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DRUG ORDER
MECHANISM OF ACTION - Inhibits bacterial cell wall synthesis, rendering the cell wall osmotically unstable, leading to cell death
INDICATIONS
CONTRAINDICATIONS
Cephalexin
Keflex
1. Treatment of LRTI 2. Skin and soft tissue infections 3. Pre-operative prophylaxis to reduce chance of post-operative surgical infections
NURSING RESPONSIBILTY PRECAUTION - Instruct the patient to take the medication as prescribed by the doctor even if she feels better
Dosage:
250-500 mg
Frequency:
250 mg q 6
Subjective cues: none Objective cues: - V/s taken as follows: T- 36.3 P- 73 R- 20 BP- 100/70
Short Term: After 2 hours of nursing interventions the patient will: - Demonstrate adequate perfusion and stable vital signs
- Inspect dressing for blood and weigh - Instruct the mother in relaxation or visualization excersises
- To obtain baseline data to determine if the patient is showing signs of shock - To measure the amount of blood loss - Promotes relaxation and may enhance the patients coping abilities by refocusing attention
After the nursing interventions the goals were met: - Patient has adequate perfusion and stable vital signs
DRUG STUDY
DRUG ORDER MECHANISM OF ACTION Methergine Stimulates uterine smooth muscles producing sustained contractions thereby shortens the third stage of labor INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT Hypertension Dizziness Headache Nausea/vomiting tinnitus NURSING RESPONSIBILTY PRECAUTION - Obtain v/s before adm. the drug - Monitor uterine contractions - Be alert for adverse reactions and drug interactions
Route:
IV
Dosage:
50 mg IV q 12 x 4 doses
Frequency:
DRUG STUDY
DRUG ORDER
MECHANISM OF ACTION - Ponstan has analgesic, antiinflammatory and antipyretic properties. It inhibits the synthesis of prostaglandins
INDICATIONS
CONTRAINDICATIONS
ADVERSE EFFECT Dizziness Flushing Headache Visual Disturbances - Tachycardia - Palpations - pancreatitis
1. Relief of pain - Presence of including post-op hypersensitivity to the and postpartum drug pain, headache as - Ulceration in the GI well as relief of tract. primary dysmenorrhea
NURSING RESPONSIBILTY PRECAUTION - Educate patient about common side effects after taking the drug
Dosage:
Frequency:
DRUG STUDY
DRUG ORDER
MECHANISM OF ACTION - Stimulates peristalsis. Also alters the fluid and electrolyte transport producing fluid accumulation in the colon
INDICATIONS
CONTRAINDICATIONS
Bisacodyl
Dulcolax
NURSING RESPONSIBILTY PRECAUTION - Assess for abdominal distention, bowel sounds, and usual pattern of bowel elimination - Assess amount, consistency and color of stool produced
Dosage:
5 mg
Frequency:
Subjective cues: none Objective cues: - V/s taken as follows: T- 36.3 P- 73 R- 20 BP- 100/70
Short Term: After 2 hours of nursing interventions the patient will: - Be able to understand the causative factors, identify signs of infection and report them to the health care provider accordingly.
- Inspect dressing and perform wound care - Monitor for elevated temperature, redness, swelling, increased pain, or purulent drainage at incisions. - Wash hands and teach other caregivers and relatives to wash hands before contact with the patient and between procedures as well.
- To obtain baseline data to determine if the patient is showing signs of infection. - Moist from drainage can be a source of infection as well as an unclean wound - These are signs of infection
After the nursing interventions the goals were met: - Patient is expected to be free of infection, as evidenced by normal vital signs and absence of drainage from the wound.
- Hand washing reduces the risk of transmitting pathogens from infecting the wound
Subjective cues: masakit ang tahi sa tyan ko.. as verbalized by the patient Objective cues: - Guarded/protective movement - Facial grimace - Irritable
Short Term: After 1 hour of nursing interventions the patient will: - Be able to verbalize management of pain or pain tolerance - Decrease facial grimace - Have little or no guarded/protectiv e movement
- Accept clients description of pain - Perform comfort measures such as arranging bed linens - Educate the mother about performing relaxation techniques such as deep breathing Collaborative: - Give analgesics as ordered by the physician
- To obtain baseline data to determine if the patient is showing signs of infection. - Pain is subjective and cant be felt by others. - To promote comfort and safety - To distract the patients mind from pain.
After the nursing interventions the goals were met: - The patient was able to verbalize management of pain, has decreased facial grimace and little or no guarded/protecti ve movement.
Objective cues: - The cord is visible and palpable - Membranes are ruptures - Changes in FHR
Short Term: After 30 minutes of nursing interventions the patient will: - FHR will return to normal
- To reliev pressure of the presenting part so that the oxygen can get through the fetus - To prevent drying of cord - Expedite termination of threat to infant
- Cover cord with a gauss soaked in saline solution - Prepare for immediate cesarean birth Collaborative: - Give terbutaline as per doctors order
After the nursing interventions the goals were met: - FHR returned to normal - Uncomplicated birth of the viable child
OBJECTIVE
INTERVENTION
RATIONALE
EVALUATION
Subjective cues: I am bleeding and I am getting worried about it as verbalized by the patient Objective cues: - Changes in fetal heart rate - V/s taken as follows: T- 36.9 P- 95 R- 20 BP- 110/60
Short Term: After 8 hours of nursing interventions the patient will: - Be able to understand the causative factors and perform appropriate interventions to be done
development of the placenta in the lower uterine segment, partially or completely covering the internal cervical os.
- Monitor amount and type of bleeding - Promote bed rest and maintain a quite environment - Position mother in left side lying position Collaborative: - Administer oxygen as indicated
- To obtain baseline data for comparison to detect any anomalies as well as a rough estimate of blood loss - Provide objective evidence for prompt intervention - Prevents fatigue and improves strength of the patient - To promote placenta perfusion
After 8 hours of nursing interventions the: - Patient was able to understand the causative factors and perform the appropriate interventions.
- Provides adequate
OBJECTIVE
INTERVENTION
RATIONALE
EVALUATION
Subjective cues: I experienced a sudden gush of water and I havent felt any labor contractions as verbalized by the patient Objective cues: - Changes in fetal heart rate - V/s taken as follows: T- 37.0 P- 85 R- 18 BP- 130/80
Short Term: After 8 hours of nursing interventions the patient will: - Be free from any signs and symptoms of infections such as foul smelling vaginal secretions and elevated temperatures
rupture of membrane is the spontaneous rupturing of the amniotic membranes before the onset of true labor. PROM can result in two major complications, cord prolapse and the fetus and the mother can develop an infection
- Monitor Fetal Heart tone - Promote bed rest and maintain a quite environment - Position mother in left lateral position
- To obtain baseline data for comparison to detect any signs of infection like rising temperature - To determine whether or not the fetus is in distress - Prevents fatigue and improves strength of the patient - To help in the circulation and avoid compressing the vena cava to supply the fetus with oxygen
After 8 hours of nursing interventions the: - Patient is free from signs and symptoms of infection
Physiology of Breech Presentation: Fetus moves and tends to seek the most comfortable position in the uterus Non-Modifiable Factors: - Multiple foetuses - Uterine abnormalities - Placenta Previa - Polyhydramnios
Overtime the fetus will fidget and maneuver around the head gravitates to the largest space of the uterus which is the lower uterine space.
In this case the mothers lower uterine space is not the largest due to factors like placenta previa, congenital abnormalities and many others Diagnostic Test: - Ultrasound - Leopolds maneuver - FHT is located at the upper quadrants of the mothers abdomen
The fetus presentation is breech position, at about 32 weeks this position will be permanent.