Saint Paul University Dumaguete

College of Nursing
Dumaguete City

ACKNOWLEDGEMENTS

I would like thank the following people with their help and support
in doing this case study:

To our clinical instructor in the area where we are having our

clinical exposure, Mrs. Rochel S. Ignacio RN MAN, who is very supportive
and giving all of her time in entertaining some of our questions
especially in dealing with the chart of the patient.

To Dean Malou V. Dinopol RN, MAN, College of Nursing, and also our
clinical instructor in OB for allowing us to have this exposure and for
all out support. And also giving us knowledge to have a full confidence
during our clinical exposure.

To my patient L.B.R. for the full cooperation for this study, for
the patience and for being approachable, cooperative and for spending
all of her time in answering my questions and for communicating well.

Lastly, I would like to extend wholeheartedly the gratitude and

praise to ever loving and merciful God for enlightening my mind and
giving me knowledge to have this study.

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 Saint Paul University Dumaguete
College of Nursing
Dumaguete City

ABSTRACT

This is a case about patient L.B.R. 26 years old born on June 16,
1992. Was born and a resident of Bindoy Negros Oriental. Patient’s
religion is Aglipay and her educational attainment is high school level.
Prior to admission, patient was at home doing some household chores when
the symptoms started. Patient had hypogastric pain from right side and
felt knifelike that would last for about 20 minutes. Symptoms occur in
the morning and patient immediately travelled and went to Negros Oriental
Provincial Hospital to have a consultation and reveled that it is an
ectopic pregnancy. Patient was admitted on March 4, 2019.

To provide further care for the patient surgical management has

been done, laparoscopy, this will be performed to ligate the bleeding
blood vessels and repair or remove the damaged fallopian tube and also
medical management has been done such as intravenous fluid, and other
medications.

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College of Nursing
Dumaguete City

CHAPTER I
CASE OVERVIEW

INTRODUCTION

Ectopic pregnancy is the abnormal implantation of a fertilized ovum

anywhere outside the uterine cavity or normal site of implantation. This
is one of the most common complications of pregnancy during the first
trimester. There is no exact statistic that would represent ectopic
pregnancy because many cases were masked by misdiagnosis. Oftentimes,
pregnancy is believed to be normal during its early phase due to the
presentation of some signs indicative of an ideal gestation. This is the
reason why ectopic pregnancy is usually diagnosed late, or when pain
starts to be manifested as sign of rupture of the fallopian tube (most
common manifestation) and begins to develop more serious problems such
as hemorrhage.

The type of ectopic pregnancy that my patient had been diagnosed

is tubal pregnancy, a tubal pregnancy occurs when the egg has implanted
in the fallopian tube. This is the most common type of ectopic pregnancy
and the majority of ectopic pregnancies are tubal pregnancies.

I choose this case because it is related to our lesson in OB and

also to learn more about ectopic pregnancy, to also help my patient to
discuss more about her case.

OBJECTIVES

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College of Nursing
Dumaguete City

The general goal of this study:

To understand and learn more important information about Varicella.

Specific Learning Objectives:

Skills
1. Complete all the action plan in the health care setting.
2. Identified the laboratory results, and pathophysiology, medical and
nursing management that is applicable to Varicella.
3. Provide quality care by instructing and record client’s response.

Knowledge
1. Discussed the management and treatment of ectopic pregnancy.
2. Have enough knowledge to have a health education who don’t have any
idea about ectopic pregnancy.
3. Gained knowledge on the definition of Ectopic pregnancy, causes,
clinical manifestations, management and treatment.
4. Secure health teaching/interventions about clients complaints

Attitude
1. Have a teamwork and trust each and every one.
2. Have an attitude that is suitable for many different situations.
3. Received the best possible medical and nursing care, leading to a
feeling of security, comfort, and good prognosis of the disease
condition.
4. Give proper quality nursing care.

SCOPE

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College of Nursing
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This clinical paper contains information regarding the patient’s

case. It includes her biographical data and other information pertaining
to her case. This clinical paper also includes information about the
nursing and medical management that is done to the patient. Also this
contains the normal Anatomy and Physiology of the system being tackled
and also the laboratory results of the patient

LIMITATIONS

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College of Nursing
Dumaguete City

In the process of making this clinical paper, I encounter some

limitations. I wasn’t able to do much assessment especially in her
abdomen because patient is still in pain. I interviewed 20precent more
on patient’s mother because her LOC is not that good.

CHAPTER II

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College of Nursing
Dumaguete City

CASE DATA AND INFORMATION

Biographical Data
Name: L.B.R.
Sex: Female
Age: 26 years old
Birthdate: June 16,1992
Occupation: None
Religion: Aglipay
Address: Bindoy, Negros Oriental
Birthplace: Bindoy, Negros Oriental
Nationality: Filipino
Culture: Filipino
Race: Asian
Marital Status: Single
Health Insurance: PhilHealth
Educational Level: High School Level
Contact Person: V.R.
Relationship: Mother
Physician: Dr.Lamante

70% - Patient
20% - Significant Other (Mother)
10% - Patient’s Chart
100%

Chief Complaint
“sigeg sakit akong tiyan konekar sa buko-buko” as verbalized by
the patient.

History of Present Illness

Prior to admission, patient was at home doing some household chores
when the symptoms started. Patient had hypogastric pain from right side
and felt knifelike that would last for about 20 minutes. Symptoms occur
in the morning and patient immediately travelled and went to Negros
Oriental Provincial Hospital to have a consultation and reveled that it
is an ectopic pregnancy. Patient was admitted on March 4, 2019.

Past Health History

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College of Nursing
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A. Childhood illness: Patient had Urinary Problem before

B.Hospitalizations: The patient had been hospitalized before due
to abortion in her first child and also due to giving birth to her
second child who is termed.
C. Surgeries: Laparoscopy
D. Immunization: Complete
E. Laboratory Examination

(✔) CBC (March 5, 2019)

Result Limits Units Remarks
WBC 11.1 4.0 – 11.0 10ˆ3/mm3 High
RBC 4.46 3.80 – 5.80 10ˆ6/mm3 Normal
HGB 12.1 11.5 – 16.0 g/dL Normal
HCT 37.7 37.0 – 47.0 % Normal
MCV 88 76 – 96 um3 Normal
MCH 28.1 27.0 -32.0 Pg Normal
MCHC 33.0 30.0 – 35.0 g/dL Normal
RDW 16.1 11.0 – 16.0 % High
PLT 327 150 – 450 10ˆ3/mm3 Normal
MPV 9.2 8.0 – 12.0 um3 Normal
PCT 0.261 0.100 – 0.500 % Normal
PDW 17.8 8.0 – 18.0 Normal

Interpretation:
- Base on the CBC result the patients WBC and RDW is high and
the rest are in in normal value.

FAMILY HISTORY
Relationship to client status

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College of Nursing
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(alive/deceased)
( ) Diabetes Mellitus none
( ) Tuberculosis none
( ) Epilepsy none
( ) Asthma none
( ) Sexually Transmitted Disease none
( ) Cancer none
( ) Mental Illness none
( ) Hepatitis none
( ) Heart Disease none
(✔) Hypertension Paternal Father/Alive/ Age 73
Sister / Alive / Age 66
( ) Others, specify none

Genetic Information:
Relationship to Client (alive/deceased)- age, cause of death and year
() Sickle Cell anemia or trait none
() Thalassemia none
() Down Syndrome none
() Cystic Fibrosis none
() huntington’s Disease none
() Muscular dystrophy none
() Tay-Sachs none
() Himophilia none
() others, specify none

FAMILY HEALTH HISTORY

GENOGRAM:

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College of Nursing
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Legend:
-Male + -Deceased
AW – Alive and well
TB - Tuberculosis
- -Female

Patient

Maternal

LR MR MT FT

82 64 76 30

AW + TB +

PT JR MR JT JT WT

36 47 43 42 36 35

AW AW AW AW AW HTN

JT
WT
W.T 11
6
14
AW
AW

INTERPRETATON:

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College of Nursing
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Patient’s maternal side, grandmother is alive and well, grandfather

died at the age of 64. Mother is still alive and well and also the other
siblings. Paternal side, grandmother has tuberculosis and grandfather
died at the age of 30 years old. Patient’s father and auntie is alive
and well and the brother has a hypertension. Patient’ siblings are all
alive and well.

FUNCTIONAL HEALTH PATTERNS

A. Health Perception and Health Management

Prior to Admission: The child has been admitted since he had a chicken
pox. The child has enough age knowledge to know what maybe the causes
of his ill. He has been hospitalized before for burns and diarrhea, her
mother mentioned that whenever he gets injected he got scared. Whenever
he has the common cold, fever or cough, they would give him over-the-
counter medications such as biogesic, neozep, etc. The medicines are in
liquid or tablet form and he usually drinks water after to get rid of
the after taste from the medications. He has difficulty in taking
medications. The child doesn’t have any allergies to medication.

During hospitalization: The child seems to show the same habits towards
how he perceives about his health. This time, they have the help and
guidance of the doctors and nurses from the hospital in understanding
and managing the child’s health. They follow all the orders for the fast
recovery.

B. Nutrition and Metabolism

Prior to admission: The family eats three meals a day and has two snack
times in between. The child goes to school early on the weekdays and
eats breakfast sometimes. In noon time he comes home and eats lunch then
goes back to school. And for dinner, they eat together with her father
,mother and siblings. Frying is the most common method on how they cook
their food. He likes to drink soda and juices. He is capable of eating
by himself with the help of her spoon and fork . He likes any type of
food except for “bangus”. She is a healthy eater based from how her
mother describes it. Patient has no any supplements that is taken. He
has no any allergies to particular food. His weight is the same and
doesn’t appear to have any feeding problems.

During hospitalization: It has been observe that s he don’t like eating

the food that is cooked in the hospital. He has eating problems. The

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child would inform her mother that he was hungry or thirsty. After the
child, finished her meal, he will directly go to bed.

C. Elimination
Prior to Admission: The child has regular toilet habits. He eliminates
once or twice a day, usually in the morning or sometimes after meal.
He has no any problems in going to the restroom because for him he is
old enough to managed and care for himself. The mother mentioned the
child sweats a lot during activities like playing basketball outside.

During Hospitalization: It is observed that, the child still follows his

regular toilet habits. But since she has an IV line, he would verbalize
to her mother and ask help in and out of her hospital bed.

D. Activity Exercise
Prior to Admission: The child goes to school on weekdays, plays with
his classmates. On weekends, he plays basketball, billiards and fun of
playing computer games. He watches television during the day at night
time they sell peanut. He watches cartoons and ABS-CBN. There are no
illnesses or disabilities that limit her activities. During bathing, he
goes alone with no companion He brushes his teeth after bathing and after
meal especially when he goes to school. Dressing or grooming is not a
problem for the child. He has no requirement for any special devices to
help him in managing himself. Patient is zero where she has full self
care before her hospitalization.

During hospitalization: The patient is a two since he now requires

assistance or supervision from her mother in doing some activities like
taking bath and going to the restroom. And due to the IV line it is
hard for him to carry. He is always in his bed lying and doing nothing
since he left his cellphone at home.

E. Cognitive-Perceptual

Prior to admission: The child can her clearly and has no difficulty in
hearing. He is not using any hearing aids. He can also see clearly and
has also no vision problems. The mother stated that he is sometimes lazy
in studying. He is grade 8 student

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During hospitalization: The child can answer questions and interact. He

share about the things he do at home or in school and even about his
siblings.

F. Self-Perception and Self-Concept

Prior to Admission: the child can make friends easily, he is talkative,

playful and friendly. He easily get angry with his siblings, they always
fight with each other. He hasn’t experienced being separated from her
mother and father. He appears to have no fears in place, objects, animals
except for her father, he is scared when his father will be angry. His
illness affected or changed the way he thinks about his self because
of the spots in his face and extremities.

During hospitalization : Patient is just silent and answers questions I

asked. He just stays in bed the whole time and sleeps.

G. Roles and Relationship

Prior to Admission: The child doesn’t have any nickname. Since the mother
is housewife, she is the one who takes care of the patient. The mother
sometimes goes home to check her child who is 5 years old and will come
back to the hospital. The father stays at home together with his younger
siblings at night. There are no any major changes in the family lately.
He plays in his school and has a group of friends who are dancers,
because the child is fun of dancing and joins competition. The child do
household chores at home. He follows commands especially to his father
and doesn’t answers back. There are also no speech or hearing problems
reported or observed. Though the family has no enough money, but the
mother stated that her husband has Philhealth that would cover the
expenses in the hospital. The family is now focused on preventing
illnesses for each of their members. The father and siblings haven’t
experience chicken pox even the mother who is the one guiding the child.
During Hospitalization: The mother and the child had a very good and
close relationship with each other. The mother is very welcoming and
very comfortable to be with.

H. Sexuality and Reproduction

Prior to Admission: The child is 14 years old . The child is not
affected the way he feels about being a male. The mother don’t talk about
sexuality because they give privacy to his son. Patient has frend and

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classmates that is close to him but hasn’t mentioned their genders and
name.

During hospitalization: he wasn’t able to interact with other patients

because he is in the isolation room. Only the patient and his mother
inside the room, he is not allowed to go out in the room.

I. Coping and Stress Tolerance

Prior to Admission: the mother stated that whenever the child is tired
he just remain silent and sleep. When he is upset, he just go out in
their house and play basketball or sometimes he just remain silent .
Whenever the child is disappointed they would talk to him and let her
understand. There haven’t been any big changes or problems in their
family recently. He hadn’t had a problem with drugs or alcohol. The
mother does think child is accident prone like riding bicycle or paying
basketball..

During hospitalization,: He is just silent and answer only whenever I

have questions. He is just sleeping or lying in his bed the whole time.
He got bored because he left his cellphone at home.

J. Values and Belief

Prior to Admission: Patient’s religion is Roman Catholic. For him
religion is important because he believes in God and he know that God
is always there for him and for hi famiy.
During Hospitalization: Patient’s pray always for his fast recovery
because wants to go home and play computer games.

Review of Systems

1. General appearance and Mental status

Upon doing the assessment in the PEDIA ward patient is awake and is
responsive. He is not well groomed, he hasn’t taking bath yet because
of his fever. Patient has good affect and facial expression is
appropriate to the situation. Speech is clear patient is lying down in
bed with her mother in the other bed because their is a vacant bed. He
answers clearly and can understand.

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2. Integumentary system

Patient has a brown skin complexion on the body and arms. Hair is
evenly distributed thick dry and black in color in upper and lower
extremities. Fingers nails and toe nails are slightly dirty and pinkish-
pale in color, Nails convex in shape. Hair color is black, and evenly
distributed. Skin has blisters both upper and lower extremities.

3. Head, Face and Neck

Head is normocephalic and at the midline proportional to the body.

Scalp is mobile, round, non-tender, no mass or depression appreciated.
Hair is evenly distributed. Face is bilaterally equal. Facial features
are symmetrical. Neck is in midline with no presence of masses. No pain
felt when head and neck is being move. Trachea is in midline, neck is
supple, non-tender, no masses. Face and has blisters.

4. Eyes, Ears, Nose, Mouth, and Throat

Eyes is non-protruding. Eyebrows are symmetrical and in line with
each other, hair is evenly distributed. Eyelashes are evenly distributed.
Iris is brown in color, flat and round. Cornea is clear and sclera is
white. Pupils converge when object is moved towards the nose. Both eyes
of the patient coordinately moved in union with parallel movement.
Patient’s ears, auricles are symmetrical and have same color with the
facial skin. Aligned to outer canthus of the eyes and is symmetrical.
The auricles are mobile, firm and non-tender upon palpation. The pinna
recoils when folded. ntact no lesions or swelling. Presence of blisters
around the ears. Nose is in midline, no discharges. No nasal flaring.
Lips are symmetrical, pale in color and dry with no lesions. Teeth are
complete and presence of cavities. Tongue is positioned midline. Uvula
is in midline. Soft and Hard palate is intact pinkish in color. Oral
mucosa is pink in color. Patient’s face has many blisters.

5. Respiratory system

Anterior and posterior chest are symmetrical. Shape is appropriate to

the body built. No spinal deformities found. No effort on breathing.
Trachea is located on midline with no tenderness and no crepitus noted.
Has normal breath sounds without dyspnea and no nasal flaring.

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6. Cardiovascular System:
Carotid artery and internal jugular vein run parallel to
sternocleidomastoid. Carotid has palpable pulsation. There is no bruit
sound. Apex, tricuspid, pulmonic, epigastria pulsations not palpable.
No presence of murmurs and has regular rhythm upon auscultation.

7. Peripheral and Lymphatic System:

Upper and lower extremities are equal in size, no involuntary
movements, no presence of edema. Presence of blisters both lower and
upper extremeties.. No varicosities. Hair is evenly distributed.

8. Abdomen:
Skin uniform in color, lighter than exposed area, round shape.
Umbilicus is inverted and in midline placement. Presence of blisters all
over his abdomen. Abdominal movement is symmetrical caused by
respiration. No vascular sound heard no bruits, no venous hums, and no
friction rub. No presence of masses and tenderness noted.

9. Genitourinary System:
Patient voids 4-6 times in a day with amber yellow color of the
urine. No pain noted upon urinating. Anus is intact and no presence
of lesions.

11. Motor and Musculoskeletal System:

Posture is erect head is in midline. No abnormal movements, and
without nodules. Both feet pointing straight, coordinated, arms swing
bilaterally. Balance is intact and has no complains of muscular or joint
pains.

12. Sensory -Neurologic System:

The patient is awake, alert and oriented to time, date, person, and
event. He is responsive and answers to questions appropriately. Able
to make faces, intact facial nerves, sensations intact. Speech is clear.
Taste on posterior tongue intact. Tongue can protrude medially.

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LABORATORY RESULTS

Result Limits Units Remarks

WBC 11.1 4.0 – 11.0 10ˆ3/mm3 High
RBC 4.46 3.80 – 5.80 10ˆ6/mm3 Normal
HGB 12.1 11.5 – 16.0 g/dL Normal
HCT 37.7 37.0 – 47.0 % Normal
MCV 88 76 – 96 um3 Normal
MCH 28.1 27.0 -32.0 Pg Normal
MCHC 33.0 30.0 – 35.0 g/dL Normal
RDW 16.1 11.0 – 16.0 % High

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PLT 327 150 – 450 10ˆ3/mm3 Normal

MPV 9.2 8.0 – 12.0 um3 Normal
PCT 0.261 0.100 – % Normal
0.500
PDW 17.8 8.0 – 18.0 Normal

Interpretation:
- Base on the CBC result the patients WBC and RDW is high and the rest
are in in normal value.

Chapter III
LITERATURE REVIEW

Normal Anatomy and Physiology

SYSTEM: Reproductive System

Ovaries

—these are considered the gonads (primary sex organs) of the female
reproductive system. Normally, there are two ovaries in a female body;
measuring approximately 3.5 centimeters long, 2.5 centimeters wide, and
1 centimeter in thickness; making an ovoid shape. These are located on
each side (shallow depression) of the wall of the pelvic cavity (ovarian
fossa), held in place by various ligaments (broad ligament-largest). The
tissues of the ovaries are composed of two indistinct regions known as

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inner medulla (loose connective tissues with numerous blood vessels,

lymphatic vessels, and nerve fibers) and ovarian cortex (compact tissues
with ovarian follicles). Its primary function is to produce egg cells.

Fallopian tubes

—these are otherwise known as oviducts or uterine tubes. There is a pair

of fallopian tubes in a normal female body. These are about 10
centimeters long and 0.7 centimeters in diameter. They are held in place
by by portions of the broad ligament. Each fallopian tube has an opening
near each ovary and connected to the uterus on its other end. The wall
of the fallopian tube is composed of inner mucosal layer, middle muscular
layer, and an outer covering of the peritoneum. The primary function of
these organs is to aid in the transport of egg cells towards the uterus.

Uterus

—the uterus is a hallow, muscular organ with a shape of n inverted pear.

This is highly flexible that is about 7 centimeters long, 5 centimeters
wide, and 2.5 centimeters in diameter on its broadest point during a
pre-pregnat state. This is held in place by the broad ligament within
the anterior portion of the pelvic cavity, above the vagina, and is bent
forward over the urinary bladder. The upper 2/3 of the uterus is called
the fundus and the lower 1/3 is called the cervix. It is composed of
three layers namely: 1. Endometrium(inner layer), 2. Myometrium (muscle
layer), and 3. Perimetrium (outer covering). The normal uterus can hold
and sustain implantation and pregnancy. Its vascular nature has all what
is needed for gestation.

Vagina

—this is a fibromuscular tube approximately 9 centimeters in length.

This connects the uterus to the outer female reproductive organs. It has
3 main functions: 1. Convey uterine secretions, 2. Receives the penis
during intercourse, and 3. Transports the fetus during delivery.

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Theoretical Background

Name of Disease

 Ectopic Pregnacy

Definition

Ectopic pregnancy is the abnormal implantation of a fertilized ovum

anywhere outside the uterine cavity or normal site of implantation. This
is one of the most common complications of pregnancy during the first
trimester. There is no exact statistic that would represent ectopic
pregnancy because many cases were masked by misdiagnosis. Oftentimes,
pregnancy is believed to be normal during its early phase due to the
presentation of some signs indicative of an ideal gestation. This is the
reason why ectopic pregnancy is usually diagnosed late, or when pain
starts to be manifested as sign of rupture of the fallopian tube (most

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common manifestation) and begins to develop more serious problems such

as hemorrhage.

The type of ectopic pregnancy that my patient had been diagnosed is tubal
pregnancy, a tubal pregnancy occurs when the egg has implanted in the
fallopian tube. This is the most common type of ectopic pregnancy and
the majority of ectopic pregnancies are tubal pregnancies.

Etiology

An infection or inflammation of the fallopian tube can cause it to become

partially or entirely blocked. Scar tissue from a previous infection or
a surgical procedure on the tube may also impede the egg’s movement.
Previous surgery in the pelvic area or on the tubes can cause adhesions.
Abnormal growths or a birth defect can result in an abnormality in the
tube’s shape.

Clinical Manifestations

- Sharp or stabbing pain that may come and go and vary in intensity.
(The pain may be in the pelvis, abdomen, or even the shoulder and
neck due to blood from a ruptured ectopic pregnancy gathering up
under the diaphragm)

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- Vaginal bleeding, heavier or lighter than your normal period

- Gastrointestinal symptoms

- Weakness, dizziness, or fainting

Medical management

 Administration of methotrexate. It is a chemotherapeutic agent that

is a folic acid antagonist. It destroys rapidly growing cells such
as the trophoblast and the zygote.

 Administration of mifepristone an abortifacient that causes

sloughing off of the tubal implantation site. Both of these
therapies would leave the tube intact and no surgical scarring.

 Withdrawing of blood sample. A large amount of blood would be lost,

so blood typing and crossmatching must be done in anticipation of
a blood transfusion. The blood sample would also be used to
determine the hemoglobin levels of the pregnant woman.

Nursing Management

1. Upon arrival at the emergency room, place the woman flat in bed.

2. Assess the vital signs to establish baseline data and determine if

the patient is under shock.

3. Maintain accurate intake and output to establish the patient’s

renal function.

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CHAPTER IV
CASE ANALYSIS AND INTERVENTIONS

PATHOPHYSIOLOGY
The most common site of ectopic implantation is a fallopian tube,
followed by the uterine cornua. Pregnancies in the cervix, a cesarean
delivery scar, an ovary, the abdomen, or fallopian tube interstitium are
rare.
Heterotopic pregnancy (simultaneous ectopic and intrauterine
pregnancies) occurs in only 1/10,000 to 30,000 pregnancies but may be
more common among women who have had ovulation induction or used assisted
reproductive techniques such as in vitro fertilization and gamete
intrafallopian tube transfer (GIFT); in these women, the overall reported
ectopic pregnancy rate is ≤ 1%.
The structure containing the fetus usually ruptures after about 6 to 16
wk. Rupture results in bleeding that can be gradual or rapid enough to

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cause hemorrhagic shock. Intraperitoneal blood irritates the peritoneum.

The later the rupture, the more rapidly blood is lost and the higher the
risk of death.

Medical Management
• Administration of methotrexate. It is a chemotherapeutic agent that
is a folic acid antagonist. It destroys rapidly growing cells such as
the trophoblast and the zygote.
• Administration of mifepristone an abortifacient that causes
sloughing off of the tubal implantation site. Both of these therapies
would leave the tube intact and no surgical scarring.
• Withdrawing of blood sample. A large amount of blood would be lost,
so blood typing and crossmatching must be done in anticipation of a blood
transfusion. The blood sample would also be used to determine the
hemoglobin levels of the pregnant woman.
Nursing Management
1. Upon arrival at the emergency room, place the woman flat
in bed.
2. Assess the vital signs to establish baseline data and
determine if the patient is under shock.
3. Maintain accurate intake and output to establish the
patient’s renal function.

PHARMACOLOGICAL MANAGEMENT
Name of drug: Paracetamol
Chemical/Therapeutic Classification: Anti-pyretic
Indication: Symptomatic relief of pain and fever
Dosage: 500 mg
Timing: every 4 hours
Route: oral
Side Effects and Adverse Reactions:
 Hematoligic:haemolyticanemia, neutropenia,leucopenia,pancytopenia
 Hepatic: Jaundice
 Metabolic: Hypoglycemia
 Skin:rash, urticaria

Nursing Responsibilities:
 Use liquid form for children and patients who have difficulty
swallowing.

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 In children, don’t exceed five doses in 24 hours

 Advise patient that drug is only for short term use and to consult
the physician if giving to children for lobger than 5 days or
adults for longer thn 10 days.

 Warm patient that high dose or unsupervised long term use can cause
liver damage.

Name of Drug: Ampicillin Sulbactam

Chemical/ Therapeutic Classification:
Indications: Intra abdominal,gynecologic, and skin structure infections
caused bysusceptible beta-lactamase-producingstrains
Dosage: 750 mg
Timing: every 8 hours
Route: IVTT
Drug action: Destroys bacteria byinhibiting bacterial cell-wall
synthesis during microbial multiplication.Addition of sulbactam enhances
drug’s resistance to beta-lactamase, anenzyme that can inactivate
ampicillin.
Side Effects and Adverse Reactions:
CNS:lethargy,hallucinations ,anxiety, confusion,agitation, depression,
fatigue, dizziness,seizure
HEENT:bluredvision, itchy eyes
GI:nausea,vomiting,diarrhea,abdominalpain,gastritis,
RESPIRATORY:wheezing,dyspnea,hypoxia,apnea
SKIN:rash,urticaria,diaphoresis

Nursing Responsibilities:
 Monitor for sings and symptoms of hypersensitivity reaction
 Check for signs and symptoms of infection at injection site.
 Watch for bleeding tendency and hemorrhage.
 Check patients’s tempetature

Name of Drug: Acyclovir

Brand name: Chemical/Therapeutic Classification: Antiviral
Indication:
-Initial and recurrent mucosal and cutaneous HSV-1 AND HSV-2 and
varicella zoster infections in immunocompromised patients
Dosage: 5 mL

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 Saint Paul University Dumaguete
College of Nursing
Dumaguete City

Timing: every 6 hours

Side Effects and Adverse Reactions:
CNS: headache, vertigo, depression, tremors
DERMATOLOGIC: inflammation or phlebitis at injection sites, rash, hair
loss
GI: Nausea, vomiting, diarrhea, anorexia
Nursing Responsibilities:
 Ensure that the patient is well hydrated.
 Start treatment as soon as possible.

Nursing Management
1. Monitor vital signs.
2. If nausea and vomiting are present, make sure the patient would
not aspirate it.
3. Administer all medications as ordered. Observe the 10 Rs
4. History taking. The history should elicit if a recent outbreak of
chickenpox in the community has occurred and if any exposure to
varicella at school, daycare, or among family members has occurred.
5. Immunizations. It should also be noted whether the child has
previously received varicella vaccine or if the child is
immunocompromised (including recent systemic steroid use) to help
guide management.
6. Immunocompromised child. Immunocompromised children often have
severe and complicated varicella, and their mortality rate is
higher than that in immunocompetent children.

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 Saint Paul University Dumaguete
College of Nursing
Dumaguete City

Progress Notes

March 19 2019

 Admit under PEDIA service to isolation room

 Problem: fever and rash

 Diet for age

 IVF: D50.3 NACL + L@ 20 gtts/min.

 Laboratory: CBC

March 20 2019

 Received patient with high fever

 Medication: Paracetamol is given.

 Acyclovir is given as ordered by the doctor.

Discharge Plan

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 Saint Paul University Dumaguete
College of Nursing
Dumaguete City

Your child will be ready for discharge when he/she is:Plan

 Drinking fluids
 Tolerating the pain, itching and swelling with compresses or
medicines
 Resolving any secondary infections

What will be the follow up for my child after discharge?

 Follow up will be with your primary health care provider

 Follow up will be within 5 to 7 days following discharge
 Your primary health care provider will examine and evaluate your
child’s recovery

Call your health care provider if your child has:

 A recurrence of fever
 Sores in the eyes
 Sores that get bigger or have pus in them
 Trouble breathing or is breathing very fast

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 Saint Paul University Dumaguete
College of Nursing
Dumaguete City

CHAPTER V

CONCLUSIONS AND RECOMMENDATIONS

Conclusion

Chickenpox is a highly contagious disease caused by the varicell-

zoster virus (VZV). It can cause an itchy, blister-like rash. The rash
appears first on the chest, back and face, and then spreads over the
entire body. Is confirmed by laboratory examinations. Throughout the
study, I was able to meet the goals and objectives in knowing deeper the
client’s case with regards on providing the outmost care needed by the
patient.

Recommendation

In order to ensure optimal health is restored and maintained, I would

like to recommend the following:

To the patient:
 Avoid dirty environment. Make sure your surrounding is clean and
have proper disposal.

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College of Nursing
Dumaguete City

 encouraged to take full responsibility in complying with

therapeutic regimen needed for her recovery.
 He must understand importance of taking her medication. In
addition, she should not hesitate on seeking medical assistance
whenever she feels very ill or experiences other manifestations
which may be due to another health condition.

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