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NURSING ASSESSMENT I
PATIENT’S PROFILE
Name: _Patient X________________________________ Address: _Korondal City, South Cotabato___________________________________________________ Age: 30 years
Sex: _F_______ Religion: Roman Catholic______ Civil Status: _Single_________________________ Occupation: _Business Woman_____________________________
HABITS
A. CHIEF COMPLAINTS:
B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.
A case of 30 years old pregnant women was admitted with present condition that started 2 days prior to admission, while the patient was watching television she suddenly saw
a moderate bleeding from her vagina and felt a severe pain in her lower back and abdomen with rapid contraction on her uterus. Her husband rushes her to the hospital and she
was advised to be confined when they found out that the baby was already suffering fetal distress with a fetal heart rate of 31b/m.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)
Patient’s previous hospitalization involved her last two normal pregnancies, wherein she felt nape pain and headache within 3 months and decided to have an ultrasound and
found out the position of the baby was in a low transverse position. Lastly, they found out that the position of the baby was back in a cephalic position during the seventh month
of pregnancy through an ultrasound.
Since the patient was 18 years old, she used to drink alcoholic beverages, caffeine-rich drinks and enjoyed eating salty foods and by 20 years old, she thought she was having a
high blood pressure but did not seek any medical consultation because she felt like she could tolerate the headache. Instead, she is taking herbal medicines like garlic to improve
her condition, but, despite continued consumption of herbal intakes, she still noticed nape pain and headache, where she finally decided to have a check-up in their barangay to
get proper medication to lower her blood pressure.
FEMALE
1. Present Illness
“Masakit ang tahi ko” as verbalized by the patient. In English, the patient’s stitches are hurting.
2. Hospital Environment
“Malinis naman dito dahil lagi naman nilang nililinisan”, as verbalized by the patient. In English, the patient stated that the place was clean because it is being regularly cleaned.
E. SUMMARY OF INTERACTION
The interaction with the patient and her S.O was cooperative; both of them answered the questions well and were able to fill in all the necessary information by interviewing
them.
Physical Examination
HEAD: Smooth Skull contour; no Nodules or masses. Hair is well distributed and
HEAD: Smooth Skull contour; no Nodules or masses. Hair is well distributed and
black in color. No head lice infestation and dandruff noted. Face is symmetrical.
black in color. No head lice infestation and dandruff noted. Face is symmetrical.
EYES: Both sclera are white. Pupils (4mm) equally round, reactive to light and
EYES: Both sclera are white. Pupils (4mm) equally round, reactive to light and
accommodation and pale Conjunctiva.
accommodation and pale Conjunctiva.
EARS: Symmetrical ears and equal size. No buildup of cerumen/ear wax. No pain
EARS: Symmetrical ears and equal size. No buildup of cerumen/ear wax. No pain
HEENT noted upon palpation and no presence of swelling and both ear auricles non
noted upon palpation and no presence of swelling and both ear auricles non tender.
tender.
NOSE: Nose is symmetrical in shape and same in color with face. Patient can
NOSE: Nose is symmetrical in shape and same in color with face. Patient can
breathe with one nostril when other is closed. No presence of discharge and no
breathe with one nostril when other is closed. No presence of discharge and no
presence of bumps and tenderness. No pain noted and non-tender Sinuses
presence of bumps and tenderness. No pain noted and non-tender Sinuses
THROAT: No lesions evident and no swelling noted. No lesions present at the
THROAT: No lesions evident and no swelling noted. No lesions present at the
tongue. Lips are symmetrical with no lesions noted.
tongue. Lips are symmetrical with no lesions noted.
Patient has poor skin turgor due to the presence of interstitial fluids on area of Patient has poor skin turgor due to the presence of interstitial fluids on area of
edema becomes dry and shiny. Her skin also is pallor and pail nail beds due to the edema becomes dry and shiny. Her skin also is pallor and pail nail beds due to the
blood loss during the post-surgical procedure/ post cesarean delivery. 3-4 capillary blood loss during the post-surgical procedure/ post cesarean delivery. 3-4
refill upon blanching manifested of decrease RBC’s due to edema. Body temperature capillary refill upon blanching manifested of decrease RBC’s due to edema. Body
INTEGUMENTAR
is 36.9°C. Hair is well distributed and black in color. No head lice infestation and temperature is 39.2°C. Hair is well distributed and black in color. No head lice
Y
dandruff noted. infestation and dandruff noted.
Respiratory Rate is 42cpm. Symmetrical chest shape & size. No barrel chest and
Respiratory Rate is 24cpm. Symmetrical chest shape & size. No barrel chest and
use of accessory muscles, (scalene and sternocleidomastoid) muscles while
use of accessory muscles, (scalene and sternocleidomastoid) muscles while
RESPIRATORY breathing. Patient appears to have resonant lung sound upon auscultation.
breathing. Patient appears to have resonant lung sound upon auscultation.
S1 corresponds with each carotid pulsation. S2 immediately follows after S1 and S1 corresponds with each carotid pulsation. S2 immediately follows after S1 and
no extra heart sounds and murmurs upon auscultation. Equal in pulse rate, no extra heart sounds and murmurs upon auscultation. Equal in pulse rate,
CARDIOVASCULA rhythm of carotid arteries, and amplitude of 2+ upon palpation. No bruits upon rhythm of carotid arteries, and amplitude of 2+ upon palpation. No bruits upon
R auscultation of the carotid arteries, and jugular vein not distended. Capillary refill auscultation of the carotid arteries and jugular vein not distended. Capillary refill
of nail beds is 3-4 second manifested of decrease RBC’s due to edema. Peripheral of nail beds is 3-4 second manifested of decrease RBC’s due to edema. Peripheral
pulses (radial, Brachial) are equal in pulse rate and rhythm and no bulging veins. pulses(radial, Brachial) are equal in pulse rate and rhythm and no bulging veins.
Patient is on vol/vol replacement regulation. No vomiting or difficulty of Patient is on vol/vol replacement regulation. No vomiting or difficulty of
DIGESTIVE swallowing observed. swallowing observed.
Pain in the abdomen is persistent from moderate to severe. Vaginal bleeding and
rapid uterine contractions are still continuous. Pain is persistently felt moderately on incision area in the abdomen.
Patient’s bowel routine is once or twice a day. The stool color is brown or
The patient was inserted an indwelling Foley catheter. She had her bowel
sometimes yellow in a usual amount. She voids 5 times a day with a urine color of
movement on her second day on the hospital.
EXCRETORY yellow.
Symmetrical and equal muscle mass, tone and strength and rate of muscle Symmetrical and equal muscle mass, tone and strength and rate of muscle
MUSCULOSKELET strength are 4 in all four extremities. strength are 4 in all four extremities.
AL
Patient has no deficit functions for sensory, cerebellar and cerebral neurologic Patient has no deficit functions for sensory, cerebellar and cerebral neurologic
NERVOUS examination; has smell, taste, sight, touch, and hearing senses are developing and examination; has smell, taste, sight, touch, and hearing senses are developing
functioning well. and functioning well.
Patient is a 30 years old mother who has 2 children. Last menstrual period was at
Patient is a 30 years old mother who has 2 children. Last menstrual period was at
ENDOCRINE 11/06/13 and an obstetric status of G3T2P0A0L2. Thyroid gland is in butterfly in
11/06/13 and an obstetric status of G3T2P0A0L2. Thyroid gland is in butterfly in
shape in midline position, non-palpable lobes, not enlarged, and rises as patient
shape in midline position, non-palpable lobes, not enlarged, and rises as patient
swallow.
swallow.
DRUG STUDY
Date Ordered: Prescribed: Inhibits cell-wall Treatment of: Skin and Contraindicated with G.I.: Determine previous
synthesis during bacterial skin structure infections, patients hypersensitivity hypersensitivity
08-04-14 500mg, 1 capsule q 8hrs
multiplication, leading to Otitis media, Sinusitis, to penicillin, infectious Diarrhea reactions to
PO cell death, shows Respiratory infections, monucleosis Nausea penicillin.
enhanced activity toward Genitourinary infections. Vomiting Check patient’s
Recommended: gram-negative bacteria Abdomin temperature.
Generic name:
compared to natural and al pain Monitor sign and
PO (Adults): 250–500mg
Amoxicillin penicillinase – resistant symptoms of
q 8hrs or 500–875mg q Resp:
penicillin. urticarial rash.
12 hr.
Rash Respiratory
Brand Name: Wheezing
Amoxil Other:
Super-infections
(Oral and rectal
Classification: candidiasis)
Fever
Antibiotic
Anaphylaxis
Pregnancy category B
DRUG STUDY
Date Ordered: Prescribed: Elevates the serum iron Prevention and Contraindicated with CNS: Advice patient to
08-04-14 concentration which treatment of Iron patients hypersensitivity take medicine as
then helps to form High deficiency anemia and to drug and severe prescribed.
1 tab BID PO x 30 days or trapped in the dietary supplement for hypotension Dizziness Caution patient to
reticuloendothelial cells Iron. Headache make position
Generic name: Recommended:
for storage and eventual changes slowly to
CV:
Ferrous Sulfate PO (Adults): Deficiency – conversion to a usable minimize orthostatic
120-240mg/day in 2-4 form of iron. Hypotension hypotension.
divided doses. Hypertension Encourage patient to
Tachycardia comply with
Brand Name: additional
GI: intervention for
Brisofer
hypertension like
Nausea proper diet, regular
exercise, lifestyle and
Classification: Derm:
changes and stress
Flushing management.
Iron Preparation
Dyspnea
Pregnancy category A
DRUG STUDY
Brand Name:
Ponstan
Classification:
Analgesic NSAID
Pregnancy category C
DRUG STUDY
Cozaar Hypotension
Classification:
Antihypertensive
Pregnancy category C
(1st trimester), D (2nd and
3rd trimester)
DRUG STUDY
Date Ordered: Prescribed: Inhibits influx of Alone or with other Contraindicated with CNS: Monitor heart rate
extracellular calcium agents in the patients hypersensitivity and rhythm and
08-06-14 10mg OD, PO ions, thereby decreasing Headach
management of to drug. blood pressure
myocardial contractility, e especially at start of
Recommended: hypertension, angina Dizziness
relaxing coronary and therapy.
vascular muscles, and pectoris, and vasospastic Drowsin
Generic name: PO (Adults): 5-10mg OD
decreasing peripheral angina. ess
Amlodipine resistance. Fatigue
Weaknes
s
Brand Name: CV:
Norvasc Bradycardia
Hypotension
Palpitations
Classification:
Resp:
Antihypertensive
Shortness of
breath
Dyspnea
Pregnancy category C Wheezing
DRUG STUDY
Date Ordered: Prescribed: Stimulates alpha- Management of mild to Contraindicated with CNS: Monitor blood
adregenic receptors in moderate hypertension. patients hypersensitivity pressure and pulse
08-07-14 75mg 1 tab PRN > CNS, decreasing to dug. Drowsin rate frequently.
160/90 PO sympathetic outflow, ess Observe patient for
inhibiting Dizziness tolerance to drug’s
Generic name: Recommended: Fatigue
vasoconstriction, and therapeutic effects,
Clonidine hydrochloride PO (Adults): 100mcg bid, ultimately reducing Sedation which may require
increase 100- blood pressure. Weaknes increasing dosage.
200mcg/day q 2-4 days s Monitor patient for
Malaise signs and symptoms
Brand Name: Depressi of adverse
on cardiovascular
Catapres
reactions.
CV:
Inform patient that
Orthostatic dizziness upon
Classification: standing can be
Hypotension
Bradycardia minimized by rising
Cardiovascular agent; slowly from a sitting
central-acting; Severe rebound
or lying position and
antihypertensive; hypertension
avoid sudden
analgesics
GI: position changes.
Constipation
Pregnancy category C Dry mouth
Nausea
Vomiting
Anorexia
DRUG STUDY
Date Ordered: Prescribed: Through the produce Mild pain and fever. Contraindicated in Derm: Instruct patient to
analgesia by blocking patients hypersensitive take with meals have
08-07-14 1 amp IV STAT PRN For > pain impulse by to drug. Rash a plenty of water
38.6 oC inhibiting synthesis of Urticaria when taking this
prostaglandin in CNS that Use cautiously in drug.
Recommended: patients with long term Others:
Generic name: synthesize pain receptor After negative
alcohol use because
PO (Adults): 325-650mg to stimulation. Hypoglycemia sensitivity must be
Paracetamol therapeutic doses causes done.
q 4-6hrs or 1g 3-4 times
hepatotoxicity in these
daily or 1300mg q 8hrs
patients.
Brand Name:
Aeknil
Classification:
Nonopoid Analgesic
Pregnancy category B
DRUG STUDY
Date Ordered: Prescribed: Inhibits cell-wall To prevent endocartitis Contradicted in patients’ CNS Monitor sodium level
synthesis during bacteria in patients having GI hypertensive to drug or because each gram
08-02-14 1gm q hrs TIV multiplication procedures other penicillin. Lethargy of ampicillin contains
Hallucinations 2.9 mEq of sodium.
Use cautiously in Seizures Watch for signs and
patients with other drug GI symptoms of
Generic: allergies because of hypersensitivity, such
possible cross-sensitivity, Nausea as maculopapular
Ampicillin Vomiting
and in those with rash, urticarial, and
mononucleosis because Diarrhea anaphylaxix.
of high risk of Glossitis
Brand: maculopapular rash.
Ampicillin-N
Classification:
Antibiotic
DRUG STUDY
Date Ordered: Prescribed: Inhibits reuptake of Moderate moderately Contradicted in patients’ CNS Assess patient’s
serotonin and severe pain hypertensive to drug or level of pain
08-02-14 50 mg
norepinephrine in CNS. other opioids, those with Dizziness atleast 30 mins
acute intoxication from Confusion before
TIV alcohol. Fatigue administration.
Drowsiness Monitor the
Generic: Every 6 hrs.
GU bowel and
bladder function
Tramadol Renal Failure Monitor for
GI physical and
psychological
Nausea drug
Brand:
Anorexia dependence
Ultram Constipation Monitor patient
for signs and
symptoms of
potentially life-
Classification: threatening
serotonin
Opioid Agonist syndrome, which
Analgesics may range from
shivering and
diarrhea to
muscle rigidity,
fever, mental-
status changes,
and seizures.
DRUG STUDY
Date Ordered: Prescribed: Reduces gastric acid To prevent Mendelson’s Hypersensitivity CNS Assess vital signs
secretion and disease (The aspiration to drug or its Monitor CBC and
08-02-14 50mg IVq 8”X4 doses
bicarbonate production, of stomach contents into components Headache liver function
the lungs during Alcohol Agitation test
creating a protective
obstetric anaesthesia) intolerance (with Anxiety
coating on gastric
some oral GI
Generic: mucosa product)
History of acute Nausea
Ranitidine Hydrochloride Vomiting
porphyria
Diarrhea
Constipation
Brand: Abdominal
discomfort or
Zantac pain
Hematologic
Reversible
Classification: granulocytopenia
Thrombocytopen
Anti-ulcer drug ia
Hepatic
Hepatitis
Skin
Rash
Other
Pain at IM
injection site
Burning
DRUG STUDY
Date Ordered: Prescribed: Replaces magnesium and For seizures Hypermagnesem Syndrome joint- Monitor patients
maintains magnesium ia swelling, fever closely during
08-02-14 4mg IM At buttock Every Heart block Anemia and following
level; as an
4 hours Myocardial Agranulocytosis infusions.
anticonvulsant, reduces
damage Hepatitis Observe
muscle contractions by
Active labor or Glomerulonephri orthostatic
Generic: interfering with release precautions.
within 2 hours of tis
of acetylcholine at delivery Acute renal
Magnesium Sulfate
myoneural junction failure
Brand:
Sulfamag
Classification:
Anti-hypertensive
DRUG STUDY
Date Ordered: Prescribed: A direct-acting Amoebic liver abscess Hypersensitivity to drug, CNS Inform patient to
vasodilator that reflexes other nitroimidazole report fever,
08-02-14 50mg TID for BP of
arteriolar smooth derivatives, or parabens Dizziness sore throat,
160/100 (topical form only) Headache bleeding or
muscle.
Ataxia bruising
Vertigo Inform patient
Generic: Insomnia that drug may
GI cause metallic
Metronidazole
taste and may
Nausea discolor urine
Vomiting deep brownish-
Brand: Diarrhea red
Abdominal pain
Flagyl Anorexia
Classification:
Antiprotozoal
DRUG STUDY
DAY 1 DAY 2
1.ACTIVITIES- REST According to the patient, she usually According to the patient, she is Patient cannot perform her usual Patient cannot perform her usual
enjoys watching television until sleep deprived and restless due to activities. She performs her ADL activities. She performs her ADL
a. Activities midnight and uses her phone more pain and discomfort. She is with assistance. She has sleep with assistance and is sometimes
often. She sometimes had afternoon sometimes uncomfortable and thus, disturbances due to pain on incision dependent. She is currently bed rest
b. Rest
naps for 1-2 hours. Habitually, she she cannot enjoy and perform her site. and usually have afternoon naps and
c. Sleeping pattern sleeps at 2am or 3am and wakes up usual routine. sleeps for about 6-8 hours.
at 9am or 10am.
2.NUTRITIONAL- METABOLIC
Patient likes to eat noodles and salty Patient is instructed of nothing by Patient eats 3-4 pandesal or soup Patient eats "lugaw", bread or soup
a. Typical intake(food, fluid) foods including junk foods. She also mouth or NPO (nothing per orem). during breakfast with coffee or milk. during breakfast. She eats hospital
eats vegetables such as bitter gourd, She is restricted to drink foods and During meals, she eats hospital- prepared foods during meals.
b. Diet
lady finger, string beans and green fluids. prepared foods. Typical foods Typical foods prepared are rice with
c. Diet restrictions beans. She usually takes 4-5 glasses prepared are rice with egg/chicken egg/chicken and vegetables. She
of water and 2-3 cups of coffee a IV is given to prevent dehydration; and vegetables. She also drinks also drinks milk, and water with an
d. Weight day. During meal, she consumes 2-3 Hydralazine 5mg and Mangnesium water for an average of 3-5 glasses a average of 3-5 glasses a day.
cups of rice and enjoys eating it with Sulfate is given to regulate blood day. Patient is still on low salt, low fat
e. Medications/supplement meats and egg dipped with soy pressure prior to operation; Patient is on low salt, low fat diet diet and takes ferrous sulfate for
food sauce. She follows no diet or has no and takes iron supplements such as iron supplementation.
diet restrictions. She is also taking Ferous Sulfate.
supplements such as folic acid, iron Medications are continuous except
and calcium. IV is given together with oxytocin for oxytocin. Additional medications
for uterine contraction 20 'u' to include amlodipine 10mg tab,
prevent excessive bleeding; mefenamic acid cap, spinirolactone
Ranitidine 50mg IV is also 50mg, Amoxicillin 500mg, Catapres,
administered for gastric acidity due Paracetamol 500mg
to NPO; Ampicillin to prevent
bacterial multiplication;
Metronidazole
3. ELIMINATION
Patient's bowel routine is 1-2 times Patient's bowel routine is 1 as of the Patient is inserted with indwelling Patient is still on indwelling Foley
a. Urine (frequency, color, daily. The stool is usually color day with color brown stool and in Foley catheter with a urine output catheter and is able to void with
transparency) brown in solid appearance. She solid appearance. She voids twice as of 30 cc, in yellow color, and is 10cc, dark yellow, transparent urine
voids 2-3 times a day with urine that of the day with yellow, transparent transparent. Patient was not able to output. Patient has able to release
appears yellow and transparent. urine output with blood spots. release stool. stool once with brown colored stool
b. Bowel (frequency, color, and in solid appearance.
consistency)
4. EGO INTEGRITY
a. Perception of self Patient's perceives herself as a Patient’s main support system Patient’s main support system Patient’s main support system
strong mom. Her main support includes her husband and her 2 kids. includes her husband and 2 kids. includes her husband and 2 kids. She
b. Coping Mechanism systems are her husband and 2 kids. She is usually sensitive and irritable. She is coping up by eating adequate is coping up by eating adequate
She is sometimes moody and often foods and takes prescribed foods and takes prescribed
c. Support System
gets irritated easily. medicines to regain her energy and medicines to regain her energy and
d. Mood/Affect for fast recovery. for fast recovery
5. NEURO-SENSORY
a. Mental state Patient is coherent and well- Patient responds correctly when Patient responds correctly when Patient responds correctly when
oriented. She also behaves asked and conveys emotions asked and conveys emotions asked and conveys emotions
accordingly. appropriately. Patient is well appropriately. Patient is well appropriately. Patient is well
b. Condition of five senses: oriented and is conscious. oriented and is conscious. oriented and is conscious.
(sight, hearing, smell, taste, Patient’s five senses are intact and Patient’s five senses are intact and Patient’s five senses are intact and
functioning well; patient responds functioning well; patient responds Patient’s five senses are intact and
touch) functioning well; patient responds
to objects of stimulation that he to objects of stimulation that he functioning well; patient responds
to objects of stimulation that he
sees, hears, and touches. She can sees, hears, and touches. She can to objects of stimulation that he
able to smell and taste well. sees, hears, and touches. She can
also able to smell odors and taste sees, hears, and touches. She can
able to smell and taste well.
foods well. able to smell and taste well.
6. OXYGENATION Vital signs were not assessed. Patient’s vital signs are as follows: Patient’s vital signs are as follows: Patient’s vital signs are as follows:
Patient has no history of respiratory Temperature = 36.9°C; BP= Temperature = 37.1°C; BP= Temperature = 39.2°C; BP=
a. Vital signs problems prior to admission. 190/120mmHg, Respiratory rate = 140/110mmHg; Respiratory rate = 140/110mmHg; Respiratory rate =
42cpm; heart rate = 98bpm, 24cpm; heart rate = 67 bpm, 24 cpm; heart rate = 117 bpm,
Temperature
O2Saturation = 96%. O2Saturation = 96%. O2Saturation = 97%
Respiratory rate
Patient appears to have resonant Patient appears to have resonant Patient appears to have resonant
Heart rate lung sound upon auscultation. lung sound upon auscultation. lung sound upon auscultation.
Blood pressure
b. Lung sounds
c. History of Respiratory
Problems
7. PAIN-COMFORT Onset of pain started a day prior to Pain in the abdomen and back is Pain is felt moderately on incision Pain is persistently felt moderately
admission. Patient felt moderate to persistent from moderate to severe. area in the abdomen and is on incision area in the abdomen and
a. Pain (location, onset, severe abdominal and back pain and Vaginal bleeding and rapid uterine alleviated by administration of is alleviated by continuous
character, intensity, was associated with rapid uterine contractions are still continuous. Tramadol 50mg through IV given administration of Tramadol 50mg
duration, contractions and moderate vaginal every 6 hours. through IV given every 6 hours
associated symptoms, bleeding.
aggravation)
Patient prompt medical assistance
from Laguna Medical Center.
b. Comfort
measures/Alleviation
c. Medications
8. HYGIENE AND ACTIVITIES Patient takes a bath once daily but Patient is not able to take a bath but Patient is not able to take a bath but Patient is not able to take a bath but
OF DAILY LIVING sometimes when she feels sponge bath is applied to her with sponge bath is applied to her with sponge bath is applied to her with
uncomfortable, she takes a bath the assistance of her husband. the assistance of her husband. She the assistance of her husband. She
twice during morning and in the usually takes a sponge bath twice or usually takes a sponge bath twice or
evening before going to bed. Patient can perform some ADL thrice a day. thrice a day.
independently such as dressing or
Patient can able to perform ADL voiding but usually needs assistance Patient can perform some ADL
independently such as bathing, when walking, sitting, etc. independently such as eating or Patient can perform some ADL
eating, sitting, walking, etc. voiding but usually needs assistance independently such as eating or
when dressing, sitting, etc. voiding but usually needs assistance
when dressing, sitting, etc.
9. SEXUALITY
a. female (menarche, menstrual Patient’s last menstrual cycle was at Patient’s last menstrual cycle was at Patient’s last menstrual cycle was at
Patient’s last menstrual cycle was at
cycle, civil status, number of 11/06/13, single with 2 kids, and an 11/06/13, single with 2 kids, and an 11/06/13, single with 2 kids, and an
11/06/13, single with 2 kids, and an
children, reproductive status) obstetric status of G3T2P0A0L2. obstetric status of G3T2P0A0L2. obstetric status of G3T2P0A0L2.
obstetric status of G3T2P0A0L2.
b. male (circumcision, civil
status, number of children)
LABORATORY AND DIAGNOSTIC PROCEDURES
NAME OF THE NURSING
DATE RESULT NORMAL VALUE INTERPRETATION NURSING IMPLICATION
PROCEDURE RESPONSIBILITY
8/2/14 Hemoglobin 5.4 g/dl M: 13-18 g/dl LOW Oxygen transport is To prevent this,
F: 12-16 g/dl accomplished by hemoglobin. advise mother to
I: 11.3-13 g/dl Hemoglobin picks up oxygen increase food intake
Child: 11.5-14.8 g/dl in the lungs and releases rich in iron like
NB: 13.6-19.6 g/dl oxygen to the other tissues. malunggay. Iron is in
whole grains, nuts,
Hematocrit is percentage of and legumes.
total blood volume composed
of red blood cells. The
hematocrit measurement is
affected by the number and
size of RBC because it is based
on volume. There’s a decrease
in hematocrit count due to
decrease in RBC.
8/3/14 Sodium 145.6 135-145 HIGH Sodium is the major Monitor serum
electrolyte of ECF that moves sodium levels
easily between intravascular Monitor fluid losses
and spaces and moves across and gains
cell membrane. It controls and Check urine specific
regulates the volume of fluids gravity
and maintains water balance Observe for
throughout the body. There is excessive intake of
increase serum sodium high sodium foods
reabsorption because there is Look for excessive
increase blood pressure. thirst
Potassium 3.85 3.5-5.0 NORMAL Potassium is the major cation Maintain healthy
of ICF. It maintains fluid and lifestyle
electrolyte balance and also Intake of 50 to 100
essential in regulation of acid- mEq daily is enough
base balance by cellular to maintain
exchange. potassium.
8/7/14 Hemoglobin 6.3 g/dl M: 13-18 g/dl LOW When the hemoglobin level is To prevent this,
F: 12-16 g/dl below 12mg/dl (hematocrit < advise mother to
I: 11.3-13 g/dl 33), iron deficiency is increase food intake
Child: 11.5-14.8 g/dl suspected. Inadequate iron rich in iron like
NB: 13.6-19.6 g/dl intake can impair hemoglobin malunggay. Irons are
production. Consequently, in the whole grains,
RBC do not fill up with nuts, and legumes.
hemoglobin during their
formation, and they remain
smaller than normal.
RBC 1.84 X 10/L M: 4.5-6.2 X 10^23/L LOW The primary function of RBC is
F: 4.0-5.4 X 10^23/L to transport oxygen from
I: 3.8-5.9 X 10^23/L lungs to the various tissues of
Child: 3.8-5.4 X 10^23/L the body and to assist in
NB: 5.0-7.0 X 10^23/L transport of carbon dioxide
from the tissues to the lungs.
Platelet 410 x 10^9/dl 150-500 X 10^9/dl NORMAL Platelets are cell fragments
involved with preventing
blood loss.
8/12/14 Hemoglobin 7.2 g/dl M: 13-18 g/dl LOW When the hemoglobin level is To prevent this,
F: 12-16 g/dl below 12 mg/dl (hematocrit advise mother to
I: 11.3-13 g/dl <33), iron deficiency is increase food intake
Child: 11.5-14.8 g/dl suspected. rich in iron like
NB: 13.6-19.6 g/dl malunggay. Iron is in
whole grains, nuts,
Hematocrit 21% M: 40-50% LOW Inadequate iron intake can and legumes.
F: 37-43% impair hemoglobin
I: 35-40% production. Consequently,
Child: 38-44% RBC do not fill up with
NB: 50-58% hemoglobin during their
formation, and they remain
smaller than normal.
8/13/14 Hemoglobin 9.2 g/dl M: 13-18 g/dl LOW When the hemoglobin level is To prevent this,
F: 12-16 g/dl below 12mg/dl (hematocrit advise mother to
I: 11.3-13 g/dl <33), iron deficiency is increase food intake
Child: 11.5-14.8 g/dl suspected. rich in iron like
NB: 13.6-19.6 g/dl malunggay. Iron is in
whole grains, nuts,
and legumes.
Hematocrit 27% M: 40-50% LOW Inadequate iron intake can
F: 37-43% impair hemoglobin
I: 35-40% production. RBC do not fill up
Child: 38-44% with hemoglobin during their
NB: 50-55% formation, remain smaller
than normal.
SUMMARY OF INTRAVENOUS FLUID
DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
SUMMARY OF MEDICATION
DATE MEDICATIONS- dosage, frequency, route Remarks
8/02/14 Hydralazine 5mg TID Well administered, been given on the exact
time indicated
8/02/14 Magnesium Sulfate 4g now then 5g TID on each buttocks then 5mg TID on alternating
buttocks every 4 hours until 24 hours postpartum Well administered, been given on the exact
time indicated
8/02/14 Tramadol 50mg slow IV Every 6hrs; 4 doses ANSTU Well administered, been given on the exact
time indicated
8/02/14 Ranitidine 50mg IV every 8hrsx 4 doses ANSTU Well administered, been given on the exact
time indicated
8/04/14 Amoxicillin 500mg 1 cap BID x 7days Well administered, been given on the exact
time indicated
8/04/14 Ferrous Sulfate 1 tab BID x 7 days Well administered, been given on the exact
time indicated
UTERUS
It is hollow, muscular, pear-shaped organ located in the lower pelvis, posterior to the bladder and anterior to the rectum.
The body of the uterus is the uppermost part and forms the bulk of the organ.
The portion of the uterus between the points of attachment of the fallopian tubes is termed the fundus. ]
The isthmus of the uterus is a short segment between the body and the cervix. During pregnancy, this portion also] enlarges greatly to aid in accommodating the growing fetus.
The cervix is the lowest portion of the uterus. ]
FUNCTIONS
1. The function of the uterus is to receive the ovum from the fallopian tube.
2. It provides a place for implantation and nourishment.
3. It furnishes protection to a growing fetus.
4. When a fetus matured, it expels it from a woman’s body.]
PLACENTA
The placenta (Latin for “pancake,” which is descriptive of its size and appearance at term) arises out of the continuing growth of trophoblastic tissue. Its growth parallels that of the
fetus, growing from a few identifiable cells at the beginning of pregnancy to an organ 15 to 20 cm in diameter and 2 to 3 cm in depth, covering about half the surface area of the internal
uterus at term.]
FUNCTIONS
As early as the 12th day of pregnancy, maternal blood begins to collect in the intervillous spaces of the uterine endometrium surrounding the chorionic villi.
By the third week, oxygen and other nutrients, such as glucose, amino acids, fatty acids, minerals, vitamins, and water, osmoses from the maternal blood through the cell layers of
the chorionic villi into the villi capillaries. From there, nutrients are transported to the developing embryo.]
Aside from serving as the conduit for oxygen and nutrients for the fetus, the syncytial (outer) layer of the chorionic villi develops into a separate, important hormone-producing
system.
Human Chorionic Gonadotropin, estrogen, progesterone, and Human Placental Lactogen (Human Chorionic Somatomammotropin).
PLACENTAL PROTEINS
The placenta also produces several plasma proteins. The functions of these have not been well documented, but it is thought that they may contribute to decreasing the
immunologic impact of the growing placenta through being part of the complement cascade.
UMBILICAL CORD
The umbilical cord is formed from the fetal membranes (amnion and chorion) and provides a circulatory pathway that connects the embryo to the chorionic villi of the placenta.
Its function is to transport oxygen and nutrients to the fetus from the placenta and to return waste products from the fetus to the placenta.
An umbilical cord contains only one vein (carrying blood from the placental villi to the fetus) but two arteries (carrying blood from the fetus back to the placental villi).]
PATHOPHYSIOLOGY
ABRUPTIO PLACENTA
PRECIPITATING FACTOR PREDISPOSING FACTOR
Age Maternal Hypertension (PIH, Chronic
Family History Hypertension)
Medical History Decrease resiliency of blood vessel at placental bed Premature Rupture of Membranes
Lifestyle Women with Previous Abruption
Maternal Hyperhomocysteinemia
Chorioaminionitis
Torn or ruptured blood vessels Traumatic Injury
Sudden Decompression of the Uterus
Uterine Anomalies
Partial Separation Short Umbilical Cord
Multiparity
Race or ethnicity
Total Separation
Mild to moderate vaginal bleeding Blood trapped to intact peripheral portion
Concealed Hemorrhage
Increase uterine wall irritability Fluids enter muscle fibers
Emergency delivery
MEDICAL MANAGEMENT
ACTUAL 08/02/14
08/02/14 Pre OP Care
Admission of patient Post OP Care
Secure Consent To ward with close monitoring
Ni per OS O2 Inhalation at 3 LPM
Intravenous Fluid Normal Saline Solution 1L x 8 hours Monitor Vital Signs
Insert Indwelling Foley Catheter NPO
Watch out for Magnesium Toxicity Medications:
Monitor Fetal Heart tone Ampicillin 2g IV: every 6 hours
Prescribed Medications: Tramadol 50mg: every 6 hours
Ranitidine 50 mg Iv: every 8 hours
Hydralazine 5mg TID for BP of > 160/100
Monitor Intake and output every 2 hours
Magnesium Sulfate 4g
Blood transfusion
Laboratory: 08/03/14
CBC with PC Diet as tolerated
Blood Urea Nitrogen and Creatinine Monitor vital signs
Serum Glutamic Oxaloacetic Transaminase (SGOT) Continue Medications
For actual pro-thrombin time
08/02/14 Still for: SGOT, BUN and Creatinine, Sodium, Potassium,
(3:40 AM) Chloride
Remove Indwelling Foley Catheter
Still for blood transfusion
Direct to operating Room for E Cesarean Section
Apply abdominal binder
Medicine:
08/04/14
Hydralazine Hydrochloride 10 ml Low salt, low fat diet
Terbulatine Sulfate ½ ampule SL Medications:
Inform OR Nurse/Chief of Clinic/Pedia/Anes/JDO/ OB Amoxicillin 500 mg x 7days
gyne Metronidazole 500 mg BID x 7 days
08/14/14
May go home
Continue meds
BP monitoring at home.
ACTUAL
Abruptio Placentae is the premature separation of the placenta that occurs late in the pregnancy. Once the condition has reached a stage that mightily endangers the life of both
patients, the surgical management that could be put into action are:
Cesarean delivery. It is the surgical delivery of a baby through a cut (incision) made in the mother’s abdomen and uterus. It might be planned ahead of time if a mother develops
pregnancy complications. It is necessary for fetal and maternal stabilization. Cesarean delivery facilitates rapid delivery and direct access to the uterus and its vasculature. It could avert
further disease progression and possible maternal death cases.
Hysterectomy. Is an operation to remove uterus through an incision in the lower abdomen. When placental abruption takes place, the placenta comes away from the wall of the uterus.
Usually, the placenta only detaches a little bit, but in some cases the placenta separates completely. This can lead to an emergency delivery of the baby, afterwards, the uterus may be
damaged extensively and that is why a hysterectomy might be performed to remove it.
DISCHARGE PLAN
CONDITION UPON DISCHARGE Must be well __ Nature: Home per request (✓) Discharge against medical advice ( )
Sodium restrictions
3. DIET - May vary from 2 to 4 grams depending on the degree of hypertension. The patient should be avoiding foods such
as cured meats, canned soups, and soy sauce.
5. SCHEDULE FOR THE NEXT VISIT Follow check-up at the OB department on August 22, 2014, Friday at 1:00PM
NURSING CARE PLAN
SUBJECTIVE CUES: Acute pain related to surgical After 8 hours of nursing Independent Independent After 8 hours of nursing
incision as evidenced by intervention, the patient will 1. Monitor the patient’s 1. To establish baseline intervention, the patient has
“Masakit ang tahi ko.” as verbal report of pain verbalize reduced discomfort vital signs. data. shown signs of reduced
verbalized by the patient. and pain. 2. Note location of surgical 2. To help determine the discomfort and pain.
Pain scale: 8/10 procedures. amount of post-operative
3. Assess referred pain as pain experienced.
OBJECTIVE CUES: appropriate. 3. To help determine the
4. Note and investigate chances of an underlying
Vital signs
changes from previous condition that may need
BP: 140/110mmHg
reports of pain. treatment.
PR: 67bpm
5. Assess skin color along 4. To rule out worsening of
RR: 24cpm
with vital signs. underlying condition or
Facial grimace
6. Provide comfort development of
Sleep disturbance measures, quiet complications.
Displaying guarding environment, and calm 5. Acute pain usually alters
behavior by laying activities. these factors.
flat on bed 7. Encourage adequate rest 6. To promote non
periods. pharmacological pain
8. Instruct and encourage management.
use of relaxation 7. To prevent fatigue.
techniques such as deep- 8. To distract attention and
breathing exercises. reduce tension.
Dependent
1. Administer opioid Dependent
analgesics as 1. Inhibits reuptake of
prescribed by the serotonin and
doctor: Tramadol norepinephrine in
CNS.
50mg TIV every 6
hours.
NURSING CARE PLAN
SUBJECTIVE CUES: Hyperthermia related to After 8 hours of nursing Independent Independent After 8 hours of nursing
increased metabolic rate as intervention, the patient’s intervention, the patient’s
“Mainit ang pakiramdam ko,” evidenced by increase in temperature will go back to 1. Monitor the patient’s 1. To establish baseline temperature has decreased.
as verbalized by the patient. body temperature above the normal range. vital signs. data.
OBJECTIVE CUES: normal range (39.2°C). 2. Perform tepid sponge 2. To promote heat loss by
bath (TSB) on patient. means of evaporation
Vital signs 3. Promote surface cooling and conduction.
T: 39.2°C by undressing/putting on 3. To promote heat loss by
PR: 117bpm thin and light clothes. means of radiation and
RR: 34cpm 4. Encourage adequate fluid conduction.
BP: 140/110mmHg intake. 4. To prevent dehydration.
Flushed skin 5. Advice to maintain bed 5. To reduce metabolic
Warm to touch rest. demands and oxygen
Malaise/weakness consumption.
Dependent
1. Administer prescribed Dependent
medication ordered as 1. Antipyretics inhibits the
such: Paracetamol 1 amp. enzyme cyclooxygenase
3000mg >38.6°C. (COX) and interrupt the
2. Administer replacement synthesis of inflammatory
fluids and electrolytes as prostaglandins.
ordered. 2. To support circulating
volume and tissue
Collaborative perfusion.
1. Refer to laboratory
for tests. Collaborative
1. To identify causative
factors.
NURSING CARE PLAN
SUBJECTIVE CUES: Decreased cardiac output After 8 hours of nursing Independent Independent After 8 hours of nursing
related to increased intervention, the patient’s 1. Monitor the patient’s 1. To establish baseline intervention, the patient’s
“Nahihilo ako,” as verbalized peripheral vascular resistance blood pressure will be vital signs. data. blood pressure was reduced.
by the patient. 2. Presence of pallor, cool,
secondary to hypertension as reduced. 2. Observe skin color,
moist skin, and delayed
OBJECTIVE CUES: evidence by BP moisture, temperature, capillary refill may be due
160/120mmHg, patient and capillary refill time. to peripheral
Vital signs complaining of dizziness. 3. Provide calm, restful vasoconstriction or reflect
T: 39°C surroundings, minimize cardiac
PR: 95bpm environmental decompensation/decreas
RR: 27cpm activity/noise. Limit the ed output.
3. Helps reduce sympathetic
BP: 160/120mmHg number of visitors and
stimulation that
Pale complexion length of stay. promotes relaxation.
Body malaise 4. Implement dietary 4. These restrictions can
sodium, fat, and help manage fluid
cholesterol restrictions as retention and, associated
indicated. hypertensive response,
decrease myocardial
workload.
Dependent
1. Administer prescribed Dependent
medication as 1. Stimulates alpha-
ordered: Cataprez 25 adregenic receptors in
mg tab Sublingual > CNS, decreasing
160/90mmHg sympathetic overflow;
inhibiting
vasoconstriction, and
ultimately reducing
blood pressure. It
generally reduces
blood pressure
through the
combined effect of
decreased total
peripheral resistance,
reduced cardiac
output, inhibited
sympathetic activity,
and suppression of
renin release.