NURSING CARE PLAN Nursing Diagnosis Ineffective tissue perfusion related to decreasehemoglobin concentration in the blood secondary to blood

loss and post partum as manifsted by pallor, pale palpebral conjunctive, weakness and a verbalization of maulawak pay nukwa. Nursing Inference RBC is necessary for the transport of oxygen to the different parts of the body for proper functioning. A decrease in circulating RBC will also mean an alteration in oxygen and nutrient supply in the cellular level to sustain demands of the body resulting in the manifestations of pallor, palpebral comjunctiva, and weakness. Nursing Goal After 2-3 days of rendering appropriate nursing intervention the patient will be able to demonstrate improved tisue perfusion as would be manifested by pinkish conjunctiva, bsence of pallor and weakness and a verbalization of haanak nga maulawen. Nursing Intervention 1. Encourage patient to have adequuate rest and sleep. Rationale: To decrease consumption of energy and oxygen. 2. Encourage patient to increase fluid intake. Rationale: To imcrease blood volume, thereby enhancing enhancing the further distribution of nutrients in the blood. 3. Position patient in high fowlers position. Rationale: To encourage lung expansion. 4. Assist patient in her activities. Rationale: To prevent exhaustion and energy congestion. 5. Provide quiet and restfull environment. Rationale: To conserve energy and lowers tissue oxygen demand. 6. Advice patient to ambulate within limits when possible. Rationale: This enhances venous return. 7. Provide bedside commode to the patient. Rationale: To decrease physical effort in going to the toilet facility conserving energy and minimizing the demand for oxygen. 8. Plan care of activities with rest periods. Rationale: To decrease oxygen supply and demand.

Nursing Evaluation After 3 days of rendering appropriate nursing intervention the patient was able to demonstrate improved tissue perfusion as manifested by pinkish conjunctiva, bsence of pallor and weakness and a verbalization of haanak nga maulawen.

DRUG STUDY

Date ordered: December 27, 2010 Generic Name: Ciprofloxacin Brand Name: None Classification: Antibacterial, Flouroquinolone Dosage, Route, Frequency: 500mg 1tab PO BID Mechanism of Action: Interferes with DNA replication in susceptible bacteria preventing cell reroduction. Desired Effect: This drug was given to my patient to treat infection. Nursing Responsibilities: 1. Inform patient the action, use and the reason of taking drugs. Rationale: So that the client is aware of what he is taking in and to gain cooperation during the drug therapy. 2. Assess clients history of hypersensitivity to the drug before administering. Rationale: To avoid allergic reaction to the drug. 3. Instruct that he should swallow extended release tablets whole, do not crush, cut or chew. Rationale: In order to receive the maximum therapeutic effect of the drug. 4. Ensure that the client is well hydrated. Drink plenty of fluids while taking the drugs. Rationale: To prevent dehydration. 5. Encourage the patient to complete full course of therapy. Rationale: In order to receive the maximum therapeutic effect of the drug.. 6. Instruct patient to report rash, visual chamges, severe GI problem, weakness and tremors. Rationale: To provide immediate action and prevent further complication.

Sherry Ann A. Pucan BSN IVE Group 4 PERSONAL DATA Name: Genevieve Roda Sedillo Hospital: 5994649 Address: Tamdagan, Vintar, Ilocos Norte Age: 22 years old Birthday: September 04, 1988 Birth place: Negros Oriental Sex: Female Status: Single Citizenship: Filipino Religion: Catholic Father: Jaime Sedillo Mother: Thelma Roda Sedillo Date of Admission: December 24, 2010 Time of Admission: 8:00 pm Admitting diagnosis: Acute pyelonephritis, t/c sepsis;anemia probably secondary to blood loss, post partum and sepsis; r/o blood dyscrasia Attending physician: Ofelia C. Datu, M.D. Grace A. Lijauco, M.D.