Assessment Nursing Diagnosis Planning Intervention Evaluation

Subjective: Acute pain related to After 2 hours of nursing Independent: After 2 hours of nursing
 Complaint of tissue contusion intervention, the patient Asses the pain, location intervention, the patient
hunger and secondary to NSVD. should feel the pain is of pain, pain scale, felt the pain is
having the urge alleviated. frequency and onset. alleviated.
to urinate, she Note for non-verbal
voided After 4 hours of cues. After 4 hours of
approximately comprehensive nursing comprehensive nursing
150 ml. intervention, patient Assess patient comfort. intervention, the patient
 Patient sates of must verbalize the relief Perform palliative verbalized the relief
severe from pain. measurements such as from pain.
postpartum pain. back massage and
 She complaint of repositioning. Patient pain will be
moderate pain reduced from a scale of
on both breasts. Encourage verbalization 8 to 0-1.
Objective: of pain and feelings as it
develops. Patient demonstrate use
 28-year-old
of relaxation and
mother, G3P3.
Collaborative: diversion activities.
Delivered a
Administer pain reliver
healthy female
such as mefenamic acid
baby via NSVD.
to relief of moderate
APGAR score of
pain as authorized by
9.
the physician.
 VS:
Temp: 36.5 °C
BP: 120/70
mmHg
PR: 90 bpm
RR: cpm
 Pain scale of 8.
 Facial grimace is
 visible.
 Breast are soft,
nipples are
intact.
 Uterus is well
contracted firm.
Moderate lochia
rubra.

DRUG STUDY
NAME OF MECHANISM DOSAGE INDICATION CONTRA- ADVERSE NURSING
DRUGS OF ACTION INDICATION EFFECT RESPONSIBILITIES
Generic name: Readily Approximately Superficial ocular No disease Allergic reactions. Wash hand before
oxytetracycline absorbed protein 1cm. infection. contradiction. administering the
binding. 4-6 times drugs.
HCI daily.
a. polymyxin Excreted: Discard the first drop
b. sulfate Urine and feces. of the ointment.

Brand name: Make sure not to let

Terramycin the medicine tube
ophthalmic touch the baby’s eye or
ointment anything else.
Essential Term babies Antidote for Premature may Renal impairment,
Generic name: hemorrhagic develop newborn esp. Monitor PT, INR
Vitamin K cofactor for the 1mg IM soon routinely in those
gamma after birth. induced by oral hyperbilirubinemia, premature.
Brand name: anticoagulant, due occurs rarely. taking coagulant.
phytonadione carboxylase
enzyme which to vitamin k Risk for hemolysis,
Mephyton jaundice, Assess skin for
catalyze the post deficiency.
hyperbilirubinemia. ecchymoses, petechiae.
translational
gamma- Assess gums for
 carboxylation of gingivitis.
glutamic acid. Relief of moderate Headache, dizziness,
500mg, route pain. Use cautiously with insomnia, rash, Check doctor’s order.
Generic name: Anti- per orem as Treatment of asthma, renal or sweating, nausea, Assess the pain.
Mefenamic inflammatory, needed. primary headache hepatic impairment, diarrhea, Assess for history of
acid analgesic, and and peptic ulcer disease, constipation, dysuria, allergy.
Brand name: antipyretic dysmenorrhea. GI bleeding, renal impairment,
Dolfenal drugs. hypertension, heart bleeding, platelet Educate the patient
Duration: 6 hrs Given to patient failure and inhibition with higher regarding desired and
Excretion: feces for relief of acute pregnancy. doses, dyspnea, adverse effects.
and urine. or moderate pain. hemoptysis, Educate the patient
pharyngitis, that prolonged use of
peripheral edema. drug may damage the
500g Dosage Can be used to liver.
treat bacterial If you have an Common side effects
Generic name: Form: Capsule allergic reaction to
Antibacterial infections in your of Droxyl-500 Tablet Check the doctor’s
Amoxicillin Route: Per Cefadroxil or other
used to fight body. It is 10's include diarrhea, order.
Brand name: Orem Cephalosporin
bacteria. effective in nausea, vomiting,
Droxyl antibiotics or any
infections of the sore tongue, Assess and monitor the
throat, ears, other ingredients of abdominal pain, patient for severe side
urinary tract, skin, Droxyl-500 tablet. If dyspepsia effects.
and soft tissues. It you have a history of (indigestion), skin
kills bacteria, severe allergic rash, and itching. Note for allergic
which helps to reactions to reactions.
improve your Penicillin.
symptoms and
cure the infection.