Cebu Institute of Technology

University

N. Bacalso Ave., Cebu City Philippines

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

ACTIVITY : FDAR; MEDICATION ADMINISTRATION DRUG STUDY

IN PARTIAL FULFILLMENT OF THE COURSE RLE 207

SUBMITTED BY:

BSN 2- SECTION-GROUP#

SUBMITTED TO:

CLINICAL INSTRUCTOR
CASE SCENARIO

A case of Mrs. P. is 30 years of age, married, from Mambaling, Cebu City, is in her 3 rd pregnancy. Stated that her first
day of her last menstruation was March 4, 2020. She has a daughter born at 36 weeks of age. One threatened abortion at 6
weeks old. She attended the antenatal clinic 2 weeks ago and has now come today December 2, 2020 @ 6am to the hospital
with her mother-in-law because labor pains started 3 hours ago. Mrs. P. reports that the pains start in her back and move
forward, last 20 seconds, and occur about every 8 minutes. Mrs. P. appears very anxious.

The doctor ordered to start venoclysis with D5 Lactated Ringer solution 1 liter + 10 units of Oxytocin to flow at
12gtts/min to start at 11am today.

Chart reviewed: Given Oxytocin 10 IU IM as stat dose , Carboprost 250 mcg (1ml) deep IM as initial dose.

History:

 Mrs. P. is 39 weeks pregnant.

 This is her third pregnancy.
 Her first pregnancy and birth were uncomplicated, although she repeatedly states that labor was more painful than she had
expected.
 She confirms that labor started 3 hours ago and that contractions seem to be growing increasingly longer and more
frequent.
 All other aspects of her history are normal or without significance.
Physical Examination:
 Mr. P. kneels to the floor and cries out with each contraction.
 On measurement of vital signs: Respirations are 18 per minute; BP is 120/82; pulse is 88
beats per minute; temperature is 37.8º C.
 On abdominal examination:
1. Fundal height is 33 cm.
2. Presenting part is four-fifths above the pelvic brim.
3. Fetal heart tones are124 beats per minute.
4. Contractions are irregular every 8–10 minutes and last 14–18 seconds.

 On cervical examination:
1. Dilation of the cervix is 3 cm.
2. Membranes are intact.
3. Presentation is vertex and there is no molding.
4. Her physical exam reveals no abnormal findings.
Testing:
 Routine CBC, Urine, Blood group is O Positive, RPR(Rapid Plasma Regain) is negative, and blood was taken for HIV
testing, HBsAG for Hepatitis B teting
 Ultrasound

EVALUATION
 Mrs. P. continues to have regular contractions; by 2 hours after admission, she is having 2 contractions in 10 minutes, each
lasting 20–40 seconds.
 Maternal pulse remains between 80 and 88 beats per minute; fetal heart rate remains between
150 and 160 beats per minute.
 Mrs. P.’s level of anxiety remains high and she continues to become agitated during
contractions.
UPDATES:
• At 1:50pm, Mrs P delivered an alive male term with an AS 9-10, Ballard score 30- 40 weeks
• Episiotomy, and repaired done. Noted with 2nd degree laceration.

TASKS:

DRUG STUDY
MEDICATION ADMINISTRATION
FDAR
NURSE’S PROGRESS NOTES
Name of Patient :________________________ Hospital Number: ___________
Age: __________________________________ Bed Number: _______________

NURSE'S PROGRESS NOTES

DATE TIME Focus D - ata A - ction R - esponse

DRUG STUDY
 MEDICATION ADMINISTRATION

Name of Patient: ____________________________ Hospital Number: ______________

Age: ____________ Bed Number: ____________

NURSE’S N INITIAL NURSE’S NA INITIAL NURSE’S NA INITIAL NURSE’S NA INITIAL

AMES MES MES MES
           
           
               
               

MEDICATI DATE
ONS / /     /     /     /     /     /     /     /     /     /     /     /     /

           

           

               

               

               

               

               

Note: Make a ticket for every medication

DOCUMENTATION

Reflection/Wrap-Up

Directions: State one word to sum up all the concepts that you have learned from today’s activities. Then, discuss the created word.

One Word to Sum UP____________________________

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Name of Student: ______________________Section:_____