COLEGIO SAN AGUSTIN- BACOLOD

COLLEGE OF HEALTH AND ALIED PROFESSIONS

NURSING PROGRAM

Name: M.D
Age: 25 Years Old
Sex: Female
Doctor: S.T.
Admission Date: September 17, 2019
Discharge Date: September 21, 2019
Chief of Complaints: Vaginal Bleeding and Anxiety
Final Diagnosis: AOG: 33 weeks,
G1P0, Placenta Previa
Attending Physician: Dr. S.T.

DISCHARGE PLAN

DIET

Instruct patient/folks to do the following:

 Eat small frequent meals a day

 Eat foods high in Iron
 Diet rich in vitamin C such as calamansi , orange, papaya, mango, and dalandan
 Eat foods high in Protein
 Eat foods high in Fiber
 Maintain all fluid intake to 1000 ml per day (such as soup,milk and water)
HYGIENE

Instruct patient/folks to do the following:

 Encourage the patient to have a good personal hygiene which includes: Daily bathing,
changing of clothes regularly, combing of hair and oral care.
 Advise to trim nails
 Instruct the client to perform perineal douching using mild, non-irritating, and pH
balanced vaginal wash.
 Advice the client to regularly check and change sanitary napkin.

ACTIVITY

Instruct patient/folks to do the following:

 Advise to avoid strenuous activity.
 Advise not to do sexual intercourse until give birth.
 Encourage breathing exercises to relieve anxiety.
 Instruct mother to lie on the left side.
 Encourage to sleep at least 6-8 hours per day.
 Avoid vices that may harm health.
 Activities that may divert attention such as reading magazines, listening to calm music
and watching entertaining videos.

MEDICATIONS

Instruct the client to have compliance in taking the following;

 Terbutaline Sulphate (Tocolytic) 2.5mg 4 times a day, by mouth , until delivery (6am
12pm 6pm 12am)
 Ferrous Sulfate (Anti-Anemic) 240mg 1 tablet a day, by mouth, with meals or after
meals.
COMMUNITY SUPPORT

Instruct client or significant others to do the following:

 Keep contact to the doctor or health care provider.
 The husband or any family member should stay to the patient most of the time.
 Ensure patients surrounding should be peace and calm for a better rest.
 Advise to have a regular checking of vital signs (Temperature, RR, HR, and BP) at the
barangay Health Center

SPIRITUAL

Advised client or significant others to do the following:

 Encourage folks to spend quality time with the patient.
 Advise to maintain spiritual activities with family such as praying and watching the mass
on the TV.
 Encourage client to share or express her feelings.

FINANCIAL RESOURCES/NEEDS
 Advise the patient to avail Phil health services and Health care insurance.
 Advise client to avail free medications in community health center.

APPOINTMENT
 Advise to go follow up check up at XXX District Hospital, Bacolod City, 1 week
after discharge , It will be on September 28,2019 8:00 AM – 4:00 PM.
 Advise Client to comply follow-up check up prior to physician’s order and given
schedule.
 Advise client to comply with the Laboratory Exam
PROBLEM LEVEL OF CARE ACTION PLAN
IDENTIFIED
RECURRENCE OF Instruct patient/folks to do the following:
VAGINAL Promotive/
BLEEDING
 Encourage the patient to have a
good personal hygiene which
includes: Daily bathing, changing of
clothes regularly, combing of hair
and oral care.
 Advise to trim nails
 Instruct the client to perform
perineal douching using mild, non-
irritating, and pH balanced vaginal
wash.
 Advised to Keep contact to the
doctor or health care provider.
 Advised the husband or any family
member should stay to the patient
most of the time.
 Encourage folks to spend quality
time with the patient.
 Advise to maintain spiritual
activities with family such as
praying and watching the mass on
the TV.
  Encourage client to share or express
her
 feelings.
 Advise the patient to avail Phil
health services and Health care
insurance.
 Advise client to avail free
medications in community health
center.

Preventive  Diet rich in vitamin C such as

calamansi , orange, papaya, mango,
and dalandan
 Eat foods high in Protein
 Eat foods high in Iron
 Instruct to maintain fluid intake up
ton 1000 ml per day.
 Ensure patients surrounding should
be peace and calm for a better rest.
 Advise to have a regular checking of
vital signs (Temperature, RR, HR,
and BP) at the barangay Health
Center
 Advise to avoid strenuous activity.
 Instruct mother to lie on the left
side.
 Encourage to sleep at least 6-8 hours
per day.
 Avoid vices that may harm health.
 Activities that may divert attention
 such as reading magazines, listening
to calm music and watching
entertaining videos.

CURATIVE
 Encourage breathing exercises to
relieve anxiety.
 Advise not to do sexual intercourse
until give birth.
 Instruct the client to have
compliance in taking the
following;

 Terbutaline Sulphate (Tocolytic)

2.5mg 4 times a day by mouth until
delivery (6am 12pm 6pm 12am)
 Ferrous Sulfate (Anti-Anemic)
240mg 1 tablet a day by mouth after
meals.

CURATIVE /  Advise to go gor follow up

REHABILITATIVE check up at XXX District
Hospital, Bacolod City, 1
week after discharge , It will
be on September 28,2019
8:00 AM – 4:00 PM.
 Advise Client to comply
follow-up checkup prior to
 physician’s order and given
schedule.

Anxiety CURATIVE  Encourage breathing exercises to

relieve anxiety.
 Activities that may divert attention
such as reading magazines, listening
to calm music and watching
entertaining videos.
 Encourage folks to spend quality
time with the patient.
 Encourage client to share or express
her feelings.
 Encourage client to pray and ask
guidance from the almighty.