Nursing Care Plan

Submitted by:

Rachelle Ann A. Reyes BSN3-6

Submitted to:

Prof. Daisy Doctor, RN, MAN

DE LA SALLE HEALTH SCIENCES INSTITUTE COLLEGE OF NURSING AND SCHOOL OF MIDWIFERY LEVEL III NURSING CARE PLAN

Patient Name: M.L.E.P to a live baby boy

Age: 22 y/o

Sex: Female

CS: Single

Medical Diagnosis: G3P3 (3002) PV 37-38 weeks AOG cephalic ROA delivered spontaneously Attending Physician: Dr. Villena/Nionuevo/Escobia/Sabado

I. Chief Complaint/Other Complaints: Labor pains for 2 days Vaginal

II. Nursing History The patient experienced labor pains for 2 days. It started last March 19, 2013 at around 2 p.m. in the afternoon until March 21, 2013 which is the day when she delivered her 3rd child. She verbalized nagumpisa yung sakit sa tiyan, sasakit ng mga 5 minutes tapos mawawala tapos babalik na naman, pero nung 21 hindi na talaga tumigil ang pag-sakit niya. She also experienced vaginal bleeding on the same day. Persistence of symptoms led them decide to brought her to the hospital.

III. Laboratory/ Diagnostic Result, Interpretation and Nursing Implication

Procedure/ Date Indications Normal Values/ Findings Hemoglobin Actual Findings and Interpretation Nursing Responsibilities Pre: 129 Check the doctors order Prepare the cleaned needed equipments

Hematology
(03-21-13)

Used to evaluate anemia, leukemia, reaction to inflammation and infections, peripheral blood cellular characters, state of hydration and dehydration, polycythemia, haemolytic disease of the newborn, to manage chemotheraphy decisions

120-170 g/L Hematocrit 0.37-0.54 RBC Count 4.1-5.1 x 12^9/L WBC 4.5-11 x 10^9/L

0.38

4.42

Intra: Explain all the procedures to the patient and its purpose Clean the site for extraction of blood with cotton soaked in alcohol and then dry Assist the patient while doing the procedure

15.0 (indicates infection, inflammation or tissue injuries)

Differential count: Segmenters 0.00-0.55 0.91 (indicates infection/ inflammation) Lymphocytes 0.00-0.34 Eosinophils 0.01-0.03 Monocytes 0.04-0.08 0.03 (indicates infection/tissue breakdown) Platelet count 150-400x10^9/L 165 0.01 0.05

Post: Dispose the needle properly Send the specimen to the laboratory after doing the procedure

IV. Medications and Treatment BN/GN Dosage/ Frequency/ Route

500 mg/ q8o/oral

Indication/CI

S/E and AR

Nursing Responsibilities

Amoxicillin/ Amoxil

Indications Infections due to susceptible strains of Haemophilus influenzae, E. coli, Proteus mirabilis, N. gonorrhoeae, S. pneumoniae, streptococci, nonpenicillinase-producing staphylococci Helicobacter pylori infection in combination with other agents Post-exposure prophylaxis against Bacillus anthracis Unlabeled use: Chlamydia trachomati s in pregnancy

Side effects: white patches or sores inside your mouth or on your lips; fever, swollen glands, rash or itching, joint pain, or general ill feeling; severe blistering, peeling, and red skin rash; pale or yellowed skin, yellowing of the eyes, dark colored urine, fever, confusion or weakness; severe tingling, numbness, pain, muscle weakness; or easy bruising, unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin. Adverse Reaction

Culture infected area prior to treatment; reculture area if response is not as expected Give in oral preparations only; absorption may be affected by presence of food; drug should be taken 1 hr before or 2 hr after meals Continue therapy for at least 2 days after signs of infection have disappeared; continuation for 10 full days is recommended Use corticosteroids, antihistamines for skin reactions

Contraindications Contraindicated with allergies to penicillins, cephalospori ns, or other allergens

Lethargy, hallucinations, seizures, Glossitis, sto matitis, gastritis, sore mouth, furry tongue, black hairy tongue, nausea, vomiting, diarrhea, abdominal pain, bloody diarrhea, enterocolitis,

pseudomembranous c olitis, nonspecific hepatitis, Nephritis, Anemia, thrombocytopenia, leu kopenia,neutropenia, prolonged bleeding time, Rash, fever, wheezing, anaphylaxis ,Superinfections--oral and rectal moniliasis, vagin itis

V. Nursing Priorities Ineffective Airway Fatigue

VI. Nursing Care Plan

CUES NURSING DIAGNOSIS LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION

S>Inuubo ako O> Received pt. lying on bed in supine position, awake, conscious, coherent and communicative >(+) productive cough >with whitish sputum

A1>Ineffective airway clearance r/t increase mucous production in bronchial airway

After a week patient will be able to maintain patent airway as evidenced by: >normal respiratory rate >no adventitious breath sounds >improve airway clearance

> Within my 8 hours span of care my patient will be able to: >understand and follow the given measures

>encouraged the patient to stay in semifowlers position >encouraged the patient to do coughing and deep breathing exercises >encouraged the patient to OFI

>to help in draining the lung secretions >to promote lung expansion & oxygenation

Short term Goal: >Goal met, The patient understood and followed the given measures

>to enhance liquefaction of lung secretions & facilitates expectoration of mucus >to provide a basis for evaluating adequacy of ventilation

>monitored rate, rhythm, depth, and effort of respirations

>monitored for increased restlessness, anxiety, and air hunger >encouraged to drink warmed foods/drinks

>to observe if hypoxia is present

>to allow for easier mucus elimination

CUES

NURSING DIAGNOSIS

LONG TERM

SHORT TERM

INTERVENTION >assessed the patients ability to perform activities of daily living

RATIONALE

EVALUATION

S>Medyo nanglalamya ako dahil hindi ako makatulog ng maayos sa sobrang init

O>(+) restlessness

A2>Fatigue related to difficulty of resting and sleeping associated with environmental factors (e.g. climate)

After a week patient will be able to: >Perform activities of daily living and participate in desired activities at level of ability

Within my 8 hours span of care my patient will be able to: >Will understand the purposes of the given measures in increasing or promoting energy

>fatigue can limit the persons ability to participate in self-care and perform her responsibilities >changes in the persons sleep pattern may be a contributing factor in the development of fatigue >to promote comfort

Short term Goal: >Goal met, The patient understood the purposes of the given measures in increasing or promoting energy

>assessed patients sleep pattern

>encouraged the pt. to have rest & sleep > taught the patient and family task organization

>organization and time management can help the

techniques and time management strategies >encouraged the patient to perform ROM exercise

patient conserve energy and prevent fatigue

>exercise can reduce fatigue & enhances strength & enables patient to become more active without undue fatigue

VII. Discharge Plan Content 1. Compliance Medication The patient will continue the prescribed medications with proper dosage and frequency in order to hasten the recovery of the patient. >Informing the patient about the prescribed medications and its importance regarding to her condition. >Reminding and reviewing the patient about the drugs in order to make familiarity with the treatment. >Encouraging the patient and to avoid using nonprescription drug unless use is approved by the physician. >Encouraging the patient to follow the diet and fluid intake recommended to her. >Educating the patient to follow the diet and fluid intake recommended by the physician for her. >Educating the patient about foods that are healthy yet appropriate for her diet. Strategy

Diet

Advised the patient to only eat foods that she can tolerate, drink plenty of water, drink warm or cool liquids and avoid drinking alcohol Patient will know and follow patients restrictions in foods and proper eating of healthy foods.

Exercise Activity/Lifestyle Changes

The patient will be engaged in doing simple ROM exercises in order to maintain muscle and bones integrity as well as maintaining a good body circulation. Be sure to get enough rest and sleep on a daily basis.

>Educate the patient about how to do simple ROM exercises like flexion of upper and lower extremities or walking for a short distance. >Educating the patient about the importance of exercise, rest and sleep in the body and its benefits to once health.