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D. History of Past Illnesses
She remembers having vaccines as a kid but she doesn't know what it is. She received tetanus toxoid in her pregnancy but can¶t remember how she have received the vaccine. She also had chicken pox and mumps when still a kid. She frequently has colds and cough. She also have hypertens
currently taking medications to lower blood pressure.
Obstetric History:
Name: CPLAge: 29 years old
Menarche: 3nd
yr high schoolTPAL: G3P3 (3003)
Last Menstrual Period: 2nd
week of March 2009Age of Gestation: 38 weeks
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E. Family Health Illness History
MP-85
+
FP -88
+
FP-60 MP- 58 FP- 56
MP+
- 53
MP-51
FL-81
+ RL + -
71
RL-54
+ S
RL-53
BL-47 YL-41
CL-33
CL ()-29
CL-30 CL-27
CL ()«client+«««.dead
«««... high bloodS«««
. stroke
«««. heart attack«««male
««.. female
BL-51 RL-45 TL-40
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The client¶s age is 29 years old. She has three siblings. Her father died at 51 years old because of stroke. Her mother is still alive
experiencing high blood pressure. Her father has seven siblings, four of them also experiencing high blood pressure. Her mother has fou
The second sibling died because of heart attack. And the elder brother is experiencing high blood pressure. The client¶s grandparents of
already died because of old age except for her grandmother on her mother side who is also experiencing high blood pressure.
F. Functional Health Pattern
Functional Health Pattern Prior to Hospitalization During Hospitalization
Health Management
Pattern
She does self medication when she has fever, cough &colds. She also uses herbal medicines like sambong,
oregano and lagundi.
She didn't take a bath in the hospital.
Nutritional Metabolic
PatternBreakfast Lunch Dinner
3 pandesal w/
mayonnaise, 1glass juice
- ginisang
monggo, 2 cuprice, 2 glasses
of water
adobong baboy,
1 cup rice, 2glasses of water
3 pandesal with pancit canton1cup coffee
1 glass water
ginataanglangka, 1 cuprice, 2 baso
tubig
menudo, 2 cuprice, 2 glassesof water
pandesal andcoffee
1 fried tilapia,1cup rice, 2
glasses of water
greenvegetables,
bangus fillet, 1cup rice 2
Breakfast Lunch Dinner
- - -NPO (admission)
-1 cup sotanghonflavored noodles
-2 glasses of water
-1 cup rice-1 pritong isda
-2glasses of water
-1 cup rice-1 cup sinigng nab
boy withkangkong
-2glasses of water
-1 nissin cup
noodles bulalo-2 glasses of
water
- 1cup rice
- 1platitongmenudo
-2 glasses water
-discharged
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glasses of water
Elimination Pattern
Characteristics Stool Urine
Frequency 1x a day 4x a day
Consistency formed Clear
Odor Foul No odor
Color brownish Orange
yellow
Discomfort None None
Characteristics Stool Urine
Frequency 1st
2nd
3rd
0 0 1
1st
2nd
3rd
0 4 2
Consistency formed Clear
Odor foul No odor
Color brownish Orange yellow
Discomfort None N
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Activity/ Exercise Pattern ADL:
Feeding-0Bed mobility-0General mobility-0
Bathing-0Dressing-0
Toileting-0Grooming-0
1st day 2nd Day 3rd Day
ADL:
Feeding-0Bed mobility-
0General
mobility-0
Bathing-0Dressing-0Toileting-0
Grooming-0
ADL:
Feeding-0Bed mobility-
0General
mobility-2
Bathing-2Dressing-0Toileting-2
Grooming-0
ADL:
Feeding-0Bed mobility-
0General
mobility-0
Bathing-0Dressing-0Toileting-0
Grooming-0
Sleep/ Rest Pattern
Our patient has a sleeping pattern of 9 pm to 6 am , with
9 hours of sleep. Whenever she wants to take rest, shewatches tv and sometimes chat with her neighbors and
takes a nap in the afternoon, usually 1 hour.
She had irregular sleep pattern because she finds it hard to
sleep in the hospital. She usually sleeps at 10 pm and wakes at6 am.
Cognitive PerceptualPattern
She's thinking of having eyeglasses because at times she
finds it hard to read newspapers because her eyes become blurred. She told us that she got teary-eyed when
expose too long to TV.
Still the same.
Self Perception/ Self Concept Pattern
She thinks herself as healthy because she has no vicesand eats all kinds of vegetables.
She feels tired/ stressed out after the delivery. She told us thateven though she already had two kids before she still feels
uneasy carrying them and cleaning their cord. She felt like shewas hurting them every time she wipes the cotton in their
umbilical cord.
Role Relationship Pattern She have a good relationship with her community. Her friends and neighbors visit her whenever they have their
free time. With her partner, they are both happy and havean open communication. Her husband accompany her
She have more time with her baby. Her friends and neighborsin their community visit her and the baby.
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during her discharged with her mother-in- law.
Sexuality ReproductivePattern
She and her partner stopped engaging themselves in
sexual act, 4 month of her pregnancy because of theenlargement of her abdomen. G3P2(2002)
She thinks of having family planning, due to difficult
pregnancy and delivery. Also, because it is already their thirdchild given that she have hypertension. G3P3(3003)
Coping Stress ToleranceShe usually solves her family problems by talking withthe family member. She seeks console from her friends
and elder family members for advice and opinions for
some matters and also asks some affirmation from her husband.
She thinks that with her mother-in-law and husband with her,she can live a happy life and can pass any obstacle, especially
now that she already have three kis.
Values Belief Pattern
She believes in "hilot", the people who heals bone
sprains. She also believes in myths about pregnancy, likeit is not healthy for a pregnant to stay long outside the
house at night. She believes in µbalis¶. She also usesherbal medicines such as oregano, sambong at bayabas.
She doesn¶t take a bath yet because of lack of facilities in the
hospital but is willing to. She believes in ³balis´ and ³hilot´.
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DRUG STUDY
Generic Name Route/ Dosage/
Frequency
Indications/
Purposes
Contrainications Sideffects Adverse Reactions Nursing Respons
Mefenamic
Acid
Route: Oral
Dosage: 500mg,i tab
Frequency:TID
This medication
relieves pain andreduces
inflammation. It isused to treat
headaches,menstrual cramps,
muscle aches,dental pain and
athletic injuries.
y liver or kidney
diseasey blood disorders
y ulcersy heart disease
y
alcohol usey high blood
pressurey eye disease
y allergies(especially drug
allergies)
y Stomach
upsety Nausea
y loss of appetite
y
dizzinessy drowsiness
y diarrheay headache
y yellowing of the eyes
y fever with or without chills
y visionchanges
y black stools
y persistentstomach/
abdominal pain
y
vomit thatlooks like
coffeegrounds
y allergicreactions:
(symptoms)rash, itching,
swelling,severe
dizziness,trouble
breathing
Instruct client to:
y Take withmilk to mi
stomach uy Most effec
relieving m pain if tak
earliest sigy Take this m
with 6 to 8(180-240m
water.y Do not lie
at least 30after takin
drug.y This shoul
taken for m7 days at a
y Report imif any sign
symptomsallergic re
occur.
Ferrous sulfate Route: OralDosage: 250mg,
i tabFrequency:OD
It is used to treatiron deficiency
anemia (a lack of red blood cells
y iron overloadsyndrome
y hemolyticanemia (a lack
y constipation;y upset
stomach;y black or dark-
y signs of anallergic
reaction:hives;
Instruct client to:y Take ferro
on an empstomach, a
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caused by having
too little iron in the
body).
of red blood
cells)
y porphyria (agenetic enzymedisorder that
causessymptoms
affecting theskin or nervous
system)
y thalassemia (agenetic disorder of red blood
cells)y if you are an
alcoholicy if you receive
regular blood
transfusions
colored
stools; or
y temporarystaining of theteeth.
difficulty
breathing;
swelling of your face,lips, tongue,
or throat.
hour befor
hours after
Avoid takiantacids oantibiotics
hours befotaking ferr
sulfate.y Take this m
with a full
water.y Do not cru
break, or o
extended-rtablet or c
Swallow twhole.
y Shake the
suspensionwell just b
measure ay Use this m
exactly as on the labe
prescribeddoctor. Do
in larger afor longer
recommeny Avoid tak
medicationhour befor
hours after
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fish, meat
whole gra
"fortified"cereals.
y Report im
if any signsymptoms
allergic reoccur.
Metronidazole Route: OralDosage: 500mg,
i tabFrequency:TID
It is an antibioticthat is used to treat
a variety of infections.
y liver problemsy seizure
disordersy any allergies
y should not beused during the
first 3 months
of pregnancyand used withcaution during
the last 6months
y It is excretedinto breast milk
and using itwhile breast-
feeding is notrecommended.
y Dizzinessy headache
y diarrheay Nausea
y stomach painy change in
taste sensationy dry mouth
y Seizuresy loss of
consciousness
y tingling of hands or feet
y unsteadinessy mood/mental
changesy rash
y Itchingy sore throat
y Fever y severe
stomach painy vomiting
y vaginalirritation.
Instruct client to;y It should b
with food glass of w
milk to prestomach u
y Antibiotic
best whenamount ofin your bo
at a constaDo this by
medicationspaced int
throughouand night.
to take thimedication
full prescramount is
even if symdisappear
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days.
y Avoid alco
beveragesy Report im
if any sign
symptomsallergic re
occur.
Cefuroxime Route: Oral
Dosage: 500mg,
i tabFrequency:BID
It is used to treat
many kinds of
bacterialinfections,including severe or
life-threateningforms.
y allergic to any
drugs
(especially penicillin)
y liver or kidney
diseasey diabetes
y heart failure,cancer
y a stomach or
intestinaldisorder
y malnourishment
y pregnanty breastfeeding
mothers
y nausea,
vomiting,
diarrhea,stomach pain;
y headache,
dizziness;y fussiness or
crying (inchildren);
y sleep
problems(insomnia); or
y vaginal
itching or discharge.
y diarrhea that
is watery or
bloody;y fever, sore
throat, and
headachewith a severe
blistering, peeling, and
red skin rash;y seizure
(black-out or convulsions);
or y jaundice
(yellowing of the eyes or
skin).
Instruct client to:
y Take this m
exactly as prescribed
y Take cefur
tablets witwithout m
y Use this mfor the ent
of time pre
by your doy Report im
if any sign
symptomsallergic re
occur.
Captopril Route: Oral
Dosage: 25mg, itab
Frequency:BID
It is used to treat
high blood pressure
(hypertension),congestive heart
failure, kidney
y Do not use this
medicationwithout telling
your doctor if you are
pregnant or
y cough;
y loss of tastesensation, loss
of appetite;y dizziness,
drowsiness,
y feeling light-
headed,fainting;
y urinatingmore or less
than usual, or
Instruct client to:
y Take this mexactly as
prescribedy Take each
a full glass
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problems caused
by diabetes, and to
improve survivalafter a heart attack.
planning a
pregnancy.y
kidney disease(or if you are ondialysis)
y liver diseasey heart disease or
congestive heartfailure
y diabetes;
y a connectivetissue diseasesuch as Marfan
syndrome,Sjogren's
syndrome,lupus,
scleroderma, or
rheumatoidarthritis.
headache;
y sleep
problems(insomnia);
y dry mouth,
sores in themouth or on
the lips;y nausea,
diarrhea,
constipation;or
y mild skin
itching or rash.
y
not at all;
y fever, chills,
body aches,flusymptoms;
y pale skin,easy bruising
or bleeding;y fast,
pounding, or
unevenheartbeats;
y chest pain; or
y swelling,rapid weight
gain.
y It is usuall
hour befor
Follow yoinstruction
y Your bloo
should be on a regul
know theeffectiven
drug.
y Avoid drinalcohol.
y Do not use
substitutes potassium
supplementaking cap
unless you
has told yoy Report im
if any signsymptoms
allergic reoccur.
Aldazide Route: Oral
Dosage: 25mg, itab
Frequency:BIDx 3days
postpartum
Essential
hypertension,oedema and ascites
of congestive heartfailure, cirrhosis of
the liver, thenephrotic
syndrome,idiopathic oedema.
y cute renal
insufficiencyy significant renal
compromisey Addison¶s
diseasey significant
hypercalcaemia,hyperkalaemia
y Gynaecomasti
a may developin association
with the useof
ALDAZIDE.Development
of gynaecomasti
y Gastro-
intestinaldisorders
y Skin andappendages:
rash, pruritis,dermatitis
y Nervoussystem
Instruct client to:
y Taken witmilk to pr
upset.y Taken earl
day so incurination w
distub sleey Arrange to
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y hypersensitivity
to
spironolactone,thiazidediuretics or to
other sulfonamide-
derivedmedicines
y Safety in
pregnancy hasnot beenestablished
y Lactation.
a is related to
both dose and
duration of therapy.Gynaecomasti
a is usuallyreversible
whenALDAZIDE
is
discontinuedy breast
enlargement
may persist.
disorders:
dizziness,
headache, paraesthesia.
y Psychiatric
disorders:impotence.
y Neoplasm: breast
neoplasm,
y Metabolicandnutritional
disorders:electrolyte
disturbances. y Haematologi
cal disorders:
thrombocyto penia.
y Other adverse
reactionsreported with
the use of ALDAZIDE
include pancreatitis
andcholestatic
jaundice.
serum, ele
hydration
function dterm thera
y Weigh you
regula basif there is
weight gaireport it to
physician
immediatey Report im
if any sign
symptomsallergic re
occur.
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HEALTH TEACHING
Goals and
Objectives
Learning Content Methodology Venue/ Time/ Date Resources Evalu
Goal:y To teach the
mother inmanaging
breast
engorgement
pain due tonot
breastfeedin
g relate totaking
captopril.
*
Objectives:y To relieve
mothers breast pain.
y To promote
mother an baby
bonding
even if the
baby is not breastfeedin
g.
Contents:y Explanations why the mother cannot continue
breastfeeding.
- captopril is a drug that lowers the blood
pressure. This drug can be passed through
breastmilk and is harmful if ingested by the baby.
y Suctioning of the mothers breasty Bottle feeding techniques
-choose an appropriate nipple size for your
child, use milk formulas according to doctorsadvice or something that fills up the baby¶snutritional needs. Also, remember to sterilized
the baby¶s things before an after using them by boiling it for 5mins.- Put a bib on your baby and have a cloth ready
to clean any spit-up milk or formula. Now,cradle your baby with his head a bit higher thanthe rest of his body. Hold the bottle; don't prop
it up by itself. This can help prevent choking,
extra gas, tooth decay, and provide bondingtime. It¶ll also help you better judge when he's
finished eating. If your baby slows his eating,try burping after every 2 oz.
y Burp method- Your baby needs a burp during or after
feeding and this is how you do it:Hold her on your lap or rest her on your shoulder. Gently pat or rub baby's back. You
can also lay baby tummy-down on your lap,
y Discussion andteaching why theclient cannot
breastfeed.
y Teaching and
demonstration of proper breastsuctioning,
effective bottlefeeding and burp
method.
Venue: OB-wardTime:2:00pm
Date: January 16, 2010
Manpower Bottle
Goal
The cto dem
prope breas
technsuctio
breasof her
The c
able twhy s
contin breas
answequest
correc
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supporting her head, while you pat her back.Your baby may spit up some milk, so have acloth on your shoulder or lap. If she doesn't
burp after a few minutes but seems comfortable,
don't worry. Not every baby burps after every
feeding.