Abruptio Placenta Case Study

Abruptio Placenta Case Study

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  1 I. Introduction
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  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)
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  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.
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  4 Classification Asto 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.
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  5 3. UterineTenderness- 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
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  6 a homevisit 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.
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  7 II. Patient’sProfile
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  8 II. Patient’sProfile 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.
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  9 III. Patient’sHistory
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  10 A. PresentHealth 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
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  11 third monthof 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.
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  12 C. FamilyHistory 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)
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  13 D. DevelopmentalHistory 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.
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  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.
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  15 K. Hygiene Before Hospitalization During Hospitalization After Hospitalization 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 Before Hospitalization During Hospitalization After Hospitalization 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.
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  16 morning afterthe 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
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  17 and aftershe 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.
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  18 IV. PHYSICALASSESSMENT
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  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
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  20  Blanchingof 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
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  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
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  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
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  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
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  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
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  25 in pulserate 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
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  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.
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  27  CNXI  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
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  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
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  29 V. Anatomy
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  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
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  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.
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  32
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  34 Maternal &Child Health Nursing 6 edition Vol.1 Chapter 9 the growing fetus Page 193, 195
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  35 VI. Pathophysiology
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  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
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  37 VII. MedicalManagement
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  38 Date DoctorsOrder 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)
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  39  IntravenousFluid 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.
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  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
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  41  SerumGlutamic- 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)
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  42  InsertIndwelling 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
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  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 pre- eclampsia 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.
  44 birth. Thepatient 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.
  45  Oxygeninhalation 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.
  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.
  47  Ranitidine50mg 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.
  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.
  49  Pleasedo 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.
  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.
  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.
  52  MonitorVital 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.
  53 o BloodUrea 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.
  54  Stillfor 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.
  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.
  56  MefenamicAcid 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.
  57  Continuemeds.  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.
  58  Refer 08-05-14  Still for correction of anemia  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.
  59  StartLosartan 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.
  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  Still for correction of anemia  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.
  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.
  62 mild andoccur 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  Still for correction of anemia  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.
  63 meds abuseof medications. 08-09-14  Still for correction of anemia  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  Still for correction of anemia  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)  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
• 64.
  64  Monitorvital 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  Still for correction of anemia  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.  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
• 65.
  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.
  66  Continuemeds  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.
  67  Continuemeds  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.
• 68.
  68 VIII. LaboratoryResult
• 69.
  69 Hematology ResultsDate: 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.
  70 Hematology ResultsDate: August 3, 2014 Test Result Normal Range Interpretation Implication Nursing Responsibility 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.
  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.
  72 Hematology ResultsDate: August 7, 2014 Test Result Normal Range Interpretation Implication Nursing Responsibility 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. To prevent this, advise mother to increase food intake rich in iron like malunggay. Iron are in whole grains, nuts and legumes. 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 Reference: Essentials of Anatomy & Physiology, 6th Edition by Rod Seeley, Trent Stephens and Philip Tate, pp. 301-318
• 73.
  73 Hematology ResultsDate: August 12, 2014 Test Result Normal Range Interpretation Implication Nursing Responsibility 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. 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
• 74.
  74 Hematology ResultsDate: August 13, 2014 Test Result Normal Range Interpretation Implication Nursing Responsibility 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. 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. 301-31
• 75.
  75 IX. DrugStudy
• 76.
  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.
  77 Drug Name Dosage Classification Action Indication / Contraindication Side Effects Nursing Responsibilities 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.
  78 Drug Name Dosage Classification Action Indication / Contraindication Side effects Nursing Responsibilities 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 (2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 1022-1024)
• 79.
  79 (26th EditionNursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 866-867) Drug Name Dosage Classification Action Indication / Contraindication Side effects Nursing Responsibilities 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.
  80 Drug Name Dosage Classification Action Indication / Contraindication Side effects Nursing Responsibilities 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. (26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 292-294)
• 81.
  81 Drug Name Dosage Frequency Route Classification Indication and Contraindication Side Effects /Adverse Reaction Mechanism of Action Nursing Responsibilities 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.
  82 Drug Name Dosage Classification Action Indication / Contraindication Side effects Nursing Responsibilities 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.
  83 (Reference: 2011McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 66-68) Drug Name Dosage Frequency Route Classification Indication and Contraindication Side Effects /Adverse Reaction Mechanism of Action Nursing Responsibilities 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.
  84 Drug Name Dosage Classification Mechanism of Action Indication / Contraindication Side Effects Nursing Responsibilities 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. (2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 623-625)
• 85.
  85 (2004 Nurse’sDrug Guide Volume 2 at page 965-966) Drug Name Dosage Frequency Route Classification Mechanism of Action Indication / Contraindication Side Effects Nursing Responsibilities 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:  Hypersensitivity to drug  Ulceration  Nausea  Vomiting  Constipation  Blurred vision  Discontinue drug promptly if diarrhea , dark stools, hematemesis, or rash occur and do no use again.
• 86.
  86 Drug Name Dosage Frequency Route Classification Mechanism of Action Indication / Contraindication Side Effects Nursing Responsibilities 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.
  87 Drug Name Dosage Frequency Route Classification Indication and Contraindication Side Effects /Adverse Reaction Mechanism of Action Nursing Responsibilities Date Ordered: 08-06-14 Generic: Amlodipine Brand: Norvasc 10 mg OD Route: P.O Antihypertensive Indication:  Essential hypertension Contraindication:  Hypersensitivity to drug 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.
  88 Drug Name Dosage Classification Mechanism of Action Indication / Contraindication Side Effects Nursing Responsibilities 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. (2011 McGraw-Hill Nurse’s Drug HandBook by Patricia Dweyer Schull at pages 264-266)
• 89.
  89 Drug Name Dosage Classification Action Indication / Contraindication Side effects Nursing Responsibilities 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. (26th Edition Nursing 2006 Drug Hand Book by Lippincott Williams and Wilkins at pages 351-352)
• 90.
  90 X. ProblemIdentification & Prioritization
• 91.
  91 Problem Identificationand Prioritization Problem 1. Difficulty of Breathing 2. Elevated High Blood Pressure 3. Generalized Edema 4. Elevated Body Temperature 5. Acute pain
• 92.
  92 XI. NursingCare Plan
• 93.
  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.
  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.
  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.
  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.
  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.
  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.
  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.
  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