Abruptio Placenta Case Study

2
I. Introduction
A. Description of Health Condition
Overview of the Case
Pre-eclampsia
Pre-eclampsia is the presence of hypertension and proteinuria occurring after the 20th week of gestation except in cases of extensive trophoblastic proliferation. Pre- eclampsia has been further classified as severe in the presence of one or more of the following signs and symptoms.
Signs and Symptoms
Mild Preeclampsia
Severe preeclampsia
Blood pressure
140/90 or higher, or an increase of 30 mmHg in systolic pressure and 15 mmHg increase in diastolic pressure
160/110, or an increase of greater than 30 mmHg in systolic pressure and greater than 15 mmHg
Edema
Mild to moderate edema of hands and face (+1 to +2)
Severe edema of hands and face (+3 to +4),including cerebral edema
Proteinuria
Greater than 0.3 g-1g/L/ 24-hour urine (+1 to +2)
5 g/L/24-hour urine or more (+3 to +4)
Weight gain
Greater than 1lb/week
Equal to or greater than 5 lb/week
Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at Chapter 39 page 587)

3
Abruptio Placenta
Abruptio Placenta is the premature separation of a normally implanted placenta occurring after the 20nd week of gestation when the clinical and pathologic criteria are met. Though it is one of the causes of third trimester bleeding, it may also complicate labor. Hypertonic uterine contractions in labor or sudden uterine decompression may precipitate abruption placenta. Other terms of abruption placenta are accidental hemorrhage, premature separation of the placenta and placental apoplexy.
Etiology / Predisposing Factors
Numerous factors have been suggested to play a role in abruption placenta but a unifying etiologic concept is still lacking.
These predisposing factors are:
1. Maternal Hypertension.
2. Maternal Cigarette Smoking.
3. Premature rupture of membrane.
4. Chorioamnionitis.
5. Severe fetal growth restriction.
6. Advanced maternal age and parity.
7. Thrombophilias.
8. Race or ethnicity.
9. Women with previous abruption.
10. Trauma.
11. Short umbilical cord late in labor as the fetus descends.
12. External or internal version.
13. Sudden decompression of the uterus in cases of over distention, loss of amniotic fluid or after delivery of the first twin.
14. Uterine anomalies or tumors like in retroplacental myomas.
15. Cocaine abuse during pregnancy increases the risk of abruption.

4
Classification
As to extent:
1. Partial – a part has separated
2. Total – the whole placenta has separated
As to onset:
1. Acute abruption- sudden onset of signs and symptoms
2. Chronic abruption- shows hemorrhage with retroplacental hematoma formation being arrested completely without delivery.
As to type of bleeding:
1. External- the bleeding passes between the membranes and the blood escapes through the cervix.
2. Concealed- the bleeding is not seen externally but is retained between the detached placenta and the uterus or may extravasate into the amniotic cavity. The fetal head is closely applied to the lower uterine segment that blood cannot pass through. The extent of bleeding may not be apparent and may present as maternal shock that is disproportionate to the amount of blood loss. The uterus may be larger than age of gestation due to the accumulation of retroplacental blood.
3. Marginal sinus rupture- the placental separation is limited to the margin with minimal bleeding but without uterine tenderness and pain.
Signs and Symptoms
1. Vaginal Bleeding- hallmark of abruption placenta. Only 10% of affected women present with concealed hemorrhage.
2. Abdominal pain- may indicate extravasation of blood into the myometrium or painful hypertonic contractions induced by the abruption.

5
3. Uterine Tenderness- may be generalized or localized to the site of placental detachment.
4. Uterine hypertonus- uterine tonus is elevated, feeling rigid or board like.
5. Fetal distress.
6. Dead fetus.
Complications
Complications of abruption are hemorrhage, coagulation failure, acute renal failure, acute corpulmonale, Sheehan’s syndrome and post transfusion hepatitis. Maternal oliguria and shock may occur. Fetal distress may end in fetal death.
(Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at Chapter 562 page 562-568)
B. Statistical Data
The reported incidence of abruption placenta varies widely in published series according to the population studied and the diagnostic criteria applied.
Incidence in the Philippines varies, from 1 in 200-300 pregnancies. Worldwide incidence is the same.
(Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at Chapter 562 page 562-568)
C. Scope and Limitation
We handled our patient on August 3, 7 and 10 2014 at 6-2 shift and 2-10 shift in Bed 10 OB Ward of Laguna Medical Center- Santa Cruz under Ms. Elizabeth Vivian Mozo, R.N, M.A.N. and Mr. Jayson Celerio, R.N.M.A.N. We received our patient lying on bed with an intravenous fluid of D5NR and Oxygen therapy at 3liters via nasal cannula. The coverage of our duty was Nurse – Patient – Interaction/ Interview, Head – to - Toe Physical Assessment, IV regulation, monitoring and recording of vital signs, and drug administration by oral route. After the patient confinement our group decided to do

6
a home visit for further assessment and to observe the patient’s progress at September 12, 2014.
During our duty we never encounter any problems in gathering data and information about our patient and her condition.
D. Background of Study
The researchers chose the case to attain additional knowledge and skills about the stated problem as presented, to gather health information regarding our client, to know the different laboratory done and result, to attain with the correct nursing care plan for our client and for us to fully understand and be reminded on one of the complications associated with pregnancy.

8
II. Patient’s Profile
Hospital no. : 000000000155915
Hospital Code: 0000194
Patient’ Name: Patient X
Address: 065 Gatid,Santa Cruz (Capital) (26) Laguna
Gender: Female
Birthday: June 3, 1984
Age: 30 y/o
Birthplace: Manila
Nationality: Filipino
Civil Status: Single
Religion: Roman Catholic
Educational Attainment: High School Graduate
Occupation: Waitress when she was 18 years old
Allergies: Seafood
LMP:11/06/13
EDC: 08/13/14
AOG: 37 weeks and 5 days
ADMISSION
Admitting Time: 4:05 am
Admitting Date: 08/02/14
Admitting Clerk: Jane Mae H. Nolasco
Admitting Diagnosis: G3 P2 37 5/7 Weeks
Other Diagnosis: Still Birth
Abruptio Placenta
Pre-clampsia Severe
Procedure: Caesarean
Admitting Physician: Dra. Marila T. Villalon
Chief Complaint: Her reason why she was admitted on the hospital is because she suddenly saw a moderate bleeding from her vagina and felt a severe pain on her low back and abdomen with rapid contractions on her uterus.

10
A. Present Health History
Last August 2, 2014, at nine o’clock in the evening, while our patient was watching television she suddenly saw a moderate bleeding from her vagina and felt a severe pain on her low back and abdomen with rapid contractions on her uterus. Her husband decided to rush her to Laguna Medical Center – Santa Cruz. There and then, her blood pressure was checked and as the doctor found it to be high of 190/120mmHg , she was advised to be confined especially when they found out that the baby was already suffering fetal distress with fetal heart rate of 31 b/m. Later that same night, due to her high blood pressure, the doctor then decided that the patient needed to undergo surgery and was scheduled at four o’clock of the following morning. While she was at the C- Section, her blood pressure was 170/100 mmHg. By 4:23 am, the baby was removed from her womb and unfortunately, the baby was found out to be dead by then. Our patient was confined for fourteen days more.
B. Past Health History
Since 18 years old, she used to drink alcoholic beverages, caffeine-rich drinks and enjoyed eating salty foods. Since she was 20 years old, she thinks she is having a high blood pressure. She did not seek any medical consultation because she felt she could tolerate the head ache. Instead, she is taking herbal medicines like garlic that improved her condition. But, despite continued consumption of herbal intakes, she noticed nape pain and headache. That was when she decided to have a check-up in their Barangay where she was given proper medication to lower her blood pressure.
When she got pregnant, her blood pressure would gradually increase from time to time. But she was able to undergo normal delivery. During pregnancy she noticed again that within the three months, she felt a nape pain and headache. And on the

11
third month of pregnancy she decided to have an ultrasound and they found out a low transverse position of the baby. Lastly, on the seven month of pregnancy, they decided again to have an ultrasound and found out that the baby’s position is back to normal which is cephalic.

12
C. Family History
Legend:
Man Woman A.W - Alive & Well
Mother
CardiomegalyDiabetes
Hypertension
R.I.P
51 y/o
Father
Hypertension
R.I.P
63 y/o
PATIENT X
Hypertensive
SISTER
A.W
SISTER
A.W
LOLO (RIP) Hypertensive
LOLA
(RIP)
(A.W) (RIP)
(A.W) A.W (R.I.P) (RIP)
(A.W) (A.W)
(A.W)

13
D. Developmental History
Experience
Indicators of Positive Resolution
Analysis
Erick Erikson’s Psychosocial
( Adulthood 30-65 old )
Generativity vs Stagnation
“Masaya naman ako sa buhay naming, nakakakain naman kami ng tatlong beses sa isang araw minsan nga pag may pera apat hanggag limang beses pa kahit na janitor ang sawa ko at nagpag- aaral ko naman ang anak ko”
Indication of positive resolution productivity and concern with others.
The patient is aware in her environmental and emphasizes that she is able to cope up with it she is satisfied in what she had now and also she understand the importance of caring for other people
E. Socioeconomic
Starting at the age of 18, the patient became a part time waitress during nighttime, AVON retailer at daytime, and sometimes a laundry washer with an estimated monthly salary of 2500-3000 pesos per month. But since when she had her new partner in life last 2013, she stopped on working and became a fulltime housewife and a mother as advised by his partner.
F. Psychological
The patient was able to answer every question that was asked to her and can appropriately give a feedback about it.

14
G. Spiritual
The patient is a Roman Catholic. She views God as the father of heaven and a supreme creator although she’s not an active member of a church. She rarely go to church. But still, she has her faith and was able to express her feelings to God through prayer sometimes.
H. Sociocultural
The patient consults to a “hilot” and herbularyo as the primary health care provider. When one of the family member experiences a cough, colds or fever, they are treating it first at their home with self-medication like taking “Mag asawang gamot” , the Antibiotic and Paracetamol. But when the time comes that a more serious health condition happens, she is immediately consulting it to the hospital.
I. Elimination
Before Hospitalization
During Hospitalization
After Hospitalization
Patient’s bowel routine is 1 – 2 times daily. The stool is color brown and solid in appearance. She voids 2 -3 times a day with a yellow color urine output.
The patient was inserted an indwelling Foley catheter. She had her bowel movement on her second day on the hospital.
Patient’s bowel routine is once or twice a day. The stool color is brown or sometimes yellow in a usual amount. She voids 5 times a day with a urine color of yellow.
J. Exercise
Patient doesn’t have regular exercise. But she always do the household chores like sweeping the floor, washing clothes and dishes and views as these as her primary body exercise.

15
K. Hygiene
The patient takes a bath once a day. But sometimes when she feels uncomfortable she’s doing it twice. In the morning before going to work and evening before going to sleep.
The patient takes a shower when she can walk through and go to the comfort room but ask her father to apply sponge bath when she cannot.
The patient takes a bath once every day.
L. Sleep and Rest
According to the patient, she enjoys watching Korean Telenovela in the middle of the night. Habitually, she sleeps at 2 am or 3 am and waking up in the morning at 9 am or 10 am.
The patient experienced disturbance in her sleeping pattern when she was on the Hospital. Every time she heard a crying baby while she’s sleeping during the night, she suddenly wakes up and imagining that this sound is from her own baby and feels like she was longing for the presence of it. She continues her sleep after 4-5 hours and mostly has time to sleep in the
The patient still enjoys watching movies at night especially Korean Telenovelas during midnight. She now sleeps at 11 pm to 5:30 am and wake up at 9 am – 10 am. Sometimes, depression during the night still disturbs her sleeping pattern.

16
morning after the rounds of the Doctor at 8 am.
M. Nutritional Status
The patient loves to eat noodles and salty foods like junk foods. She also eats vegetables like bitter gourd, lady finger and green beans. She drinks 3-4 glasses of water and consumes 3-4 cups of coffee a day. For her meal she consumes about 2-3 cups of rice and she enjoys eating with condiments such as 1 ½ tablespoon of soy sauce and fish sauce. Sometimes, she consumes 3 matchbox size of meat a day. During her hospitalization, the patient always eat 6-7 pandesals or sometimes 1-2 cups of rice per meal with vegetables soup, fried chicken and a cup of coffee in the morning. And at home after her hospitalization, she still loves to eat noodles and salty foods like junk foods. She drinks 4 glasses of water and consumes almost 4 cups of coffee a day. For her meal, she consumes about 1 ½ - 2 cups of rice and still enjoys eating with condiments such as 1 ½ tablespoon of soy sauce and fish sauce.
N. Alcohol Use
According to her, she starts drinking alcoholic beverages at a young age of 18. She feels like it is a stress reliever when she’s in pain or depressed. She likes drinking with her friends. They drink beer and sometimes Lambanog. In a group of 3-4 people, each can consume 6 bottles of beer and they sometimes consume 4 bottles of Lambanog every session, thrice a month. But as the time goes by, reaching the age of 30’s, she drinks alcohol occasionally. Until now, the patient is drinking alcohol whenever her friends invite her or when she and her partner want.
O. Tobacco Use
According to our patient, she started using tobacco at the age of 18, she consumes 6-7 sticks a day but when she got her first pregnancy she stopped smoking

17
and after she delivered the baby she started consuming tobacco again. The same when she was pregnant in her 2nd baby and the last baby whose stillbirth. At the present, she stated that she have already stopped smoking.
P. Obstetric
The patient is G3 T2 P0 A0 L2. She first became pregnant when she was 22 years old. She delivered her first baby normally. It was a full term baby boy. At the age of 24, she became pregnant again and delivered a full term baby girl. And she got pregnant again at 30 years old.

19
PHYSICAL ASSESSMENT
Area
Methods
Findings
Interpretation & Reference
Integumentary System
 Skin
 Inspection/ Palpation
- Pallor
- poor skin turgor
 This is due to the blood loss during the post surgical procedure/ post caessarean delivery.
 In the presence of excess of interstitial fluids on area of edema becomes dry and shinny
Ref: Fundamentals of Nursing by Kozier, Erbs
Vol 2 pg 1436
 Hair
 Inspection
- well distributed & black in color hair
NORMAL
 Nails
 Inspection
- Pale Nail Beds
 This is due to the blood loss during the post surgical procedure/ post caessarean

20
 Blanching of capillaries
- 3-4 seconds capillary refill upon blanching
delivery.
 This is manifested of decrease level of RBC`s due to edema.
Head
 Skull & Face
 Inspection
 Palpation
- Facial& periorbital Edema
- Smooth Skull contour; no Nodules or masses
 Increased interstitial fluid due to sodium & water retention in areas where the tissue pressure is low, the areas become more permeable, allowing fluid to escape into interstitial tissues.
Ref.: Fundamentals of Nursing by Kozier, Vol 2 pg 1436
 NORMAL
 Eyes & Vision
 Inspection
- both sclera are white
 NORMAL

21
 Ears & Hearing
Inspection
- with blurring of vision
-Pupils(4mm)
equally round, reactive to light and accommodation
- Pale
Conjunctiva
- symmetrical ears and equal size
- no build up of cerumen/ear wax
No pain noted upon palpation and no presence of swelling
- both ear auricles non tender
 This is due tohigh blood pressure of 160/100
 This is due to post anesthetic effect
 NORMAL
 This is due to the blood loss during the post surgical procedure/ post caessarean delivery.
 NORMAL
Nose & Sinuses
Inspection
- nose is symmetrical in shape and same in color with face
- patient can breathe with one nostril when other is closed
 NORMAL

22
Palpation
- no presence of discharge
-No presence of bumps and tenderness
-No pain noted
- Non tender Sinuses
 NORMAL
Mouth & Oropharynx
Inspection
- Pale Oral Mucosa

Neck
 Neck Muscles
 Lymph nodes of the neck
 Trachea
 Thyroid gland
Inspection
Palpation
Palpation
Auscultation
Palpation
-symmetrical in strength
-symmetrical movement of neck muscles
-lymph nodes are non palpable
-trachea is in midline position
- tracheal sound is heard
-butterfly in shape in midline position, non palpable lobes, not enlarged, and rises as patient swallows
 NORMAL
 NORMAL
 NORMAL
 NORMAL
 NORMAL

23
Thorax & Lungs
 Chest shape & size
RR = 15cpm
 Breath sounds
Inspection
Palpation
Percussion
Auscultation
-symmetrical chest shape & size
-No barrel chest
-no use of accesory muscles,(scalene and sternocleidomastoid) muscles while breathing
-there are no retractions of intercostals spaces
-upon deep breathing anterior thoracic expansion: approximately 2 cm.
-symmetrical chest expansion
-symmetrical fremitus
-resonant tone in intercostal spaces
- clear breath sound heard on both lungs
 NORMAL
 NORMAL
Cardiovascular & Peripheral Vascular system
 NORMAL

24
 Heart (sound)
 Central Vessels(carotid arteries & jugular vein)
 Perpheral Vascular System(Peripheral pulses,veins and perfusion)
Auscultation
Palpation
Palpation
Auscultation
Inspection
- S1 corresponds with each carotid pulsation. S2 immediately follows after S1
- no extra heart sounds and murmurs
-apical pulse >3cm:displaced away from MCL 5th ICS
-equal in pulse rate, rhythm of carotid arteries, and amplitude of 2+
-no bruits upon auscultation of the carotid arteries
-jugular vein not distended
-Capillary refill of nail beds is 3-4 second.
-peripheral pulses(radial,
Brachial) are equal
 NORMAL
 NORMAL
This is manifested of decrease level of RBC`s due to edema
 NORMAL

25
in pulse rate and rhythm
-No bulging veins
Neurologic:
 Mental status
 Level of consciousness
Inspection
Inspection
- speech is of appropriate age and flows easily
-maintains eye contact, can smile and frown appropriately
-awake, alert and oriented to date,time and place, person and responds to stimuli - Glascow coma Scale: Score 15
 NORMAL
 NORMAL
Cranial Nerves
 CN I (olfactory)
 CN II
 CN III,CN IV,
Inspection/ Observation
- identifies odors correctly
-can read a printed writing at 16 inches without difficulty
-eyes move
 NORMAL

26
CN VI
 CN V
 CN VII
 CN VIII
 CN IX & X
smoothly and coordinated coordinated motion in all six cardinal directions
-temporal and masseter muscles contarct bilaterraly
-correctly identified sharp and dull stimuli of an object
-there symmetry of the left side of the face upon puffing of cheeks, smiling,rising of eyebrow
-can hear whisphered words at a distance of 1/2 ft. In both ears
-uvula and sift palate rises bilaterally and symmetrical upon saying “ ah”
-gag reflex is present
-there is symmetric contraction of the trapezius muscles upon shrugging of shoulders against resistance
-tongue movement is symmetrical and smooth and strength is bilateral.

27
 CN XI
 CN XII
- no tremors seen
- having no difficulties of rapid alternating movements
-intact light touch sensation
-correctly identifies direction of movement of finger & toes withe yes is closed
Breast and Axillae
Inspection
Palpation
- Breast is smooth, undimpled and the same color of the skin
- no edema noted
- with breast assymmetry on left side
- no lesion seen
- no palpable
Mass
- with both breast tenderness

Uterus
Inspection
Palpation
Uterus is in midline
- uterus is firm, globular and contracted
- with periumbilical incision
 Normal

28
Bladder
Palpation
- bladder is not distended
 The Patient have a foley catheter.
Bowel Movement
observation
- with positive bowel movement
- with positive flatus

Lochia discharge
Inspection
- pinkish in color

Inscision
Inspection
- dry and intact

Extremities
Inspection
- there is edema seen on both extremities
 Due to sodium retention and high blood pressure
 Due to decrease oncotic pressure
Musculoskeletal system:
 Muscle
Inspection
- symetrical and equal muscle mass,tone and strength
-rate of muscle strength is 4 in all four extremities

Breast and Axillae
Palpation
Inspection
- No breast engorgement
 Normal

30
Reproductive System
Functions:
 Production of female sex cells.
The reproductive system produces female sex cells, or oocytes, in the ovaries.
 Reception of sperm cells from the male.
The female reproductive system includes structures that receive sperm cells from the male and transports the sperm cells to the site of fertilization
 Nurturing the development of and providing nourishment for the new individual.
The female reproductive system nurtures the development of a new individual in
the uterus until birth and provide nourishment in the form of milk after birth.
 Production of female sex hormonesormones produced by the female reproductive system control the development of the reproductive system itself and of the female body form. These hormones are also essential for the normal function of the reproductive system and reproductive behavior.
Uterus:
 Uterus is a big as a medium-sized pear.
 Oriented in the pelvic cavity with the larger, rounded part directed superiorly.
 The part of the uterus superior to the entrance of the uterine tube is called the fundus.
 Main part of the uterus is called body, and the narrower part, the cervix.
The Placenta
 The placenta (Latin for “pancake” which is descriptive of its size and appearance at term ) arises out of the continuing growth of trophoblast tissue. Its growth parallels that of the fetus growing from a few identifiable cells at the beginning of pregnancy to an organ 15 to 20 cm in diameter 3 cm in depth covering about half the surface area of internal uterus at term.
 Functions of the Placenta
 Nutrition- transport nutrients and water soluble vitamins.
 Exchanges- Fluid and gas transport (diffusion- oxygen, carbon dioxide, electrolytes)
 Facilitated transport (glucose)
 Active transport- Amino acid, Calcium, iron

31
Circulation
 As early as the 12th day of pregnancy, maternal blood begins to collect in the intervillous spaces of the uterine endometrium surrounding the chorionic villi.
 By the 3rd week, oxygen and other nutrients such as glucose, amino acids, fatty acids, minerals, vitamins, and water, osmose from maternal blood through the cell layers of the chorionic villi into the villi capillaries. From there, nutrients are transported to the developing embryo.
Blood Vessels
Arteries
Are blood vessels that carry blood away from the heart.
Veins
Blood vessels that carries blood toward the heart.

34
Maternal & Child Health Nursing 6 edition Vol.1
Chapter 9 the growing fetus Page 193, 195

36
Precipitating Factor
 Age
 Family History
 Medical History
 Lifestyle
Predisposing Factor
 Maternal Hypertension
(PIH, Chronic HTN,
 Maternal Cigarette Smoking
 PROM
 Chorioaminionitis
 Severe fetal Growth Restriction
 Advance maternal Age and parity
 Race or ethnicity
 Women with previous abruption
 Traumatic injury
 Maternal hyperhomocystinemia
 Short umbilical cord
 External and internal version
 Sudden decompression of the uterus
 Uterine anomalies
 Cocaine abuse
Decrease resiliency of blood vessel at placental bed
Decrease resiliency of blood vessel at placental bed
Torn or ruptured blood vessels
Partial Separation
Peripheral portion detached
Mild to moderate vaginal bleeding
Increase uterine wall irritability
FHT may be reassuring
Progressive separation
Uterine tetany fetal distress (decrease variability) (late acceleration)
50% separation severe fetal distress
Central Portion Detached
(mild to moderate concealed bleeding)
Blood trapped to intact peripheral portion
Fluids enter muscle fibers
Uterus turns
blue or purple
uteroplacental apoplexy
Total separation
Massive Vaginal or Concealed Hemorrhage
Decrease Platelet
Decrease Fibrin
Degeneration
Maternal Shock
(100%)
Decrease BP
Increase PR
DIC
Renal Failure
Heart Failure
Maternal death
Fetal Death (100%))
Uterine tetany
Board like rigidity
Abdomina/
Backpain
Increase abdominal
Fetal Hypoxia
Fetal Death

38
Date
Doctors Order
Remarks
08-02-14
 Please admit
 Secure consent
 Nil Per Os
 Hospital policy designates the exact procedure that should be followed when admitting the patient to the holding area or operating room suite. Admission will help to monitor the client’s condition. The admitting procedure is continued with reassessment of the patient and allowance of time for last minute question. (references: medical-surgical nursing 5th edition by Lewis, Heitkemper & Dirksen Chapter 17 Patient During Surgery, page 380)
 Before signing the consent, The risks and benefits of the procedure must be explained in terms the client could easily understand.(References Maternal and Child Health Nursing 6th Edition by AdellePilliteri Chapter 24 page 658)
 Patient must be instructed about preoperative food and fluid restrictions. The patient is usually instructed to have nothing by mouth (NPO), including food and fluids.)For decades, obstetricians, midwives, and anesthesiologists have debated the need for women in labor to be restricted to nil per os (NPO). Competing concerns include risk of gastric aspiration if women required general anesthesia.(References: Medical Surgical Nursing Fifth Edition by Lewis Heitkemper Dirksen at page 366, Singata, M., Tranmer, J. & Gyte, G.M.L. (2010). Restricting oral fluid and food intake during labour)

39
 Intravenous Fluid Normal Saline Solution 1L x 8 hours
Laboratory:
 Complete Blood Count with
 Platelet count
 Blood Urea Nitrogen and Creatinine
 It is indicated as a source of water and electrolytes. This is used for fluid replenishment or administration of medication
 CBC is done to the patient to test if there is blood loss, abnormalities and destruction of blood cells. And to determine what kind of blood is decreased or increased to determine what intervention must be done to correct it.(references: cell medicine, 24th edition by Golman and Schater page 345)
 Provide basis for coagulation to occur; maintains homeostasis. Pre- eclampsia has been further classified as severe in the presence of one or more of the signs and symptoms such as Low platelet count (thrombocytopenia), 100,000/mm is probably due to micro angiopathic hemolysis induced by spasm. The triad of Hemolysis, Elevated Liver Enzymes and Low Platelet Count is given the pnemonic HELLP syndrome. (References: (Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at pages 586- 587)
 Blood Urea Nitrogen measure the by product or protein metabolism in the liver, filtered by the kidney and excreted in urine. And Creatinine is end product of muscle and protein metabolism; filtered by the kidney and excreted in urine.

40
 Urinalysis
 Serum Glutamic Pyretic Transaminase (SGPT)
This is done to determine how well the kidneys and liver are working. Pre-eclampsia has been further classified as severe in the presence of one or more of the signs and symptoms such as Proteinuria of at least 4 grams/day or a persistent qualitative 2+ or more on dipstick. With severe renal involvement, the serum creatinine will be expected to rise. (References: Nursing Care Plan Edition 8 of 2010 by Marlynn E. Doenges, Mary Frances Moorhouse, Alice C. MurrChapter 10 Renal and Urinary Tract page. 540 , Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at pages 586-587)
 Study of a general examination of urine to establish baseline information or provide data to establish a tentative diagnosis and determine whether further studies are to be ordered.For establishment of Abruption Placenta. (References: Medical-Surgical Nursing 5th Edition by Lewis, Heitkemper & Dirksen, Chapter 42 Urinary System, page 1250-1251)
 Marker of hepatic injury; more specific of liver damage than Aspartate Amino Transferase. Baseline laboratory examinations should be obtained for organs likely to be affected by hypertensive changes or to deteriorate during pregnancy. (References: Kozier & Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 803, Physiologic & Phatologic Obstetrics) 3rd Edition by

41
 Serum Glutamic- Oxaloacetic Transaminase (SGOT)
 Medicine
 Hydralazine 5mg TID for BP of >160/100
 Magnesium Sulfate 4g now then 5g TID on each buttocks then 5mg TID on alternating buttocks every 4 hours until 24 hours postpartum
Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 597)
 Found in the heart, liver and skeletal muscles. Can also be used to indicate liver injury. Baseline laboratory examinations should be obtained for organs likely to be affected by hypertensive changes or to deteriorate during pregnancy. (References: Kozier & Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 803,Textbook of Obstetrics (Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 597)
 A direct vasodilator that relaxes arteriolar smooth muscle. It is given to the patient to control hypertension because she was manifesting an increase in BP of 190/120 at time of 12:40am. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 293)
 May decrease acetylcholine released by nerve impulses, but its anticonvulsant mechanism is unknown. It is given to the patient in preparation to the upcoming operation of having a high blood pressure to prevent convulsion that will lead to eclampsia.(References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 425, Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 587 and 599)

42
 Insert Indwelling Foley Catheter
 Watch out for Magnesium toxicity
 Monitor every 1 hour Fetal Heart Tone
 Refer
 To drain the bladder prior to surgery that prevents the involuntary elimination under anesthesia, lessens the chance of accidental nicking of the bladder during surgery, and reduces the possibility of urinary retention during early postoperative recovery. This is inserted to accurately measure the patient’s urine output (References: Medical Surgical Nursing Fifth Edition by Lewis Heitkemper Dirksen at page 370)
 Magnesium Sulfate is a central nervous system depressant. Magnesium excess could develop in the pregnant woman who receives magnesium sulfate for the management of eclampsia and prophylaxis of eclampsia in patients with severe pre-eclampsia.(References: Medical Surgical Nursing by Lweis Heitkemper Dirksen, Fifth Edition at pages 341-342)
 To detect the fetal distress so immediate delivery is accomplished for fetuses to have a chance of surviving. References: Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 586)
08-02-14
3:40 am
 Direct to Operating Room for ‘E’ Cesarean Section
 The patient is directed for emergency cesarean section because of the fetal distress as

43
Medicine:
 Hydralazine Hydroclhoride10 mL
 Terbutaline sulfate one half ampule SL now
 Inform OR Nurse/ Chief of clinic /Pedia/ Anes/JDO/ OB gyne
manifested by the fetal heart rate of 31 beats per minute due to preeclampsia severe. Fetal distress is the third common reason for the rise in cesarean birth over the last decade. References: Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 7953)
 A direct vasodilator that relaxes arteriolar smooth muscle. It is given to the patient to control hypertension because she was manifesting an increase in BP of 190/140 at time of 3:40am (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 293)
 Relaxes bronchial smooth muscle by stimulating beta2 receptors. Because the client is experiencing difficulty o (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page631)
 For preparing their department that there is an upcoming procedure and they will need at a time.
08-02-14
3:50 am
 Pre Op Care
 Begins when the decision to proceed with surgical intervention is made and ends with the transfer of the patient onto the operating room. Table. The psychosocial outcomes of unplanned or emergency cesarean birth are usually more pronounced and negative in nature when compared with the outcomes associated with a scheduled or planned cesarean

44
birth. The patient experience abrupt changes in their expectations for birth, post birth care, and the care of the new baby at home.This may be an extremely traumatic experience. Maternal vital signs and blood pressure and fetal heart rate and pattern continue to be assessed. (References: Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever,Chapter 18 preoperative nursing management, page 425, References Maternal and Child Health Nursing at page 574-575)
08-02-14
Post – Op Order
 To ward with close monitoring
 Postoperative patients must be monitored and assessed closely for any deterioration in condition and the relevant postoperative care plan or pathway must be implemented. The National Early Warning Score (NEWS) was developed by a working party to provide a national standard for assessing, monitoring and tracking acutely and critically ill patients (not for use with children under 16 years or in pregnancy); the intention was that trusts would use it to replace their locally adapted early warning systems (Royal College of Physicians, 2012). Like other early warning systems, NEWS has six physiological parameters:  Respiratory rate;  Oxygen saturation;  Temperature;  Blood pressure;  Pulse rate;  Level of consciousness;  Fluid Balance  Intravenous Infusion  (References: Liddle C (2013) Postoperative care 1: Principles of Monitoring Postoperative

45
 Oxygen inhalation at 3 LPM via nasal cannula
 Monitor Vital Signs every 15 minutes until stable and record please
 Nothing Per Orem
 Intravenous Fluid Normal Saline Solution 800 mL + Oxytocin 20 ‘u’ x 30 gtts
patients. Nursing Times; Chapter 109 at pages 22, 24-26) 
 Administration of oxygen helps increase the percentage of oxygen in inspired air. The goal of oxygen administration is to supply the patient with adequate oxygen to maximize oxygen carrying ability of the blood.(References: Medical Surgical Nursing by Lweis Heitkemper Dirksen, Fifth Edition at pages 689)
 Monitoring in uncomplicated pregnancy; intermittent auscultation should be done after a contraction at least every 15 minutes (References: Physiologic & Phatologic Obstetrics) 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 424)
 Spinal and epidural anesthesia may result sensory block and motor block. The patient is advised to nothing per mouth to prevent aspiration by nausea and vomiting especially when was under anesthetic agents.(References: Medical Surgical Nursing Fifth Edition by Lewis Heitkemper Dirksen at page 386-387 & 399)
 Intravenously, it is used for hydration, and as a carrier to get other things (drugs, banked blood) into a person. It has the same amount of salt as most of our body fluids do (0.9%).

46
To follow:
o Intravenous Fluid D5NR 1L uncorporate Oxytocin 10 ‘u’ x 8 hours
 Medicine:
 Ampicillin 2g IV; ANST then 1g IV every 6 hours
 Tramadol 50mg slow IV every 6 hours x 4 doses, ANSTU
Traditionally, 10 units of oxytocin are incorporated in 1 liter dextrose. It is a potent drug for adequate uterine contraction after cesarean section to control bleeding after childbirth.
 D5NR is an hypertonic solution to prevent dehydration and to replace the blood loss after delivery. The oxytocin was uncorporate as manifested of uterine firmed and contracted.
 A broad-spectrum semi-synthetic aminopenicillin, is highly bactericidal even at low concentrations, but is inactivated by penicillinase. It will minimize the risk of developing puerperal sepsis and pelvic abscess.(References: Nurses Drug Guide of 2004 Volume 1 by Billie Ann Wilson, Margaret Shannon, Carolyn Stang, page86, Physiologic & Phatologic Obstetrics 3rd Edition by Sumpaico, Andres, Capito, Carnero, Diamenteband Gamilla at page 902-904)
 Inhibits reuptake of serotonin and norepinephrine in CNS.The patient was administered of Tramadol because the client has moderate pain (4-6 on a 0-10 scale) on her incised wound from C section.(References: Nurses Drug Guide of 2004 Volume 2 by Billie Ann Wilson, Margaret Shannon, Carolyn Stang, page1561: Kozier&Erb’sFunadamental of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb Chapter 45 at

47
 Ranitidine 50mg IV every 8 hours x 4 doses, ANSTU
 Flat on Bed x 6 hours
 Monitor Intake and Output every 2 hours and record please
 Refer
page1208-1209)
 Due to NPO of the patient it may cause gastric acidity. An Antihistamines reduce gastric fluid volume and gastric acidity. (References: Kozier&Erb’sFunadamental of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb Chapter 37 at page 950)
 Position the client as ordered. Clients who have had spinal anesthetics usually lie flat for 8 to 12 hours. An unconscious or semi conscious client is placed on one side with the head slightly elevated, if possible, or in a position that allows fluids to drain from the mouth. It will prevent maternal hypotension. (References: Kozier&Erb’sFunadamental of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb Chapter 37 at page 962)
 Accurate intake and output is necessary for determining fluid replacement needs and reducing risk of fluid overload and reflects circulating fluid shifts, and response to therapy. (Reference : Nursing Care Plan Edition 8 of 2010 by Marlynn E. Doenges, Mary Frances Moorhouse, Alice C. MurrChapter 10 Renal and Urinary Tract page. 542 )
08-02-14
Medicine:

48
5:45 am
 Voluven 500mL stat.  Therapy & prophylaxis of hypovolaemia. (References: http://www.scribd.com/doc/131436121/ Drug-Study-Po)
08-02-14
 Nil Per Os
 Serve and transfuse 3 ‘u’ PRBC properly typed and cross matched
 Medicine:
 Ampicillin 1g every 6 hours x 24 hours
 Metronidazole 50g TID for every 8 hours ANST x 24 hours
 Spinal and epidural anesthesia may result sensory block and motor block. The patient is advised to nothing per mouth to prevent aspiration by nausea and vomiting especially when was under anesthetic agents.(References: Medical Surgical Nursing Fifth Edition by Lewis Heitkemper Dirksen at page 386- 387 & 399)
 Blood transfusion is the introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. This is ordered to replace the blood that has been loss while the client is undergoing the operation.The patient might have >1500 ml of total amount of blood loss because of Abruptio Placenta.(Reference: Fundamentals of Nursing 8th Edition, Volume 2 by Snyder, Berman, Kozier and ErbChapter 52 Fluid, Electrolyte and Acid – Base Balance page 1473,Maternal Child Nursing Care Volume 1 3rd Edition by Wong, Hockenberry,Wilson, Perry,Lowdermilk at page 401)
 Inhibits cell wall synthesis during bacterial multiplication. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 81)
 Direct-acting trichomonacide and amebicide that works inside and outside the intestines. It’s thought to enter the cells of

49
 Please do repeat:
o HIH for:
o Serum Pyretic Transaminase (SGPT)
o Serum Glutamic- Oxaloacetic Transaminase (SGOT)
o Blood Urea Nitrogen and Creatinine
o Sodium
microorganisms that contain nitroreductase, forming unstable compounds that bind DNA and inhibit synthesis, causing cell death. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 22)
 Marker of hepatic injury; more specific of liver damage than Aspartate Amino Transferase. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 803)
 Found in the heart, liver and skeletal muscles. Can also be used to indicate liver injury. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 803)
 BUN measure the by product or protein metabolism in the liver, filtered by the kidney and excreted in urine. And Creatinine is end product of muscle and protein metabolism; filtered by the kidney and excreted in urine. (Reference : Nursing Care Plan Edition 8 of 2010 by Marlynn E. Doenges, Mary Frances Moorhouse, Alice C. MurrChapter 10 Renal and Urinary Tract page. 540 )
 Regulating ECF volume and distribution, maintaining blood volume, transmitting nerve impulses and contracting muscles. (References: Kozier&Erb’s

50
o Chloride
 Maintain Indwelling Foley Catheter
 Please continue Magnesium Sulfate 5g TIM on alternating buttocks every 4 hours x 24 hours
 Blood Transfusion to run for 1 hour
Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 1431)
 HCl production. Regulating ECF balance and vascular volume. Regulating acid-base balance. Buffer in oxygen-carbon dioxide exchange in RBCs. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 1431)
 Trauma to the bladder may occur during the birth process, so the bladder wall may be hyperemic and edematous, often with small areas of hemorrhage. Clean-catch or catheterized urine specimens after delivery often reveal hematuria from bladder trauma.(References :Maternal and Child Health Nursing volume 1 3rd edition Chapter 19 at page 594)
 May decrease acetylcholine released by nerve impulses, but its anticonvulsant mechanism is unknown.Intramuscular (IM) magnesium ssulfate is used rarely because the absorption rate cannot be controlled(References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 425)
 Blood transfusion is the

51
 Refer
introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. In these case (Reference: Fundamentals of Nursing 8th Edition, Volume 2 by Snyder, Berman, Kozier and ErbChapter 52 Fluid, Electrolyte and Acid – Base Balance page 1473)
08-03-14
 Diet as Tolerated
 Monitor Vital sign every 4 hours and record please
 Continue medications
 Ordered when the client’s appetite, ability to eat, and tolerance for certain foods may change. And a flatus and bowel movement is now present in the patient. ( (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 1262)
 Vital signs should be performed in accordance with local policies or guidelines and compared with the baseline observations taken before surgery, during surgery and in the recovery area. (references:http://www.nursingtimes.net/nursing-practice/specialisms/critical- care/principles-of-monitoring-postoperative- patients/5059272.article)
 For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of symptoms of for prevention of

52
 Monitor Vital sign every 4 hours and record please
 For Actual ProThrombin Time
 Still for
o Serum Glutamic Pyretic Transaminase (SGPT)
o Serum Glutamic- Oxaloacetic Transaminase (SGOT)
disease..(Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter
 Vital signs should be performed in accordance with local policies or guidelines and compared with the baseline observations taken before surgery, during surgery and in the recovery area. (references:http://www.nursingtimes.net/nursing-practice/specialisms/critical- care/principles-of-monitoring-postoperative- patients/5059272.article)
 It is a measure of how long it take for the blood to start clotting. (References: 5th Edition Essentials of Anatomy and Physiology by Seeley, Stephens,Tate at page 318)
 Marker of hepatic injury; more specific of liver damage than Aspartate Amino Transferase. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 803)
 Found in the heart, liver and skeletal muscles. Can also be used to indicate liver injury. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 803)

53
o Blood Urea Nitrogen and Creatinine
o Sodium
o Potassium
o Chloride
 Remove Indwelling Foley Catheter at 12 noon
 BUN measure the by product or protein metabolism in the liver, filtered by the kidney and excreted in urine. And Creatinine is end product of muscle and protein metabolism; filtered by the kidney and excreted in urine. (Reference : Nursing Care Plan Edition 8 of 2010 by Marlynn E. Doenges, Mary Frances Moorhouse, Alice C. MurrChapter 10 Renal and Urinary Tract page. 540 )
 Regulating ECF volume and distribution, maintaining blood volume, transmitting nerve impulses and contracting muscles. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 1431)
 Maintaining ICF osmolarity, transmitting nerve and other electrical impulses, regulating cardiac impulse transmission and muscle contraction. Skeletal and smooth muscle function. Regulating Acid-base balance. . (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 1431)
 HCl production. Regulating ECF balance and vascular volume. Regulating acid-base balance. Buffer in oxygen-carbon dioxide exchange in RBCs. (References: Kozier&Erb’s Fundamentals of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb, page 1431)

54
 Still for blood transfusion
 Apply abdominal binder
 Refer
 The spout of any drainage bag can become contaminated when opened to drain the bag. Bacteria enter the urinary drainage bag, multiply rapidly, and then migrate to the drainage tubing, catheter and bladder and not allowing urine to flow back into the bladder, this risk is reduced. (References: Brunner&Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume two by Smeltzer, Bare, Hinkle and Cheever, Chapter 45 Management of Patients with Urinary Disorders, page 1372)
 Blood transfusion is the introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. This is ordered to restore the blood’s oxygen carrying capacity since the patient has hemoglobin result of 5.4 g/dL as of August 2, 2014 .Blood typing and cross matching is done to determine the blood type of the patient for blood transfusion purposes not because all blood is compatible with each other and if unmatched blood has been transfused to the client it may cause harmful effect to the client. (Reference: Fundamentals of Nursing 8th Edition, Volume 2 by Snyder, Berman, Kozier and ErbChapter 52 Fluid, Electrolyte and Acid – Base Balance page 1473)
 This wraps help women recovering from a C-section with their posture and abdominal support.

55
08-04-14
 Low salt, Low fat diet
Medicine:
 Amoxicillin 500mg 1 cap x 7 days
 Metronidazole 500 mg 1 cap BID x 7 days
 Ferrous Sulfate 1 tab BID x 30 days
 A healthy diet with adequate calories, protein and other nutrients is important to maintain good immune function and increase resistance to disease. Along with certain vitamins and minerals, dietary protein is important to prevent anemia. High salt intake can affect blood pressure and contribute to the development of hypertension. It may increase the release of a hormone called natriuretic hormone which indirectly contributes to hypertension. The patient manifested a blood pressure of 160/90 (References: Kozier&Erb’s Fundamentals of Nursing 8th edition Volume 2 by Berman, Sunder, Kozier&Erb, Chapter 51 Circulation, page 1411)
 Prevents bacterial cell-wall synthesis during replication. Increases amoxicillin effectiveness by inactivating betalactamases, which destroy amoxicillin. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 77)
 Direct-acting trichomonacide and amebicide that works inside and outside the intestines. It’s thought to enter the cells of microorganisms that contain nitroreductase, forming unstable compounds that bind DNA and inhibit synthesis, causing cell death. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 22)
 Provides elemental iron, an essential component in the formation of hemoglobin.

56
 Mefenamic Acid 500 mg 1 cap every 6 hours
 Amlodipine 10 mg 1 cap BID x 30 days
 Spironolactone 50 mg 1 cap TID x 7 days
(References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 879)
 Elevates the serum iron concentration which then helps to form High or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.(References:2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 623-625)
 Inhibits calcium ion influx across cardiac and smooth-muscle cells, thus decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 260)
 Potassium –Sparing diuretic; steroidal compound and specific pharmacologic antaonist of aldosterone. Presumably acts by competing with aldosterone for cellular receptor sites in distal renal tubule. Promotes sodium and chloride excretion without concomitant loss of potassium. Diuretic effect reportedly not associated with hyperuricemia or hypoglycemia. Activity depends on presence of endogenous or exogenous aldosterone.(References: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia DweyerSchull at pages1097-1099, nurse’s drug handbook of 2004 Volume 2 by Wilson, Shannon &Strang,page 1444)

57
 Continue meds.
 Refer laboratory result
 Still for correction of anemia
 For change of dressing today
 For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of symptoms of for prevention of disease. To prevent occurrence of further complications (Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozierand Erb Chapter 35 Medications page 830)
 So that the health worker would be able to analyze the result and to determine the problem and the needed intervention to correct the abnormalities.
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder.Due to the latest laboratory result of Hemoglobin 5.4 g/dL and Hematocrit 16%. (References: Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)
 To prevent infection in incision site and provide comfort of the patient.

58
 Refer
08-05-14
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder. The patient still not undergo laboratory exam. (References: Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)
08-06-14
 Low salt, Low fat diet
Medicine:
 Decrease amlodipine 10 tab OD (5pm)
 A healthy diet with adequate calories, protein and other nutrients is important to maintain good immune function and increase resistance to disease. Along with certain vitamins and minerals, dietary protein is important to prevent anemia. High salt intake can affect blood pressure and contribute to the development of hypertension. It may increase the release of a hormone called natriuretic hormone which indirectly contributes to hypertension. (References: Kozier&Erb’s Fundamentals of Nursing 8th edition Volume 2 by Berman, Sunder, Kozier&Erb, Chapter 51 Circulation, page 1411)
 Inhibits calcium ion influx across cardiac and smooth-muscle cells, thus decreasing myocardial contractility and oxygen demand; also dilates coronary arteries and arterioles. (References: nursing 2006 Drug Handbook 26th edition by Lippincott Williams & Wilkins, page 260)

59
 Start Losartan 50 mg tab OD (6am)
 Continue meds
 Still for blood transfusion to run for 4 hours
 Blocks vasoconstricting and aldosterone- secreting effects of angiotensin II at various receptor sites, including vascular smooth muscle and adrenal glands. Also increases urinary flow and enhances excretion of chloride, magnesium, calcium, and phosphate.(References: 2011 McGraw- Hill Nurse’s DrugHandBook by Patricia DweyerSchull at pages 685)
 For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of symptoms of for prevention of disease..(Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter
 Blood transfusion is the introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. This is ordered to restore

60
 Refer
the blood’s oxyen carrying capacity since the patient has hemoglobin result of 5.4 g/dL as of August 2, 2014 .Blood typing and cross matching is done to determine the blood type of the patient for blood transfusion purposes not because all blood is compatible with each other and if unmatched blood has been transfused to the client it may cause harmful effect to the client.
08-07-14
 Continue oral meds and blood pressure monitoring
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder.Due to the latest laboratory result of Hemoglobin 6.3 g/dL and Hematocrit 16% as of August 7, 2014.(References: Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)
 For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of

61
 Refer
symptoms of for prevention of disease. And to be able to know if the blood pressure is now normal range and to be able to perform proper intervention (Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, KozierandErb Chapter 35 Medications page 830)
08-07-14
 Medicine:
 Paracetamol 1 amp FV stat PRN for Temperature ≥ 38.6˚C every 6 hours
 Paracetamol 8 mg 1 tab every 4 hours ≥ 37.8˚C for CBC
 A nonopoid analgesic with indication for fever was given to the patient because of the temperature of 39 degree celcius at 3:30 pm.(26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 351-352)
 Cardiovascular agent; central-acting; antihypertensive; analgesics. It will be given to if the patient manifested decrease at temperature of at least ≥ 37.8˚C (2011 McGraw-Hill Nurse’s Drug HandBook by Patricia DweyerSchull at pages 264)
 Catapres 75 mg
1 tab SL stat PRN ≥ 160/90
 Stimulates aplha2 adrenergic receptors in CNS to inhibit sympathetic vasomotor centers. Central actions reduce plasma concentrations of norepinephrine. It decreases systolic and diastolic BP and HR. orthostatic effects tends to

62
mild and occur in frequently. Also inhibits renin release from kidneys. The patient manifested a blood pressure of 150/90 mmHg. (References:2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 264-266)
08-08-14
 For change of dressing
 For Blood transfusion 3 ‘u’ PRBC properly typed and cross matched
 Facilitate availabilities of
 To prevent infections in incision site and provide comfort to the patient.
 Blood transfusion is the introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. In these case (Reference: Fundamentals of Nursing 8th Edition, Volume 2 by Snyder, Berman, Kozier and ErbChapter 52 Fluid, Electrolyte and Acid – Base Balance page 1473)
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder.Due to the latest laboratory result of Hemoglobin 6.3 g/dL and Hematocrit 16% and RBC of 1.84 X 1023/L as of August 7, 2014(References: Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)
 For preventing diversion and

63
meds
abuse of medications.
08-09-14
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder. Due to the latest laboratory result of RBC 1.84 X 1023/L, Hemoglobin 6.3g/dL and Hematocrit 16% as of August 7, 2014.(References: Brunner &Suddarth’s Textbook of Medical- Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)
08-10-14
 Continue meds.
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder. Due to the latest laboratory result of RBC 1.84 X 1023/L, Hemoglobin 6.3g/dL and Hematocrit 16% as of August 7, 2014. (References: Brunner &Suddarth’s Textbook of Medical- Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)

64
 Monitor vital signs every 4 hours then record please
 Refer
symptoms of for prevention of disease..(Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter
 Take Vital signs and compare initial findings with clients data. (References: Kozier&Erb’sFunadamental of Nursing 8th Edition Volume 2 by Berman, Snyder, Kozier, Erb Chapter 37, page 958)
08-11-14
 For change of dressing today
 Continue meds
 A condition in which the hemoglobin concentration is lower than normal; reflects a presence of fewer erythrocytes within the circulation; amount of oxygen delivered to body is also diminished; not a specific disease but a sign of an underlying disorder. The patient still not undergo on laboratory exam. (References: Brunner &Suddarth’s Textbook of Medical-Surgical Nursing 12th edition Volume 1 by Smeltzer, Bare, Hinkle and Cheever, page 910)
 To prevent infections from incision site and provide comfort to the patient.

65
 Refer
symptoms of for prevention of disease To prevent occurrence of further complications.(Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter
08-12--14
 Still for Low Fat diet
 Continue medication
 Refer
 High salt intake can affect blood pressure and contribute to the development of hypertension. It may increase the release of a hormone called natriuretic hormone which indirectly contributes to hypertension. For sodium retention. (References: Kozier&Erb’s Fundamentals of Nursing 8th edition Volume 2 by Berman, Sunder, Kozier&Erb, Chapter 51 Circulation, page 1411)The patient manifested a high blood pressure of 150/90 mmHg.
 To prevent occurrence of further complications.
08-13-14
 Serve and transfuse 2 ‘u’ PRBC properly typed and cross-matched
 Blood transfusion is the introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. This is ordered to restore the blood’s oxygen carrying capacity since the patient has hemoglobin result of 7.2 g/dL as of August 13, 2014. Blood typing and cross matching is done to determine the blood type of the patient for blood transfusion purposes not because all blood is compatible with each other and if unmatched blood has been transfused to the client it may cause harmful effect to

66
 Continue meds
 For daily change of dressing
 For blood transfusion to run for 4 hours
 Refer
the client. (Reference: Fundamentals of Nursing 8th Edition, Volume 2 by Snyder, Berman, Kozier and ErbChapter 52 Fluid, Electrolyte and Acid – Base Balance page 1473)
 For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of symptoms of for prevention of disease To prevent occurrence of further complications.(Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter
 To prevent infections from incision site and provide comfort to the patient.
 Blood transfusion is the introduction of whole blood or blood components in venous circulation. Packed Red blood cells is used to increase the oxygen-carrying capacity of blood. In these case (Reference: Fundamentals of Nursing 8th Edition, Volume 2 by Snyder, Berman, Kozier and ErbChapter 52 Fluid, Electrolyte and Acid – Base Balance page 1473)
08-14-14
 May go home
 The patient does not need an overnight stay on the hospital because she was feeling better and able to tolerate the pain.

67
 Continue meds
 Blood pressure monitoring at home
 For supportive Drug; supports body function until other treatments or the body’s treatments or body’s response can take over; because medication is a substance administered for the diagnosis, cure treatment or relief of symptoms of for prevention of disease.(Reference:Fundamentals of Nursing 8th Edition of 2008 by Berman, Synder, Kozier and Erb Chapter
 To monitor the wellness of the patient and immediately asses for further complication.

69
Hematology Results Date: August 2, 2014
Test
Result
Normal Range
Interpretation
Implication
Nursing Responsibility
Hemoglobin
Hematocrit (%)
5.4 g/dl
16 %
M: 13-18 g/dl
F: 12-16 g/dl
I: 11.3-13 g/dli
Child: 11.5-14.8 g/dl
NB: 13.6-19.6 g/dl
M: 40-50%
F: 37-43%
I: 35-40%
Child: 38-44%
NB: 50-58%
LOW
LOW
Oxygen transport is accomplished by hemoglobin. Hemoglobin picks up oxygen in the lungs and releases oxygen to the other tissues.
Hematocrit is percentage of total blood volume composed of red blood cells. The hematocrit measurement is affected by the number and size of RBC because it is based on volume. There’s a decrease in hematocrit count due to decrease in RBC.
Inadequate iron intake can impair hemoglobin production. Consequently, RBC do not fill up with hemoglobin during their formation, and they remain smaller than normal.
To prevent this, advise mother to increase food intake rich in iron like malunggay. Iron are in whole grains, nuts and legumes.
Reference: Essentials of Anatomy & Physiology, 6th Edition by Rod Seeley, Trent Stephens and Philip Tate, pp. 301-318

70
Test
Result
Normal Range
Interpretation
Implication
Sodium
145.6
135 - 145
HIGH
Sodium is the major electrolyte of ECF that moves easily between intravascular and spaces and moves across cell membrane. It controls and regulates the volume of fluids and maintains water balance throughout the body. There is increase serum sodium reabsorption because there is increase blood pressure.
 Monitor serum sodium levels
 Monitor fluid losses and gains
 Check urine specific gravity
 Observe for excessive intake of high sodium foods
 Look for excessive thirst.
Potassium
3.85
3.5 - 5.0
NORMAL
Potassium is the major cation of ICF. It maintain fluid and electrolyte balance and also essential in regulation of acid- base balance by cellular exchange.
 Maintain healthy lifestyle
 Intake of 50 to 100 mEq daily is enough to maintain potassium.

71
Chloride
107.5
97 – 107
HIGH
Chloride is an electrolyte in extracellular anion found in blood and interstitial fluid. It helps maintain proper fluid and acid-base balance in the body. It also acts with sodium to maintain osmotic and pressure in blood and has important buffering action of oxygen and carbon dioxide exchange in RBC.
 Keep safe well dehydrated
 Intruct to avoid caffeine and alcohol
 Proper dietary intake
(Reference: Fundamentals of Nursing , 5th edition ,Carol Taylor, Carol Lillis, Priscilla Lemone, pp.1453-1454.)

72
Test
Result
Normal Range
Interpretation
Implication
Hemoglobin
Hematocrit (%)
6.3 g/dl
16 %
M: 13-18 g/dl
F: 12-16 g/dl
I: 11.3-13 g/dli
Child: 11.5-14.8 g/dl
NB: 13.6-19.6 g/dl
M: 40-50%
F: 37-43%
I: 35-40%
Child: 38-44%
NB: 50-58%
LOW
LOW
When the hemoglobin level is below 12mg/dl (hematocrit < 33), iron deficiency is suspected. Inadequate iron intake can impair hemoglobin production. Consequently, RBC do not fill up with hemoglobin during their formation, and they remain smaller than normal.
The primary function of RBC is to transport oxygen from lungs to the various tissues of the body and to assist in transport of carbon dioxide from the tissues to the lungs.
WBC protects the body against microorganisms and removes dead cells and debris.
Platelets are cell fragments involved with preventing blood loss.
RBC
1.84 X 1023/L
M: 4.5-6.2 X 1023/L
F: 4.0-5.4 X 1023/L
I: 3.8-5.9 X 1023/L
Child: 3.8-5.4 X 1023/L
NB: 5.0-7.0 X 1023/L LOW
WBC
-----
4.5 – 10.5 x 10 9/L
---
Platelet
410 x 10 9/dL
150-500 x 10 9/dL
Normal

73
Test
Result
Normal Range
Interpretation
Implication
Hemoglobin
Hematocrit (%)
7.2 g/dl
21 %
M: 13-18 g/dl
F: 12-16 g/dl
I: 11.3-13 g/dli
Child: 11.5-14.8 g/dl
NB: 13.6-19.6 g/dl
M: 40-50%
F: 37-43%
I: 35-40%
Child: 38-44%
NB: 50-58%
LOW
LOW
When the hemoglobin level is below 12mg/dl (hematocrit <33), iron deficiency is suspected.

74
Test
Result
Normal Range
Interpretation
Implication
Hemoglobin
Hematocrit (%)
9.2 g/dl
27 %
M: 13-18 g/dl
F: 12-16 g/dl
I: 11.3-13 g/dli
Child: 11.5-14.8 g/dl
NB: 13.6-19.6 g/dl
M: 40-50%
F: 37-43%
I: 35-40%
Child: 38-44%
NB: 50-58%
LOW
LOW
When the hemoglobin level is below 12mg/dl (hematocrit <33), iron deficiency is suspected.
.

76
Drug Name
Dosage
Classification
Action
Indication / Contraindication
Side effects
Nursing Responsibilities
Date Ordered:
08-02-14
Generic:
Ampicillin
Brand:
Ampicillin-N
1gm
q 6 hrs
TIV
Antibiotic
Inhibits cell- wall synthesis during bacteria multiplication.
Indication:
 To prevent endocartitis in patients having GI procedures.
Contraindication:
 Contraindicated in patients hypertensive to drug or other penicillins.
 Use cautiously in patients with other drug allergies because of possible cross- sensitivity, and in those with mononucleosis because of high risk of maculopapular rash.
CNS
 Lethargy
 Hallucinations
 Seizures
GI
 Nausea
 Vomiting
 Diarrhea
 Glostitis
 Monitor sodium level because each gram of ampicillin contains 2.9 mEq of sodium.
 Watch for signs and symptoms of hypersensitivity , such as maculopapular rash, urticuria, and anaphylaxis.
 After negative sensitivity must be done.
(26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages at 80-81)

77
Drug Name
Dosage
Classification
Action
Side Effects
Date ordered:
08-02-14
Generic:
Tramadol
Brand:
Ultram
50 mg
TIV
Every 6 hrs.
Opioid Agonist
Analgesics
Inhibits reuptake of serotonin and norepinephrine in CNS.
Indication:
 Moderate to moderately severe pain
Contraindication:
 Contraindicated in patients hypersensitive to drugs or other opioids, those with acute intoxication from alcohol.
CNS
 Dizziness
 Confusion
 Fatigue
 Drowsiness
GU
 Renal failure
GI
 Nausea
 Anorexia
 Constipation
 Assess patient’s level of pain atleast 30 mins before administration.
 Monitor the bowel and bladder function.
 Monitor for physical and psychological drug dependence.
 Monitor patient for signs and symptoms of potentially life- threatening serotonin syndrome, which may range from shivering and diarrhea to muscle rigidity, fever, mental-status changes, and seizures.
(2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 1183-1185)

78
Drug Name
Dosage
Classification
Action
Side effects
Date Ordered:
08-02-14
Generic:
Ranitidine Hydrochlori- de
Brand:
Zantac
50 mg IV q 8°X 4 doses
Anti-ulcer drug
Reduces gastric acid secretion and bicarbonate production, creating a protective coating on gastric mucosa
Indication:
 To prevent Mendelson’s disease (The aspiration of stomach contents into the lungs during obstetric anaesthesia)
Contraindication:
 Hypersensitivity to drug or its components
 Alcohol intolerance (with some oral product)
 History of acute porphyria
CNS
 Headache
 Agitation
 Anxiety
GI
 Nausea
 Vomiting
 Diarrhea
 Constipation
 Abdominal discomfort or pain
Hematologic
 Reversible granulocytopenia
 Thrombovytopenia
Hepatic
 Hepatitis
Skin
 Rash
Other
 Pain at IM injection site
 Burning
 Assess vital signs
 Monitor CBC and liver function test

79
(26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 866-867)
Drug Name
Dosage
Classification
Action
Side effects
Date Ordered:
08-02-14
Generic:
Magnesium Sulfate
Brand:
Sulfamag
4 mg IM
At buttocks
Every 4 hours
Anticonvulsant
Replaces magnesium and maintains magnesium level; as an anticonvulsant, reduces muscle contractions by interfering with release of acetylcholine at myoneural junction.
Indication:
 Seizures
Contraindication:
 Hypermagnesemia
 Heart block
 Myocardial damage
 Active labor or within 2 hours of delivery  syndrome joint- swelling,fever) reaction  anemia  agranulocytosis  hepatitis  glomerulonephritis  acute renal failure  Monitor patients closely during and following infusions. Observe orthostatic precautions.

80
Drug Name
Dosage
Classification
Action
Side effects
Date Ordered:
08-02-14
Generic:
Hydralizine
Brand:
Alphapress
50 mg TID for BP of 160/100
Antihypertensive
A direct- acting vasodilator that relaxes arteriolar smooth muscle.
Indication:
 Preeclampsia
Contraindication:
CNS
 Peripheral neuritis
 Headache
 Dizziness
GI
 Nausea
 Vomiting
 Constipation
 Monitor patient’s blood pressure and pulse rate. Hydralizine may be given with diuretics and beta blockers to decrease sodium retention.
 Don’t confuse hydralazine with hydroxyzine or Apresoline with Apresazide.
 Instruct the patient to take oral form with meals to increase absorption.

81
Drug Name
Dosage
Frequency
Route
Classification
Indication
and Contraindication
Side Effects
/Adverse Reaction
Mechanism of Action
Date Ordered:
08-02-14
Generic:
Metronidazole
Brand:
Flagyl
500 mg tab
BID
X 7 days
Anti- protozoal
Indication: Amoebic liver abcess
Contraindication:
 Hypersensitivity to drug, other nitroimidazole derivatives, or parabens (topical form only)
CNS
 Dizziness
 Headache
 Ataxia
 Vertigo
 Insomia
GI
 Nausea
 Vomiting
 Diarrhea
 Abdominal pain
 Anorexia
Disturbs DNA synthesis in susceptible bacterial organism. (But the mechanism of this action is not well understood)
 Inform patient to report fever, sorethroat, bleeding or bruising.
 Inform patient that drug may cause metallic taste and may discolor urine deep brownish- red.
(Reference: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages751-753)

82
Drug Name
Dosage
Classification
Action
Side effects
Date ordered:
08-04-14
Generic:
Spironolactone
Brand:
Aldactone
50mg
Cap
TID
PO
Potassium – Sparing diuretic
Inhibits aldosterone effects in distal renal tubule, promoting sodium and water excretion and potassium retention.
Indication:
 Essential hypertension
Contraindication:
 Hypersensitivity to drug
 Anuria
 Acute or renal insufficiency
 Hyperkalemia
CNS
 Headache
 Drowsiness
 Lethargy
 Ataxia
 Confusion
GI
 Vomiting
 Diarrhea
 Cramping
 GI ulcers
Skin
 Rash
 Pruritus
 Hirsutism
 Monitor electrolyte levels (especially potassium). Watch for signs and symptoms of imbalances and metabolic acidocis.
 Monitor weight and fluid intake and output. Stay alert for indications of fluid imbalance.
 Monitor CBC with white cell differential.
 Advise patient to restrict intake of high potassium foods .
(2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages1097-1099)

83
(Reference: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 66-68)
Drug Name
Dosage
Frequency
Route
Classification
Indication
Side Effects
/Adverse Reaction
Mechanism of Action
Date Ordered:
08-04-14
Generic:
Amoxicillin
Brand:
Amoxil
500 mg
1 capsule
q 8
Antibiotic
Indication:
Infection
Contraindication
 Hypersensi-
tivity to penicillin ,infectious monucleosis
G.I
 Diarrhea
 Nausea
 Vomiting
 Abdominal pain
Skin
 Rash
Respiratory
 Wheezing
 Other:
 superinfections (oral and rectal candidiasis)
 Fever
 Anaphylaxis
Inhibits cell- wall synthesis during bacterial multiplication, leading to cell death. Shows enhanced activity toward gram-negative bacteria compared to natural and penicillinase- resistant penicillins.
 Determine previous hypersensitivity reactions to penicillin.
 Check patient’s temperature.
 Monitor sign and symptom of urticarial rash.

84
Drug Name
Dosage
Classification
Mechanism of Action
Side Effects
Date Ordered:
08-04-14
Generic:
Ferrous Sulfate
Brand:
Brisofer
1 tab
BID
PO
X 30day
Iron Preparation Elevates the serum iron concentration which then helps to form High or trapped in the reticuloendothelial cells for storage and eventual conversion to a usable form of iron.
Indication:
 Prevention and treatment of Iron deficiency anemia.
 Dietary Supplement for Iron.
Contraindication:
 Hypersensitivity
 Severe Hypotension
 Dizzziness
 Nasal Congestion
 Dyspnea
 Hypotension
 Muscle Cramps
 Flushing
• Advise patient to take medicine as prescribed. • Caution patient to make position changes slowly to minimize 84rthostatic hypotension. • Encourage patient to comply with additional intervention for hypertension like proper diet, regular exercise, lifestyle and changes and stress management.

85
(2004 Nurse’s Drug Guide Volume 2 at page 965-966)
Drug Name
Dosage
Frequency
Route
Classification
Mechanism of Action
Side Effects
Date ordered:
08-04-14
Generic:
Mefenamic
Brand:
Ponstan
500 mg
1 cap
Every 6 hrs.
P.O
Analgesic
NSAID
Inhibits prostaglandin synthesis and affects platelet function.
Indication:
 Short term relief of mild to moderate pain.
Contraindication:
 Ulceration
 Nausea
 Vomiting
 Constipation
 Blurred vision
 Discontinue drug promptly if diarrhea , dark stools, hematemesis, or rash occur and do no use again.

86
Drug Name
Dosage
Frequency
Route
Classification
Mechanism of Action
Side Effects
Date Ordered: 08-06-14
Generic: Losartan
Brand: Cozaar
100 mg 1tab OD
Route: P.O
Antihypertensive
Blocks vasoconstricting and aldosterone- secreting effects of angiotensin II at various receptor sites, including vascular smooth muscle and adrenal glands. Also increases urinary flow and enhances excretion of chloride, magnesium, calcium, and phosphate
Indication:
 Treatment of hypertension
Contraindication:
 Hypersensitivity to losartan Pregnancy (2nd trimester and 3rd trimester
 CNS
 Headache
 Dizziness
 Syncope GI
 Dry mouth CV
 Hypotension
 Monitor blood pressure and drug
 Notify physician of symptoms of hypotension.
 Always count the dose given.
 Assist patient when moving.
References : 2011 LIPPINCOTT’S Nursing Guide by Amy M. Karch at pages 728-729
2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 685-687)

87
Drug Name
Dosage
Frequency
Route
Classification
Indication
Side Effects
/Adverse Reaction
Mechanism of Action
Date Ordered:
08-06-14
Generic:
Amlodipine
Brand:
Norvasc
10 mg OD
Route:
P.O
Antihypertensive
Indication:
 Essential hypertension
Contraindication:
CNS
 Headache
 Dizziness
 Drowsiness
 Fatigue
 Weakness
CV
 Bradycardia
 Hypotension
 Palpitations
Respiratory
 Shortness of breath
 Dyspnea
 Wheezing
Inhibits influx of extracellular calcium ions, thereby decreasing myocardial contractility, relaxing coronary and vascular muscles, and decreasing peripheral resistance.
 Monitor heart rate and rhythm and blood pressure, especially at start of therapy.
(Reference: 2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 65-66)

88
Drug
Name
Dosage
Classification
Mechanism of Action
Side Effects
Date ordered:
08-07-14
Generic:
Clonidine hydrochloride
Brand:
Catapres
75 mg 1 tab PRN
> 160/90
Cardiovascular agent; central- acting; antihypertensive; analgesics
Stimulates alpha- adregenic receptors in CNS, decreasing sympathetic outflow, inhibiting vasoconstriction, and ultimately reducing blood pressure.
Indication:
 Mild to Moderate hypertension
Contraindication:
 Hypersensitivity to drug.
CNS:
 drowsiness
 dizziness
 fatigue
 sedation
 weakness
 malaise
 depression
CV:
 orthostatic
 hypotension
 bradycardia
 severe rebound hypertension
GI:
 constipation
 dry mouth
 nausea
 vomiting
 anorexia
 Monitor blood pressure and pulse rate frequently
 Observe patient for tolerance to drug’s therapeutic effects, which may require to increase dosage
 Monitor patient for signs and symptoms of adverse cardiovascular reactions
 Inform patient that dizziness upon standing can be minimized by rising slowly from a sitting or lying position and avoid sudden position changes.

89
Drug Name
Dosage
Classification
Action
Side effects
Date Ordered:
08-07-14
Generic:
Paracetamol
Brand:
Aeknil
1 amp IV STAT
PRN
For > 38.6 degree
Nonopoid Analgesic
Through the produce analgesia by blocking pain impulse by inhibiting synthesis of prostaglandin in CNS that synthesize pain receptor to stimulation
Indication:
 Fever
Contraindication:
 Contraindicated in patients hypersensitive to drug.
 Use cautiously in patients with long term alcohol use because therapeutic doses causes hepatotoxicity in these patients.
 Hypoglycemia
 Rash
 Uticaria
 Instruct patient to take with meals have a plenty of water when taking this drug.
 After negative sensitivity must be done.

90
X. Problem Identification & Prioritization

91
Problem Identification and Prioritization
Problem
1. Difficulty of Breathing
2. Elevated High Blood Pressure
3. Generalized Edema
4. Elevated Body Temperature
5. Acute pain

93
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EXPECTED OUTCOME
S:
“Nahihirapan akong huminga” as verbalized by the patient.
O:
 Dyspnea
 Use of accessory muscles
 Shortness of breath
 Altered chest excursion
 Restleness
 Generalized pale
 RR: 24 b/m
 PR: 68 b/m
 Temp: 37 ˚c
 BP: 140/110
Ineffective breathing pattern related to difficulty of breathing as manifested by prolonged expiration phases than inspiration
After 4 hours of nursing intervention the patient will able to do coping mechanisms to improve her breathing pattern
Independent:
 Asses spontaneous pattern, rate, depth, and rhythm
 Elevate the head
 Provide calm approach
 Identify signs and symptoms requiring prompt medical evaluation/ intervention
Provide prompt tactile stimulation
 To measure work of breathing.
 To alleviate dyspnea and to facilitate oxygenation through promoting lung expansion.
 To promote relaxation, decreasing energy and oxygen requirements
 To provide timely treatment may prevent progression of problem
The patient will able to maintain the normal vital signs of Temp: 36.5-37.5, PR : 60-100 b/m, RR: 12-20 b/m, and BP : 120/80 and Reestablish and maintain effective respiratory pattern via oxygen administration thru nasal cannula without the use of accessory muscles and other signs of hypoxia.

94
Dependent:
 Administer O2 inhalation via nasal cannula at 3 liters per minute as ordered.
 For management of underlying pulmonary condition and respiratory distress
August 03, 2014

95
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EXPECTED OUTCOME
S: “Nahihilo ako as verbalized by the patient.
O:
 Temp: 39˚c
 PR: 95 b/m
 RR : 27
 BP: 160/120
 Generalized pale
 Body malaise
Hypertension related to dizziness as manifested by the blood pressure of 160/120 mmHg.
Short Term Goal:
Within the 4hrs of shift the patient will verbalized no dizziness.
Long Term Goal:
Within the 8hrs of duty the patient will able to maintain the normal blood pressure of 120/80 mmHg.
Independent:
 Monitor vital signs.
 Observe skin color, moisture, temperature, and capillary refill time.
 Provide calm, restful surroundings, minimize environmental activity/ noise. Limit the number of visitors and length of stay.
 Implement dietary sodium, fat, and cholesterol restrictions as
 To obtain baseline date
 Presence of pallor; cool, moist skin; and delayed capillary refill time may be due to peripheral vasoconstriction or reflect cardiac decompensation/ decreased output.
 Helps reduce sympathetic stimulation that promotes relaxation.
 These restrictions can help manage fluid retention and, with associated hypertensive  The patient will able to maintain BP within individually acceptable range.

96
indicated.
Dependent:
 Administer prescribed medication as ordered such as :
 Cataprez 25 mg tab Sublingual
> 160/90
response, decrease myocardial workload.
 Stimulates alpha- adregenic receptors in CNS, decreasing sympathetic outflow, inhibiting vasoconstriction, and ultimately reducing blood pressure. It generally reduce BP through the combined effect of decreased total peripheral resistance, reduced cardiac output, inhibited sympathetic activity, and suppression of renin release. (2011 McGraw- Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 264-266)
DATE: August 07, 2014

97
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
S:
O:
 With generalized edemat
 With adventitious breath sounds (crackles)
 Dyspnea
 Weaknesses
 Temp: 37 ˚c
 PR: 67 b/m
 RR: 24b/m
 BP: 140/110 Excess fluid volume related to inability of the kidneys to maintain body fluid balance.
Short Term Goal:
Within the 4 hours of shift the patient will reduce of recurrence of fluid excess.
Long Term Goal:
Within the 8 hours of duty the patient will stabilize fluid volume as evidence by balanced input and output, vital signs within the client’s normal limits, and free of signs of edema.
Independent:
 Monitor vital signs
 Note presence of medical conditions or situations.
 Record Intake and Output
 Restrict fluids
 To obtain baseline data.
 To prevent contribution of excess fluid intake or retention.
 Accurate Intake and Output is necessary for determining renal function and fluid replacement needs and reducing risk of fluid overload.
 Fluid management is usually calculated to prevent further fluid retention.
The patient will have reduce of recurrence of fluid excess and stabilize fluid volume as evidence by balanced input and output, vital signs within the client’s normal limits, and free of signs of edema.

98
Dependent:
 Administer Diuretic as ordered.
 Administer Antihypertensive as ordered.
 To excrete excess fuid.
 To treat hypertension by counteracting effects of decrease renal blood flow.
August 03, 2014

99
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EXPECTED OUTCOME
S:”Mainit ang pakiramdam ko” as verbalized by the client.
O:
 Temperature: 39.2˚
 PR: 117
 RR: 34 BP: 140/110
 Flushed skin,
 Warm to touch  Tachycardia  Malaise/weakness
Hyperthermia related to increased metabolic rate as manifested by temperature of 39 ˚c
Short Term Goal:
Within the 4hrs of shift the patient will able to verbalize the decrease of the temperature on her body.
Long Term Goal:
Within the end of shift the patient’s temperature will be in normal range of 36.5 – 37.5
Independent:
 Monitor vital signs especially the temperature.
 Perform tepid sponge bath.
 Promote surface cooling by means of undressing.
 Encourage adequate fluid intake.
 Advise to maintain bed rest.
 To have
Baseline
 It will promote heat loss by means of evaporation and conduction.
 It promotes heat loss by radiation and conduction.
 To prevent dehydration.
 To reduce metabolic demands and oxygen consumption.
The patient will verbalized the t decrease in temperature on her body and will have the normal temperature at range 36.5-37.5 ˚c.

100
Dependent:
 Administer prescribed medication as ordered such as :
 Paracetamol 1 amp. 3000 mg > 38.6
 Administer replacement fluids and electrolytes as ordered.
Collaborative:
 Refer for laboratory test.
 Through the produce analgesia by blocking pain impulse by inhibiting synthesis of prostaglandin in CNS that synthesize pain receptor to stimulation
 To support circulating volume and tissue perfusion.
.
 To identify causative factors.
August 07, 2014

101
Assessment
Diagnosis
PLANNING
INTERVENTION
RATIONALE
EVALUATION
S:”masakit ang tahi ko” as verbalized by the client.
O:
 BP:140/110
 PR: 67 b/m
 RR: 24 b/m
 Pain r/s of 8/10
 With facial grimace
 With sleep disturbance
Guarding behaviour: flat on bed
Acute pain related to incision site after caesarian section as manifested by pain r/s of 8/10
After the series of nursing interventions the patient will verbalize reduce of discomfort and pain.
Independent:
 Monitor client’s vital signs and recorded.
 Note location of surgical procedures.
 Assess for referred pain as appropriate.
 Provide comfort measures, quiet environment and calm activities.
 Instruct and encourage
 To obtain baseline data.
 This can influence the amount of postoperative pain experienced.
 To help determine possibility of underlying condition or organ dysfunction requiring treatment.
 To promote non- pharmacological pain management.
The patient will be able to feel comfortable and verbalize reduce of pain.

102
use of relaxation techniques such as deep breathing exercise.
 Encourage verbalization of feelings about the pain.
Dependent:
 Administer opioid analgesics as doctor’s prescribed , such as:
 Tramadol 50 mg TIV Every 6 hrs.
 To distract attention and reduce tension.
 To distract attention and promote non- pharmacological pain management.
 Inhibits reuptake of serotonin and norepinephrine in CNS.

103
ASSESSMENT
DIAGNOSIS
PLANNING
INTERVENTION
RATIONALE
EVALUATION
S:
O:
 Restleness
 Deep sadness
 Tem: 37˚c
 PR: 71 b/m
 RR: 24
 140/100 mmHg
Anxiety related to Loss of significant other as evidenced by Feelings of helplessness and discomfort
Within 8 hours of giving effective nursing intervention patient will manage anxiety with positive copping mechanism as evidenced by acknowledge and discuss fear.
Independent:
 Monitor vital signs
 Observe behaviors.
 Assess stage of grieving being experienced by patient: denial, anger, bargaining, depression, and acceptance.
 Use therapeutic communication skills.
 Provide calm, peaceful setting and privacy as appropriate.
 To obtain the baseline data.
 To point to the client’s level of anxiety.
 To deal with appropriate management
 To provide empathic interventions.
 Promotes relaxation and ability to deal with situation.
The patient is a able to manage anxiety and to cope positive mechanism by verbalizing her feelings.

105
XII. Recommendation
Our group recommend:
To the patient
 To minimize drinking of alcohol beverages
 To stop using tobacco
 To avoid eating foods high in cholesterol and salt like noodles
 To avoid too much caffein
 To maintain healthy weight and increase physical activity like doing exercise.
To the Family
 To encourage the patient on her proper diet
 Give spiritual support
 Encourage the patient to have a healthy lifestyle
To the students
 Keep informing the patient about her condition
 Provide health teaching
 Give deep empathy

107
Discharge Plan
Medications:
 Catapres 75mg 1tablet as needed for Blood pressure of ≥160/90
 Losartan 10mg 1tablet OD (6am)
 Amlodipine 10mg 1tablet OD (6pm)
 Amoxicillin 500mg 1capsule every 8hours for 7 days
 Metronidazole 500mg 1tablet BID for 7 days
 Ferrous Sulfate 1capsule BID for 1 month
 Mefenamic acid 500mg 1 capsule every 8hours for pain
 Spinorolactone 50mg 1 capsule BID for 7 days
Environment: Client needs clean and safe environment.
Treatment: no follow up treatment.
Health teaching:
 The patient should be instructed to monitor her Blood pressure
 Advise to for a minute of exercise
 Advise to avoid salty and fatty foods
 Explain the action and side effects of the drugs to the patient.
Out-patient department: Follow check-up at OB on August 22, 2014 , Friday at 1pm
Diet:
 Sodium restrictions
- Sodium- restricted diets may vary from 2 to 4 g depending on the degree of hypertension. The patient should be avoiding high-sodium foods such as cured meats, canned soups, and soy sauce.

Abruptio Placenta Case Study

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (20)

Similaire à Abruptio Placenta Case Study

Similaire à Abruptio Placenta Case Study (20)

Plus de Rozelle Mae Birador

Plus de Rozelle Mae Birador (20)

Dernier

Dernier (20)

Abruptio Placenta Case Study