SOUTHWESTERNUNIVERSITY

PHINMA

Name: Tirol, Mary Grace M. BSN 2-A9

Concept: Promotion of health and prevention of illness.
Clinical Instructor: Erika Claire C. Pino RN

PATIENT DATA
Name: C.C.M.
Age: 28 yrs. old
Gender: Female
Address: 356 Nasipit Talamban, Cebu City
Birth Date: August 1, 1992
Birth Place: Cebu City
Occupation: Housewife
Marital Status: Married
Religion: Jehovah’s Witness

Chief Complaint: Scheduled cesarean section on May

14, 2020
LMP: 8/16/19
AOG: 38 ⅝ weeks, Prev. CS one for CPD (2014 CHH)
EDC: 5/23/20

Vital Signs
BP: 100/70
HR: 95
RR: 18
Temp: 36.4
O2 Sat: 98%

DEFINITION OF THE DISEASE (No disease)

Cesarean delivery (C-section)
A surgical procedure used to deliver a baby through incisions in the abdomen
and uterus. A C-section might be planned ahead of time if you develop
pregnancy complications or you've had a previous C-section and aren't
considering a vaginal birth after cesarean (VBAC). Cesarean is credited as
being named after the great Julius Caesar. While the exact timeline is
debatable, the University of Washington (UW) reports that some believe
Caesar was the first one to be born via C-section. The name is actually derived
from the Latin word “caedare,” which
means “to cut.
ASSESSMENT OF SIGNS AND SYMPTOMS
Assessment of body parts Findings
Neck: head movement, muscle strength, Normal
lymph
nodes, and thyroid gland

Thorax and Lungs: anterior thorax Normal

Abdomen: abdominal (+) hypo gastric pain mild to

movements and auscultation of moderate by 60 mins.
bowel sounds

Upper and Lower Extremities: muscles, (+) hypo gastric pain radiating to the
bones and left sacrum anterior with a pain score
joints. of 1/10.

Mental Status/ Gross Motor Function: Normal

language, orientation, attention span,
level of consciousness,and walking gait.

Integumentary: skin, hair, nail, skull, and Normal

face.

Eyes and Normal

Vision: eyebrows, eyelashes, bulbar
conjunctiva,
palpebral conjunctiva, sclera, lacrimal
gland, lacrimal sac, nasolacrimal duct,
cornea, and
pupils.

Ear and Hearing: auricles and external Normal

ear canal

Noses and Sinuses: external nose and Normal

nasal cavity

Mouth and Oropharynx: teeth, tongue, Normal

floor of
the
mouth, tongue movement, uvula, and gag
reflex.

Reproductive: external and internal (-) No watery or vaginal discharge

female organ (+) A7M

LABORATORY TEST
Date Type of Patient’s Normal Significance/
exam Result Values Interpretation
Urine Macroscopic
Analysis Examination Macroscopic Within normal
Color: Yellow Examination range
Transparency: Color: Pale
Clear yellow to
Volume: 50 mL deep amber
Specific Transparency:
Gravity: 1.015 Clear or
Chemical slightly cloudy
Examination Specific
Albumin: Gravity:
Negative pH: 1.005-1.30
6.5 Chemical
Ketone: Examination
Negative Albumin: Less
Blood: than 30 mg
Negative pH: 4.5-8
Glucose: Ketone: Less
Negative than .6
Nitrite: Blood: 4
Negative Glucose:
Bilirubin: Negative
Negative Nitrite:
Urobilinogen: Negative
Normal Bilirubin:
Microscopic Negative
Examination Urobilinogen:
WBC: 1-3/HPF 1mg/dl
RBC: 5-7/HPF Microscopic
Epithelial Examination
Cells: WBC: >10
Moderate RBC: <5
Mucus Thread: Epithelial
Few Cells: <5
Bacteria: Few Mucus Thread:
Negative
Bacteria:
Absent
Amorphous
Phosphates:
Normal
CBC WBC: 11.80 WBC: 4.4 - Within normal
NEU: 67.8 11.0 range
LYM: 21.1 NEU: 37.0 -
MON: 9.4 80.0
LYM: 10.0 -
50.0
EOS: 1.3 MON: 0.0 -
BAS: 0.4 12.0
RBC: 3.96
HGB: 12.1 EOS: 0.0 - 7.0
HCT: 36.1 BAS: 0.0 - 2.5
MCV: 91 RBC: 4.5 - 5.1
MCH: 30.5 HGB: 12.3 -
 MCHC: 33.5 15.3
RDW: 13.0 HCT: 35.9 -
PLT: 212 44.6
MPV: 7.4 MCV: 80 - 96
MCH: 27.5 -
33.2
MCHC: 32.0 -
36.0
RDW: 11.6 -
14.8
PLT: 150 - 450
MPV: 6.0 -
11.0

DIAGNOSTIC TEST
Date Type of Patient’s Result Significance/
exam Interpretation
05/14/20 X-ray Lung Normal
Report fields are clear.
Heart is
not enlarged. The
pulmonary vascular
markings are within
normal limits. Both
hemidiaphragms
and costophrenic
sulci are sharp
and distinct.
The visualized
osseous structures
are unremarkable.

DRUG STUDY
Name of Mechanism of Indication Adverse Nursing
Drug Action Effects Responsibilitie
s
s
Generic Inhibits Treatment of CNS: Before:
Name: histamine active duodenal confusion, 1. Baseline
Ranitidine action ulcers and dizziness, Assessment:
Brand at histamine gastroesophage drowsiness, Receive full
Name: H2-receptors of al reflex hallucinations, medication
Zantac gastric disease(GERD). headache history and
Classificatio Parietal Management of CV: screen for
n: cells.Therapeut Gastric hyper arrhythmia s contraindication
H2 blockers ic secretory GI: s
Dosage: 50 Effect: states constipation, .
mg Inhibits IV: diarrhea, 2.Question
Route: gastric Prevention drug-induced history of
IVTT acid and hepatitis, hepatic
Frequency: secretion. treatment of nausea impairment,
Now Reduces upper GI bleed. GU: long
 gastric decreased QT syndrome.
volume, Contraindicati sperm
hydrogen Ion on count, During:
Concentration. ns impotence 1. Administer
Hypersensitivity Endo: drug.
to gynecomastia 2. Record onset,
ranolazine. Heat: type, radiation,
Hepatic agranulocytosi location,intensit
cirrhosis, s, y, duration of
concurrent use a plastic inguinal pain,
of strong anemia precipitating
CYP3A MISC: factors.
inhibitors pr hypersensitivit 3. Obtain
VYP3A inducers y baseline EKG
reactions After:
1.Interventions/
Ev
valuation: Assist
with ambulation
if dizziness
occurs.
Give with food
if nausea occurs

NURSING CARE PLAN

Defining Nursing Scientific Plan of Nursing Rationale
Characteri Diagnosis Analysis Care Interventio
stic n
cs
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Objective: like they s, contributing experiencing
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be over their be able to ess on
frightened situation verbalize s. n, which
due to hx and fears and 2. Consider includes
of may act out feelings options in fear of
CPD with Of care when the
- V/S as indifference, vulnerabilit possible unknown.
follows; anger, y. (e.g., IV Unplanned
BP: 100/70 violent 2. Patient placement, (and
HR: 95 behavior, or expresses choice of sometimes
RR: 18 passivity. individual anesthesia, planned)
Temp: 36.4 Also, needs and use of cesarean
O2 Sat: patients and mirror) birth may be
98% who are desires. 3. characterize
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weakness, teaching
sickness, builds on
and previous
affliction. knowledge
Or
experience.
5. Providing
a climate
Of
acceptance
Allows
patients to
be
themselves
and to hold
their own
beliefs
As
appropriate.
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FDAR
Date Focus Time DAR

05/13/2020 Risk for acute pain 12:00 PM D: The patient is

related to increased awake, conscious,
muscle contraction face grimacing.
as evidenced by Complained hypo
hypo gastric pain. gastric pain
mild-mod by 60
ins. by 60
radiating to the
LSA

Vital Signs:

BP: 100/70; HR:

95; RR: 18; Temp:
36.4;
O2 Sat: 98%;
Weight: 135 lbs

A: Encourage the pt
to do deep
breathing exercises
and relaxation
techniques.
Perform a
comprehensive
assessment of
pain. Provide non
pharmacologic pain
management.
Provide
pharmacologic pain
management as
ordered. Provide
health teachings
based on the
 patient’s condition.
R: The patient
verbalized that
pain was
minimized and
relieved.

DISCHARGE PLANNING
Date Focus Time DAR

05/16/2020 Discharges 09:20 AM D: With discharge

instructions order from attending
physician Dr.
Mercado Activity:
The client is
instructed not to do
light exercises and
avoid heavy chores
or work and also, to
avoid heavy works
especially lifting and
straining heavy
things that may
shock the patient
body physically.

The following are

specific suggestions
by the physician:

-Bed rest: The client

may need to stay in
bed all the time. The
client will be allowed
to get up briefly to
go to the bathroom.
-Pelvic rest: This
means that the client
should not put
anything in your
vagina, such as
tampons. Do not
have sex.
-Temperature
monitoring: The
client may need
to check your
temperature
each day to
make sure you
do not have a
fever. A fever
may be a sign of
infection.

Medication: The
client knows the
name, action,
purpose, dose,
route of
administration, and
side effects of each
drug she is taking.
The client is
instructed to report
or contact the
physician if adverse
reactions are
present.

- Cefuroxime
( Altoxime) 500
mg 1 tab BID
P.O./ 6 more
days -
Mefenamic Acid
(Almefen) 500
mg 1 cap q 6ᵒ
- MV + Iron (Beniforte)
1 cap OD P.O./ x 3
months
- Calcium
+ Vit. D
( Osteo-D)
1 tab BID
P.O./ x 3
months -
Vitamin C
(Alto Cee)
1 tab OD
P.O./ x 1
month.

Environment: The
client knows the
importance of
having a clean,
comfortable, and
healthy
environment free
from any actual or
potential hazards.
This can contribute
to the client’s
improvement of her
health condition.
Homemaking
services; and
emotional and
 economic support
systems are in
place.
Treatment: The
client and family will
know the purpose
and action of any
treatment.
Take-home
medications are
vital for the
improvement of the
client’s condition.

Health Teaching:
Provide incision care.
Shower as needed. Pat
your incision dry. Watch
your incision for signs
of infection, like more
redness or drainage.
Hold a pillow against
the incision when you
laugh or cough and
when you get up from a
lying or sitting position.
Remember, it can take
as long as 6 weeks for
your incision to heal.

Outpatient Phone
follow-up on May 13,
2020, via RITU

Diet: Drink plenty of

liquids. Eat foods that
have protein such as
milk, cheese, meat,
and fish. Eat fruits
and vegetables.

Avoid alcohol and

caffeine.

R: Out of the room

per wheelchair with
improved condition