the importance of having a good nutrition.

4. Encouraged the patient to eat foods of her choice.

5. Instructed to limit visitors as needed.

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S

lisod kog tulog kay saba ang palibot, as verbalized by the patient.

O

- fatigue

- weakness

- noisy and crowded

A

Sleep pattern disturbance related to ambient noise

P


have comfort and manage to rest and fall asleep.

I

Independent:

1. Instructed to drink milk before bedtime

2. Encouraged to have relaxation technique before bedtime such asdeep breathing exercise.

3. Instructed to limit or provide linens to have comfort and promote

sleep.

4. Encourage to limit visitors.

5. Provide comfort such as back rubbing.

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V. Actual Nursing Management (SOAPIE) for the newborn

S Not applicable

O - Fresh cut umbilical cord

A Risk for infection related to exposed umbilical cord

P At the end of 1 hour of nursing interventions, patient will be able

to prevent from getting an infection.

I

INDEPENDENT:

1. Encouraged mother to bond her baby and keep it warm2. Instructed mother to wash hands before and after contact to

the baby.

3. Instructed to mother in proper cleaning the umbilical cord.

4. Reminded mother to avoid exposing the baby from unclean

environment.

5. Instructed the mother to have a check-up when things go

wrong.

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S Not applicable

O - Abnormal breath sounds

- crackles

A

Risk for aspiration related to presence of secretions

P

At the end of 30 minutes of nursing interventions, patient will beable to experience no aspiration as evidence by noiseless

respiration

I

Independent:

1. Instructed to elevate head2. Instructed mother to position infant properly3. Recommended mother to breastfeed baby from time to

time4. Reminded mother to let her baby burp after breastfeeding5. Instructed to maintain position

E

At the end of 30 minutes nursing intervention, patient was able to

experience no aspiration as evidence by noiseless respiration

S N t li bl

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S Not applicable

O - Cool skin

A Hypothermia related to cold environment

P

At the end of 30 minutes of nursing interventions, the baby will be

able to prevent from having hypothermia.

I

INDEPENDENT:

1. Monitored vital signs (e.g., T, RR, HR)

2. Instructed mother to keep baby warm.

3. Demonstrated proper bundling of baby.

4. Placed knit cap on infants head.

5. Instructed mother about the importance of proper clothing of

baby.

E

After 30 minutes of nursing interventions, baby was able to

display core temperature within normal range.

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O - The baby is place in the bed

A Risk for injury related to the weakness of the mother to provide

safety for the baby.

P At the end of 1 hour of nursing interventions, the baby will be

provided care and safety by the mother.

I

INDEPENDENT:

1. Instructed the mother to place the baby nearer to her.

2. Encouraged to raise the side rails as necessary.

3. Taught the mother in the proper handling of the baby.

4. Instructed the mother to arrange the things that could cause

any injury to the baby.

5. Encouraged the mother to lower the bed position.

E

After 1 hour of nursing interventions, the baby was provided care

and safety by the mother.

O Thin in appearance

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O - Thin in appearance

A Risk for imbalance Nutrition: less than body requirements relatedto the weakness of the mother in breastfeeding the baby

P At the end of 2 hours of nursing interventions, the baby will be

breastfeed and will be provided good nutrition by the mother.

I

INDEPENDENT:

1. Instructed the mother to beast feed the baby for at least

6months to 2 years.

2. Encouraged mother to pay attention on the babys nutrition.

3. Instructed the mother to visit the pediatrician to check for

babys health.

4. Reminded the mother for the needed vitamins of the baby.

5. Encouraged the mother to have a complete immunization .

E

After 2 hours of nursing interventions, the baby was able to be

breastfed by the mother.

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VI. Drug study

GenericName of

Ordered

Drug

BrandName

DateOrdered

Classification Dose/Frequency

Route

Mechanismof Action

SpecificIndication

Contraindication Side

Effects

NursingPrecautions

Co-

amoxiclav

Augme

ntin

1-14-11 Antibiotic 500mg 1

tab PO BID

(8am-6pm)

A

combination

of a

penicillin

and a

substance

called

clavulanic

acid. It kills

bacteria by

interfering

their ability

to form cell

walls. The

bacteria

therefore

breakdown

and die.

To kill the

bacterias

since the

patient

has in the

postpartu

m .

Contraindicated

with an allergy to

its ingredients,

history of jaundice

and liver disease

caused by the

medication.

Headca

he,

itching

or rash,

diarrhe

a,

vomitin

g,

nausea

and

jaundic

e.

Use with

caution in

patients with

a history of

allergies,

kidney and

liver disease.

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Name of patient:Irish Balacuit

Generic

Name of

Ordered

Drug

Brand

Name

Date

Order

ed

Classification Dose/

Frequency

Route

Mechanism

of Action

Specific

Indication


Effects

Nursing

Precautions

Mefenamic

acid

Dolfenal 1-14-

11

Anti-

inflammatory

and analgesic

500mg 1

cap PRN

It inhibits the

growth and

replication of

susceptible

bacterial

organism

To relieve

pain

caused by

perineal

sutures.

Hypersensitivity

to mefenamic

acids and with GI

problems.

CNS:

dizzine

ss,

headac

he,

insomni

a.

CV:

periphe

ral

edema.

Skin:

rash.

.Assess for

allergic

reaction:rash,

fever, pruritus

urticaria:prod

uct should be

discontinued.

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Generic

Name of

OrderedDrug

Brand

Name

Date

Order

ed

Classification Dose/

Frequency

Route

Mechanism

of Action

Specific

Indication


Effects

Nursing

Precautions

Ferrous

Sulfate

(Feosol) 1-14-

11

Iron

supplement

1cap OD

PO

Elevates the

serum iron

concentratio

n, which

then helps to

form HgB or

trapped in

the

reticuendoth

elial cells for

storage and

eventual

conversion

to a usable

form of iron.

To prevent

iron

deficiency

anemias

after

delivery.

Patients with

allergy to any

ingredients ;

sulfite allergy,

hemochromatosis

, hemosiderosis,

hemolytic

anemias.

CNS:

CNS

toxicity,

acidosi

s coma

and

death

with

overdos

e

G.I: G.I

upset

anorexi

a

History:

allergy to any

ingredient,

sulfite,

hemachromat

is.

Encouraged

to drink it with

calamansi

juice for

faster

absorption.

VI. Discharge Planning

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g g

MEDICATION

Patient was advised to take her prescribed medications at exact time

with the right dosage, route and frequency. These drugs were as follow:

Co-amoxiclav 500mg 1 cap BID, Mefenamic acid 500mg I cap PRN,

Ferrous sulfate1 cap OD PO. Patient was also taught the rationale of

each medication and its possible side effects. Medications should be

taken religiously. Strict compliance must be observed

EXERCISE Encouraged patient to avoid extraneous activities to prevent

exhaustion. Encourage also performing activity gradually such as

walking to improve blood circulation, maintain good body posture,

relieves pain and promotes comfort. Patient was also taught and

encouraged to do deep breathing exercises to maximize lung

expansion for proper oxygenation.

TREATMENT Encouraged the patient to follow strict regimen in cleaning the perineal

area. Patient was also taught to use alternative herbal medicine to

wash her perineal area such as boiling the guava leaves.

OUT

PATIENT

Advised the patient to return one week after discharge on January 21,

2011 on OPD. In addition, the check-up will note any changes in the

health status of the patient for further analysis.

DIET Advised the patient to eat fruits and vegetables especially those rich in

protein for it repair the tissue and prevent further tissue breakdown.

This includes fish, meat and eggs. Also foods rich in iron to prevent

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VIII. References

y Doenges, M., et al.(2002). Nursing Care Plans 6th edition.

Thailand: F.A. Davis Company (Reprinted). Pgs 911- 912,

y http://www.google.com.ph/mefenamic acid

y Deglin, J. H. and April Hazard Vallerand(2005). Daviss Drug Guide for Nurses

10th edition. Thailand: iGroup Press Co., Ltd. pp 257-258, 264-266, 419-

421,

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Documents

Case Study 203