RAD RLE Guide – Written Requirements

Name of Student:
Section:
Concept: Care of Mother, Child, Adolescent (Well Client)
Name of Clinical Instructor: Miss Sarah Mae Abunda

Patient Data:

Name: Mrs. Jennifer Tan Lee

Gender: Female
Birth Date: October 21, 1997
Birth Place: Cebu City
Age: 23 years old
Address: Inayawan, Cebu City
Educational Level: College
Marital Status: Married
Occupation: HR personnel
Nationality: Filipino
Religion: Roman Catholic
Source of Data:
Date & Time of Admission: May 14, 2020 at 10:00am
Attending Physician: Dr. Moltefalcon
Diagnosis: Labor Pain

Chief Complaint: Hypogastric Pain

LMP: unrecalled
AOG: 38 weeks 1/7
EDC: May 26, 2020

VITAL SIGNS:
BP: 110/70mmHg
Temperature: 36.2◦C
Pulse Rate: 104bpm
RR: 21cpm
O2 Saturation: 98%
Weight: 109lbs

Brief History Upon Admission:

▪ G1P0
▪ LMP: 8/1st week/2019
▪ EDC: May 26, 2020
▪ AOG: 38 1/7
▪ S: 10 hours PTL, noted onset of crampy hypogastric pain radiating to Lumbosacral area, associated
with mucoid bloody
▪ discharge noted and persistence of symptoms thus decided to seek consult ▪ OE: awake,
afebrile, NRD
▪ Abd: FH: 28
▪ FHT: 135
▪ EFW: 2680 grams
▪ IE: 6 cm, 90% eff., St-2, IBOW, Cephalic
▪ A: G1P0, PU, 38 1/7 weeks AOG
▪ Cephalic in Active Labor
▪ Admit

Antenatal Hx:
▪ 1st Prenatal at APS clinic: 15 weeks AOG
▪ Total Prenatal visits: 6 visits
▪ Vital Signs: BP: 100/70
▪ Took FA, MV + Iron and calcium OD
▪ Illnesses: vulvovaginal candidiasis – 15 1/7
▪ cF̅ luconazole 150 mg/cap once a month x3 months
▪ Bacterial vaginosis at 17 weeks AOG
▪ cN ̅ eo-penotran Vag-supp HS x 1 week
▪ Total weight gain: 2.3 lbs.
▪ Menstrual Hx: 13 y.o. irregular x 4-7 days, 3-4 pads/day, (-) dysmenorrhea
▪ Sexual Hx: 19 y.o. x 5 sexual partners since then
▪ (-) dyspareunia, (-) post coital bleeding
▪ OB Hx: Primipara
▪ PSH: College Grad. B.A. works as an HR personnel, Pt started working at
▪ 19 y.o. until 21
▪ Occasional alcoholic beverage drinker
▪ Family Hx: DM + HPN - maternal
▪ PE: awake, conscious, coherent
▪ BP: 100/70, HR: 100, RR: 21, T: 36.2, Wt.: 109 lbs.
▪ Skin; warm , good turgor
▪ HEENT: ALS, PPC
▪ C/I: CCE, CBS
▪ CVS: DHS, (-) mur
▪ Abd: FH 28 (2635 grams)
▪ FHT: 130
▪ LOT
▪ IE: 6 cm, 90% Eff, St. -2, I/C
▪ Ext: (-) Edema
▪ IMP: G1P0 PU 38 1/7 weeks AOG, Cephalic in active phase of labor
 Admitting Diagnosis: Labor Pain or Hypogastric pain

Anatomy & Physiology

(This will show a drawing of the organ affected related to the diagnosis of the patient)

The womb and the birth canal are surrounded by the bones of
pelvis that the baby passes through is only about 11
centimeters wide at its narrowest point.

Common risk factors:

- fetal macrosomia
- narrow pelvis
- gestational diabetes
- post- term baby

The pelvic inlet is oval shaped and is widest from side to side. It divides
the bony pelvis into the false pelvis above (made up mainly of the ala of
the ilium on each side which forms the lower lateral portion of the
abdomen), and the true pelvis below (the pelvic cavity). the inlet to the
true pelvis, bounded by the sacral promontory, the horizontal rami of the
pubic bones, and the top of the symphysis pubis. Because the infant must
pass through the inlet to enter the true pelvis and to be born vaginally,
the anteroposterior, transverse, and oblique dimensions of the inlet are
important measurements to be made in assessing the pelvis in pregnancy.
There are three anteroposterior diameters: the true conjugate, the
obstetric conjugate, and the diagonal conjugate.

Followed by:
Parts of the organ and function of each part
Definition of the disease
Clinical Manifestation/Signs & Symptoms
Laboratory Test
Date Type of exam Patient’s Result Normal Values Significance/Interpretation

5/14/2020 CBC RBC: 3.95 4.5 – 5.1 LOW (sign of Iron Deficiency
Anemia)
RDW: 11.5 11.6- 14.8
ABOVE LOW (sign of Iron
Deficiency Anemia)

5/14/2020 URINE COLOR: DARK Light yellow Dark yellow urine can be sign of
ANALYSIS YELLOW to deep dehydration.
amber
High
VOLUME: 60mL 30-200ml
High
WBC: 8-10/HPF 0-5/HPF
High
RBC: 50-60/HPF 0-4/HPF

5/14/2020 Immunology Non-active Normal result are negative or

nonactive, meaning that no
hepatitis B surface antigen was
found

5/14/2020 Ultrasound No. of fetus: 1 Single, live, intrauterine pregnancy,

25 weeks and 6 days by fetal
BDP: 6.31cm biometry in cephalic presentation.
Placenta posterior, high lying,
HC: 23.9cm grade 2 Adequate amniotic fluid
volume. Incidentally the fetus is
female.
AC: 20.7cm

FL: 4.91cm

AVERANGE
ULTRASOUND
AGE 25W6D

EFW: 860

ULTRASONIC
EDC: 05/20/2020

Problem List
 Number of Focus / Nursing Diagnosis
Priority

1 Risk for infection related to preterm rupture of membrane as

evidenced by watery vaginal discharge

2 Hypogastric pain related to uterine contractions

3 Knowledge Deficit

Drug Study

Drug name Classification Mechanism of Indication Contraindication Adverse Nursing

action reaction responsibilities

GENERIC Cephalexin is used to Cephalexin Long term: Documente Abdominal Before

NAME: treat a wide will not work Superinfections and d pain - do skin
Cefalexi variety for viral infect promotion of hypersensiti testing
n of bacterial infectio ions (such nonsusceptible vity Agitation -check the
(Canelin ns. as common organisms may doctor’s
) This medication is cold, flu). occur with Low blood order
known as a Unnecessary prolonged use or iron -observe
BRAND cephalosporin anti use or misuse repeated therapy (anemia) the 15
NAME: biotic. It works by of any Prolonged right drug
Keflex, stopping the antibiotic can treatment may be administrat
Skin
and growth of bacteria. lead to its associated with ion
increased internat swelling
Panixine decreased
Disperd effectiveness. ional normalized After
Cephalexin is ratio (INR) Confusion
ose Administer
available Prolonged use is the drug at
Actual
under the associated Diarrhea the right
Dosage:
following with fungal or dosage and
500 mg
different bacterial Dizziness route in
1 cap
brand superinfection the right
names: Keflex , Short Term: Use time check
ROUTE: Indigestion
and Panixine the the
Disperdose. lowest effective patency of
TID dose for the Elevated
transamina the IV site
shortest duration and IV line
consistent with ses
Frequen
cy: individual patient
Skin During
treatment goals.
redness Report
x 7 days severe
allergic
Fatigue reactions
Stomach
such as
pain
rash, hives,
itching,
Hypersensi dyspnea,
tive tightness in
the chest,
swelling of the
mouth, face,
lips or tongue.

Nursing Care Plan

 Defining Nursing Scientific Goal of Care Intervention Rationale
Characteristics Diagnosis Analysis

Subjective - deficient Risk of Long term: Independent: - to give relaxation and

data: knowlegde infection is After 2 week Assess pt to comfort to the pt.
- 10 hours PTL defined as at of nursing positioning or
- risk for risk for being intervention right side.
fluid invaded by the pt. will be
- noted onset
pathogens able to Dependent:
of crampy volume
organisms. achieve
hypogastric deficit
During appropriate - to lessen the pain of the pt.
pain radiating Cold compress
to pregnancy, nutrition
- risk for the cervix intake.
Lumbosacral injury - patient receive
area secretes a Collaborative:
-risk for give the medication appropriate to
thick, jelly like Short term:
infection prescribe their clinical needs.
fluid to kepp the After 8 hours
-associated -risk for are moist and medication
with mucoid of nursing
ineffective protected.
bloody intervention
coping This fluid
discharge the client will
-risk for eventually verbalize
noted and anxiety accumulates understanding
persistence of and seals the of causative
symptoms cervical canal, factors and
thus, decided creating a
to seek necessary
thick plug of intervention
consult mucus. The to promote
mucus plug optimum
Objective sets as a nutrition.
data: barrier and
can keep
BP: unwanted
bacteria and
110/70mmHg
can keep
unwanted
Temperature:
36.2◦C bacteria and
other sources
Pulse Rate:
of infection
104bpm
from
RR: 21cpm
travelling into
O2 Saturation:
your uterus.
98%
Weight: 109lbs

FDAR
 Date Focus Time DAR

4/28/2020 Hypogastric pain related to 3pm D: reports onset of crampy

urine contractions. hypogastric pain radiating to
Lumbosacral area; associated
with mucoid bloody discharge;
scale of 9 out of 10; facial
grimacing.

A: Administer a drug that can

reduced the pain; encourage deep
breathing exercises and relaxation
techniques; keep patient
comfortable and safe

R: Patient reports pain was

relieved; pain score 3 out of 10

Discharge Planning (SAMPLE)

AMETHOD of discharge planning was developed and modified to provide a systematic method for
ensuring client’s needs during the termination phase of hospitalization. The AMETHOD represent
areas the nurse should consider before the client goes home. The Discharge plan follows the FDAR
format. AMETHOD is placed in the Implementation.
 DATE FOCUS TIME DAR

5/15/2020 DISCHARGE INSTRUCTION 11:33am D: With discharge order from attending

physician Dr. Moltefalcon

A:
ACTIVITY:
Advice the pt to avoid stress and so some
exercise. Eat health food. Drink a lot of
liquids such as water, milk, etc.

MEDICATION:
Take Home Meds:
1. Cefalexin (Cenelin) 500 mm1 cap TID P.O x
6 days
2. Celecoxib (Coxto) 200 mg 1 cap BID P.O
3. Senna (Senokot Forte) 1 cap BID P.O 4.
Moringa (Feralac) 1 cap BID P.O
5. MV + Iron (Foralivit) 1 cap OD P.O

ENVIRONMENT:
• Environment must be clean and stress free
for the PTL patient from any actual or
potential hazard. This can contribute to the
client’s improvement for her health.

HEALTH TEACHING:
• Bed Rest: You may need to stay in bed all
the time. You will be allowed to get up
briefly to go to the bathroom.
•Pelvic Rest: This means you should not put
anything in your vagina, such as tampons. Do
not have sex.
• Temperature Monitoring: You may need to
check your temperature each day to make
sure you don’t have a fever. A fever may be a
sign of infection.
• Quit smoking: Smoking can also cause the
placenta to detach and bleed leading to early
contractions.

OUTPATIENT REFERRAL:
Follow up after 1 week.

DIET: May have soft diet. Eat iron-rich food

which helps regain the blood lost during
delivery and easily digestible food. Drink
plenty of water. Avoid caffeinated drinks,
alcohol, and consumption of acidic food
R: Discharged on improved condition
BIBLIOGRAPHY

https://www.healthline.com/health/cbc

https://www.chegg.com/homework-help/questions-and-answers/table-1-urinalysis-test-specimen result-
normal-value-yellow-amber-clear-50-90-color-cleo-l-q23440959

https://www.ouh.nhs.uk/immunology/diagnostic-tests/tests-catalogue/immunoglobulins.aspx

https://www.rxlist.com/consumer_cephalexin_keflex/drugs-condition.htm

https://www.scribd.com/document/176252810/Nursing-Care-Plan-of-Labor-Pain

https://nurseslabs.com/labor-stages-labor-induced-nursing-care-plan/