Davao Doctors College

General Malvar St., Davao City

Nursing Program

Nursing care plan

Name Of Patient: Sharon Lee Mendoza Date Of Admission: August 8, 2022 Room: OB Ward
Age: 29 Years Old Sex: Female Civil Status: Married Chief Complaint: Consistent labor pain with 30-70
seconds duration and 5 to 10 minutes frequency

Date & time Cues Nursing diagnosis Goals & objectives Nursing interventions Rationale Evaluation
August 8, Subjective: Ineffective health At the end of my 8  Assess interest and  • The patient may be At the end of my 8-
2022 “lagi lang ako nasa maintenance related to hours shift the patient desire to improve unmotivated or lack hour shift: Goal
bahay, nakahiga unhealthy lifestyle choices must be able to: health. a comprehensive Partially Met.
nanunuod, nag- as evidence by not engaging  Discuss the patient’s knowledge of the
cecelphone, ganun to any prenatal exercise. A. Adopt lifestyle habits and health need to improve
kaya siguro baka changes to support maintenance in the health behaviors. A. Patient is adopting
mahirapan ako
Scientific basis: health goals. past  This provides lifestyle chance to
manganak di ako Pattern of regulating and  Have family and information on support her health
nagkikilos” integrating into daily living a B. Patient will express friends participate in whether these goals
therapeutic regimen for the willingness to the patient’s health habits are new
Objective: treatment of illness and its participate in activities and lifestyle changes owing to recent B. Patients is showing
Not engaging into sequelae that is improving health status  Praise the patient for changes or if the interest in participating
prenatal exercises unsatisfactory for meeting achieving goals patient has been activities to improve
specific health goals. dealing with them health status.
for a long time. To
Vital signs: break habits that
Temperature 36.5˚c have been part of
Pulse 84 bpm the patient's life for
Respiration 20 cpm a long time, a new
strategy may be
required.
 In order for the
patient to make
lasting adjustments,
his or her
environment must
be encouraging.
 Compliments on
accomplishments
increase motivation
and validate the
 appropriateness of
activities taken.

REFERENCE:
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
Hartney, E. (2021, May 30). What Is Motivational Interviewing? Verywell Mind. https://www.verywellmind.com/what-is-motivational-interviewing-22378
Canadian Institute for Substance Use Research. (2017). Understanding Substance Use: A health promotion perspective. Here to
Help. https://www.heretohelp.bc.ca/infosheet/understanding-substance-use-a-health-promotion-perspective#applies

Davao Doctors College

General Malvar St., Davao City
Nursing Program

FDAR Charting

Name of patient: Sharon Lee Mendoza Date of Admission: August 8,2022 Room: OB ward
Age: 29 years old Sex: Female Civil Status: Married Chief Complaint: consistent labor pain with 30-70 seconds
Duration and 5 to 10 minutes frequency

Date & time Focus Progress notes (dar)

 August 8, 2022 Pregnancy Sleeping Position Data:
“I cannot sleep properly due to large abdomen”

Action:
Teach the patient sleeping positions for pregnant woman such as:
Placing a pillow between your knees or underneath your tummy can give you extra
support. This is a great use for a full-body pillow. If you put your pillow in the right
place, it can also keep you from rolling over and sleeping on your back or stomach.

Response:
The patient is comfortably sleeping

GOAL MET

REFERENCE:
https://www.healthline.com/health/sleeping-with-pillow-between-legs#benefits

DAVAO DOCTORS
COLLEGE
General Malvar St.,
Davao City Nursing
Program
DRUG STUDY
Name of Patient: Sharon Lee Mendoza Date of Admission: August 8, 2022 Room: OB Ward
Age: 29 years old Sex: Female Civil Status: Married Attending Physician: Dr. Ana Lorca
 DRUG NAME CLASSIFICATION/ INDICATIONS CONTRAINDICATIONS SIDE EFFECTS ADVERSE EFFECTS NURSING RESPONSIBILITY
MECHANISM OF ACTION
 Do not exceed with the
BRAND NAME: DRUG CLASSIFICATION: Ferrous sulfate can Ferrous sulfate has Occasional: CNS:
recommended dose.
Pharmacotherapeutic: Enzymetic relieve: contraindications to:
 Headaches
 Nausea  assess nutritional status,
Mineral Prevention or Hemochromatosis, bowel function
treatment of iron  Transient CV:
hemolytic anemias.  monitor hemoglobin,
deficiency anemia nausea.
Cautions: Peptic ulcer,  Heartburn hematocrit and iron
MECHANISM OF ACTION: due to inadequate
regional enteritis, GI: levels
Iron is essential for hemoglobin, diet, malabsorption, ulcerative colitis, pts Rare:  Monitor daily pattern of
myoglobin and enzymes, it is pregnancy, blood
receiving frequent  Peptic ulcer
bowel activity, stool
Ferricore transported to organs where it loss.  Heartburn
blood transfusions  Regional enteritis consistency.
GENERIC becomes part of iron stores.
 Anorexia  Assess for clinical
NAME:  Ulcerative colitis
improvement, record
Ferrous  Constipatio Hypersensitivity Reactions:
relief of iron deficiency
Sulfate n
 Anaphylaxis symptoms.
 Diarrhea
DOSAGE:
60mg

ROUTE:
Oral

FREQUENCY:
OD
References:
https://tmedweb.tulane.edu/pharmwiki/doku.php/antianemia_drugs#:~:text=Ferrous%20Sulfate&text=in%20Anemia%20(microcytic)-,Mechanism%20of%20Action%3A,small
%20erythrocytes%20with%20insufficient%20hemoglobin.
https://myhealth.alberta.ca/Health/aftercareinformation/pages/conditions.aspx?hwid=ug5526#:~:text=You%20also%20may%20feel%20grumpy,take%20up%20to%206%20months.
https://go.drugbank.com/drugs/DB13257