ASSESSMENT DIAGNOSIS PLANNING IMPLEMENTATION EVALUTATION

GOAL OF CARE INTERVENTION

WITH RATIONALE
Subjective Cues: Interrupted sleep due At the end of 6  Provide  Administered after 5 hours of nursing
“Nahihirapan ako to Acute pain resulting hours of nursing measures to oxytocin to the intervention, the
makatulog, sa surgical incisions as intervention, patient relieve pain. patient. patient was able to:
madaling araw bigla evidence by verbal shall be able to: Consult with  Reduced the
nalang nagigising at reports and grimace.  Report pain is physician in pain as
hirap na makabalik sa relieved or administering evidence by
pagtulog” controlled medication to pain scale.
relieve pain.  Demonstrate
Objective cues:  Demonstrate use  Collaborate with  Advised the patient the relaxation
 Blood pressure: of relaxation patient for to do deep skills and
 Respiration: skills and relaxation breathing and diversional
 Pulse Rate: diversional techniques/ aromatherapy. activities.
 Body Temperature: activities as activities.
indicated for  Promote
Facial grimrace  Patient’s partner
individual wellness by provided assistance
situation. collaborating by assistance by
with patient’s transporting the
partner in patient to prevent
assisting the walking long
client with pain distance,
management. encouraged eating
nutritious meals.
 DRUG STUDY
DRUG MECHANISM OF INDICATION/ ADVERSE REACTION/ NURSING
ACTION CONTRAINDICATION SIDE EFFECTS, DRUG RESPONSIBILITIES
INTERACTION
Dexamethasone Unclear. Decreases Inflammatory joint CNS: euphoria, insomnia, Observe for signs of
Brand Name: inflammation, mainly by diseases Adult: 333 mcg psychotic behavior, adverse reactions.
DexPak stabilizing leukocyte to 5 mg depending on the pseudotumor cerebri,
Dosage: 6 mg lysosomal membranes; degree of inflammation and vertigo, headache, Monitor blood pressure 2 -
Frequency: suppresses immune the size and location of the paresthesia, seizures, 3 times daily.
Classification: response; stimulates bone joint. For soft tissues: 2-6 depression. Observe closely for signs
marrow; and influences mg. CV: HF, HTN, edema, C of infection.
protein, fat, and ulceration.
carbohydrate metabolism GI irritation, increased
appetite nausea, vomiting.
GU: menstrual
irregularities, increased
urine glucose and calcium
levels.

Oxytocin Maternal CNS:

Brand Name: pitocin subarachnoid hemorrhage,
Dosage: Injection: 10 seizures, coma.
units/mL CV: arrhythmias, HTN,
Frequency: 4 to 20 mg/day PVCs, hypotension,
given in a single daily dose tachycardia.
or in 2 to 4 divided doses GU: abruptio placentae,
Classification: known tetanic uterine contractions,
as corticosteroids. postpartum hemorrhage,
uterine rupture, impaired
uterine blood flow.
Cefuroxime
Dosage:
Frequency:
Classification:
Celecoxib
Dosage:
Frequency:
Classification:
Ferrous Sulfate
Dosage:
Frequency:
Classification:
Ascorbic Acid
Dosage:
Frequency:
Classification:
 Clinical Case Research

Name: Lauzon, Mia Grace Obstetric Record:

Age: 25 Gravida 2, Para 1, Abortion 0

Occupation: Unemployed

Maiden Name: Linggas

Status: Single Date of Birth: 08/17/1996

Place of Birth: Zamboanga City Religion: Catholic

Address: Swai Drive Suterville, Zamboanga City Citizenship: Filipino
Name of Partner: Jun P. Erpestan
Age: 31
Occupation: Unemployed Telephone/Cellphone Number:
09973690760
Charge Hospital Account: Admitted At:
PhilHealth 10:23 pm, March 15 WA2

Diagnosis:
Pregnancy uterine Vaginal Birth after Cesarian Section extracted a lie preterm cephalic baby girl.
Apgar Score: 8.9
Body Weight: 900 grams

Operation:
Vaginal Birth After Cesarian Section
Anesthesia:
None

Obstetrical Record
Chief Complain: Uterine contraction
Present Illness: 3 days onset of & with few contractions
Past Diseases/Operation:

Menstrual History
Menarche: 13 years old Interval: Irregular
Duration: 7-8 days AOG: 28 6/7 weeks LMP
LMP: 08-25-2022
EDC: 06-01-2023

Prenatal Checkup: YES

Smoker: NO
Alcohol: NO
Tetanus Toxoid: YES
Family History:
Twins (-) Diabetes: (-) Hypertension: (-)

PHYSICAL ASSESSMENT  No presence of masses, lesions and

deformities.
Head
 Hair is evenly distributed, color
 Patient’s head is smooth, round and black, smooth and no presence of
symmetrical. dandruff.
  Patient’s face is symmetrical, as well  Patient has no problems
as the nose and ears.
Lower Extremities
Neck
 Lower extremities report no lesions,
 Patient has smooth, controlled, full bruises and swelling.
range of motion of neck.  No signs of deformities and capillary
 No presence of rashes and bulging refill at less than 2 seconds.
masses.
Eyes and Ear
 Patient’s right eye is slightly bigger
than the left, in normal position, with
no discharges, redness and other
abnormalities observed.
 Patient has narrow ear shape
Upper Extremities
 No signs for rashes, lesions and
injury.
Chest and Back
 Patient has a normal posture with
symmetrical bone
 No tenderness or lumps
 Patient’s capillary refill at less than 2
seconds
Abdomen
 Presence of surgical incision from
previous cesarian section.
 No presence of lesion and masses.

Genitals
 No rashes and other
abnormalities reported.
Anus and Rectum