Introduction

The disorder usually occurs in the third trimester of pregnancy and gets worse over
time. In severe disease there may be red blood cells breakdown, a low blood platelet
count, impaired liver function, kidney dysfunction, swelling, shortness of breath due to
fluid in the lungs, or visual disturbances. The risk of poor outcomes for both the mother
and the baby.

Risk factors for PE include: obesity, prior hypertension, older age, and diabetes mellitus.
It is also more frequent in women's first pregnancy and if she is carrying twins. Risk
factors for PE include: obesity, prior hypertension, older age, and diabetes mellitus. It is
also more frequent in women's first pregnancy and if she undergo already 2 Cesarean
section.

Biographical Data

Name RSD Age 38 Gender F Religion Roman Catholic

Address Quezon City Occupation Budget and MGT Analyst

Reason for Seeking Health Care/Chief Complaint:

For Scheduled Caesarian Section Delivery and Bilateral Tubal Ligation

Perception of Health Status

Before Hospitalization:
The client is aware of her health condition and obeyed her Physician’s order which is to undergo another
Caesarian Section Delivery because of her maternal age which is 38 years old and her history of
pregnancy induced Diabetes on her 1st baby at 33 years old.

Previous Illness/Hospitalization/Surgeries
Patient came for scheduled Ceasarian Section with Bilateral Tubal Ligation with history of watery/bloody
vaginal discharge, with good fetal movement.
.
.

Family Medical History

Addiction(Drugs/Alcohol) Occasional Other none Arthritis none Dm History of preeclamsia
Mental Disorder none Cancer none Heart Disease none Hypertension Bp
Kidney Disease none Others .

Immunization/Exposure to Communicable Disease

- With no previous diagnosed communicable disease and no known immunization.
.
Allergies
- No known allergies
.
Home Medication/Alternative Medicine
- Biogesic (Paracetamol)

Psychosocial History
Alcohol Use Occasional Tobacco Use NO .
Drug Use NO Caffeine Intake YES .

Obstetrical History
OB Score(GPFPALM) G3P2
.
LMPFebruary 15, 2019
EDC November 22, 2019
AOG38 weeks.

Patterns of Functiong(Gordon’s Functional Patterns)

Pattern Before Hospitalization During Hospitalization Analysis
Health Perception The patient stated that She has an idea that her The patient received
since her previous pregnancy is at risk proper instructionsfrom
pregnancy were all because of her age, her attending Physician
delivered by CS, she that’s why she’s and got aware of her
decided to undergo the grateful that her baby status.
same procedure once came out alive and well.
again.

Nutritional-Metabolic The patient verbalized Usual meal is porridge The patient knows her
avoiding salty and fatty or soup. limitation to her food
foods but sometimes intake because of her
eating in a fastfood high risk pregnancy
chain. Usual meal is half condition but still
cup of rice, vegetable, cannot avoid eating
occasionally meat and unhealthy food.
fish and saging na saba.
Aside from water, she
drink ice tea and
softdrinks.

Elimination Usual pattern is every 2 Positive stool during the Eliminated during the
days and with frequent first day (1x) first day of
urination pattern. Have void after the hospitalization and was
Usual void is 8 a day removal of the catheter able to switch to Soft
Diet.
Activity/Exercise Participated to Zumba Bedrest and limited The patient has a
sessions, with ambulation from bed to limited ROM due to her
continuous walking and comfort room. previous surgery.
commute from home to
work

Sleep-Rest Sleeping pattern is Usual time of sleep is at The patient is lacking of

between 11 pm to 4 am 11 pm and woke up at 6 good sleep because of
with no naps during the due to hunger and her work and her duty
day due to her work but nurses’ at rounds. as a mom.
was able to sleep with
ease.
Cognitive/Perception Functioning well and is Is easy to talk to with The patient has a good
working during the clear and good level of understanding
days, with clear response with fast and and can communicate
perception and was detailed answers to well.
able to communicate questions.
well.
Role/Relationship Has a positive With good relationship No alterations.
relationship with her towards her family ,
family even if she is not accompanied by her live
yet married in partner during
hospitalization
Sexuality/Reproductive No family planning Underwent Bilateral The patient and her
method used – Tubal Ligation partner agreed to do
withdrawal method the procedure since
they are sexually active.
Coping/Stress Tolerance The patient verbalized Watching TV and Patient accepts
sleeping, eating, surfing surfing the net. present condition with
the net (Facebook) and a positive attitude.
ignore things if
stressed.

Value/Belief Roman Catholic , with Bigkis and bracelet for Due to her
frequent visitations to the baby due to certain confinement, patient
church every Sunday. beliefs. is trusting God that
she will be discharged
soon and will recover
without any
complications.

Physical Assessment(Abnormal Findings ONLY)

THE HEAD TO TOE EXAMINATION

BODY PART Result NORMAL FINDINGS

A. HEAD
» Proportional to the size of the body,
round, with prominences in the
1. Skull
no masses, lumps, bulges and frontal area anteriorly and the
tenderness occipital area posteriorly,
symmetrical in all planes & gently
curved
2. Scalp

free from masses and scars; hair is » White, clean, free from masses,
black and evenly distributed with few lumps, scars, nits, dandruff, and
strands of white. lesions.

3. Hair » Black, evenly distributed and covers

thick with split ends. the whole scalp, thick, shiny, free
from split ends.
» Coarse or fine.

*Note:
Terminal Hair
- It is the long,
thick, and
coarse hair of
the body
which is
easily visible
on the scalp,
axilla, and the
pubic area.

Vellus Hair
- It is the soft, small, tiny hair that covers the
whole body except for the palms and the
soles.
4. Face oval shaped face, with appropriate
facial expression and no involuntary » Oblong or oval or square or heart
muscle movements shaped, symmetrical, facial
expression that is dependent on the
mood or true feelings, smooth and
free from wrinkles, no involuntary
muscle movements.
5. Eyes

» Parallel and evenly placed,

symmetrical, non-protruding, with
scanty amount of secretions, both
eyes black and clear.

Eyebrows thin and can raise it with ease » Black, symmetrical, thick can raise
lower eyebrows symmetrically and
without difficulty, evenly distributed
and parallel with each other.
Eyelashes
» Black, evenly distributed and turned
black and evenly distributed
outward

Eyelids
» Upper lids cover a small portion of
the iris, cornea and the sclera
(limbus) when the eyes are open.
lids completely meet, symmetrical » When the eyes are closed, the lids
and no mass and lumps. meet completely.
Symmetrical, color is the same as the
surrounding skin.
» No palpable mass

Lid Margins
» Clear, without scalings or secretions,
with evident lacrimal duct openings lacrimal duct openings (puncta) are
and without abnormal secretions. evident at the nasal ends of the upper
and lower lids.

Palpebral Fissures

» Appear equal when the eyes are

symmetrical
open.

Lower palpebral
conjunctiva » Salmon pink, shiny, moist and
pink and moist
transparent

Sclera
clear and slightly red » White and clear
Iris
» Proportional to the size of the eye,
symmetrical, round and dark brown
round, black/brown, and symmetrical

Pupils

» From pinpoint to almost the size of

round, symmetrical and it constrict
the iris, round, symmetrical, constrict
and dilate
with increasing light and
accommodation.

Eye Movement

» Able to move eyes in full range of

able to move eyes in all directions motion or able to move in all
direction.

Visual Acuity

» 20- distance from the chart

client vision: 550
» 20- distance at which a normal eye
can read.

Field of Vision

» Able to see 60 degrees superiorly, 90

cannot be able to see far away
degrees temporally, and 70 degrees
objects without her glasses
inferiorly.

6. Ears » Parallel, symmetrical, proportional to

bean shaped, parallel and the size of the head, bean-shaped,
symmetrical with presence of helix is in the line with the outer
cerumen canthus of the eye, skin is the same
color as the surrounding area, clean.
Ear Canal with scant amount of cerumen and
» Pinkish, clean, with scant amount of
few cilia
cerumen and a few cilia.
Hearing Acuity able to hear whispers in both ears

» Able to hear whisper spoken 2 feet

away.

7.Nose

midline and symmetrical » Midline, symmetrical, and patent

Internal nares
clean with presence of cilia » Clean, pinkish, with few cilia

Septum straight » Straight

8. MOUTH » Pinkish, symmetrical, lip margin well
lips - pale, symmetrical, slightly dry.
Lips defined, smooth and moist
Gums
» Pinkish, smooth, moist, no swelling,
moist, no swelling, smooth.
no retraction, no discharge

Teeth well aligned teeth, slightly yellow » 32 permanent teeth, well-aligned,

and with cavities free from caries or filling, no halitosis
Tongue
» Large, medium, red or pink, slightly
moist and freely movable; free from rough on top, smooth along the
cuts or bruises; pinkish lateral margins, moist, and freely
movable.
Frenulum
midline, thin and aligned with
» Midline, straight, and thin.
tongue

Cheeks
(Buccal Mucosa) free from scars or bruises. » Pinkish, moist, and smooth

Palate pink, smooth and moist

Soft Palate » Pinkish, smooth and moist
Hard Palate slightly pink, moist
Uvula
symmetrical, in the midline, pinkish
Tonsils
pinkish and not inflamed.
Voice
can be able to speak clearly with no
hoarseness
proportional, symmetrical and
9. Neck aligned with the body; no lumps,
masses and free from tenderness;
can freely move and able to resist
applied force
10. Thorax and chest is symmetrical, spine is
Lungs straight, there is no bulging, free
(Anterior and from lumps, masses and tenderness
Posterior) and vibrations are prominent; no
presence of deformities, surgical
scars and s3 and s4.
» Slightly pinkish
» At the center, symmetrical, and freely
movable
» Pinkish, non-inflamed, no exudates
» No hoarseness and well-modulated.
» Proportional to the size of the body
and head, symmetrical, and straight
» No palpable lumps, masses, or areas
of tenderness
» Adam’s apple palpable.
» Freely movable without difficulty.
» Symmetrical and able to resist applied
force (both muscles)
» Able to resist applied force.
Symmetrical in structure of size and
muscular strength.
» The chest contour is symmetrical and
the chest is twice as wide as deep
(anteroposterior diameter in a 1:2
ratio).
» The spine is straight. Posteriorly the
ribs tend to slope across and down.
The ribs are prominent in a thin
person. There is no bulging or
retraction of the ICS during breathing.
The chest wall moves symmetrically
during respiration.
 » No lumps, masses, areas of
tenderness.
» Sides of the thorax expand
symmetrically. The examiner’s thumb
separate approximately 3-5
centimeters during excursion.

» Vibrations are prominent over the

areas near the bronchi. It increases
with intensity of the voice. Vibrations
are strongest between the first and
second ribs along the sternum
anteriorly and between the scapulae
posteriorly.

» Percussion note varies with the

thickness of the chest wall:

» Resonance- sound created by air-

filled lungs. It is clear, long, low pitch.

» Dull- short, high pitch, soft and

thudding, heard over the heart.

» Flat- absolute dullness; absence of air

in the underlying tissue.

» Tympany- moderately loud with

music quality with specific pitch.
Noted in the left upper quadrant of
the abdomen.

Location Percussion Note

L R
Supra-
clavicular Flat
1st ICS Resonant
2nd ICS Dull Resonant
3rd ICS Dull Resonant
4th ICS Dull Resonant
5th ICS Dull Resonant
6th ICS Resonant Resonant

HEART
clear and audible "lubdub" sound;
cardiac rate is __ beats/min; visible
and palpable abdominal aortic
pulsations; no s3 and s4
7th ICS Tympanic Dull
8th ICS Tympanic Dull
9th ICS Tympanic Dull
» Normal breath sounds differ in
character depending on the area of
the lung being auscultated.
» Bronchovesicular sounds are
medium-pitched sound or medium
intensity, heard posteriorly between
the scapulae. The sounds have a
blowing quality with the inspiratory
phase equal to the expiratory phase.
» Vesicular sounds are heard over the
lung periphery. The sounds are
created by air moving through the
smaller airways. They are soft, breezy,
and low-pitched and the inspiratory
phase is about three times longer
than the expiratory phase.
» Bronchial sounds are hollow high
pitched; whistling sounds which are
normal if heard over large airways
like the trachea.
No pulsations
No pulsations
No pulsations
Pulsations visible and palpable
Abdominal aortic pulsations visible and
palpable.
The two sounds are audible in all areas but
loudest at apical area.
Cardiac rate ranges from 60-100
beats/minute.
Age Range bpm Ave
Newborn 100-170 140
1 yr 60-160 120
 3 yrs 80-120 110
6 yrs 70-115 100
10 yrs 70-110 90
14 yrs 60-100 85-90
adult 60-100 72

BREASTS
Females: variable in size depending on body
build.
* obese - large and pendulous.

*Slender - thin and small.

*Young clients - firms, elastic in consistency,

cone shaped symmetrical, skin surface
smooth.

*older women - breasts sag, nipples lower,

stringy and nodular.

Males: flat, symmetrical. If obese, may be

slightly rounded.

» Color of the skin same with

body built; breasts are firm, elastic, the abdomen, no retraction,
cone shaped and smooth; no lumps, no dimpling.
masses or deformities; no dimpling;
with slight discharge with slight » No mass or lump, no areas of
tingling sensation. tenderness.

» In younger client, borders of

the breasts are clearly
delineated. In older client
irregular consistency,
glandular/nodular.

» Lobular feel of glandular

tissue is normal.

» The lower edge of the each

breast may feel firm and
hard.

» Premenstrual fullness,
nodularity and tenderness
may be present.

» Warm to touch and smooth.

AREOLA
round, symmetrical and no masses
and areas of tenderness.
NIPPLES
round, equal in size and pointing in
one direction; with slight discharge,
no masses, scars and lesions
ADBOMEN Abdomen - presence of surgical
incision due to recent cs delivery;
vertical incision and color is uniform,
visible respirations, umbilicus is
located midline and is inverted;
tender and with restricted movement
» Round or oval, color darker than
surrounding skin, symmetrical.
» 1QFor dark – skinned client, color is
darker than other skin surfaces.
» No masses and areas of tenderness.
» Round or inverted, equal in size,
similar in color, nipples point in one
direction, no discharge, no lesion, no
dimpling, and no crusting.
» No masses, no tenderness, no
discharge.
» Skin is unblemished, no scars, color is
uniform, flat, rounded (convex), or
scaphoid (concave),
» Symmetrical movements caused by
respiration, aortic pulsation at
epigastric area visible in thin persons
» Umbilicus is flat or concave,
positioned midway between the
xiphoid process and the symphysis
pubis
» Color is the same as the surrounding
skin.
» There are clicks and gurgles, the
frequency of which has been
estimated at from 5-34 per minute.
Occasionally, borborygmi (loud
prolonged gurgles of hyperperistalsis)
the familiar “stomach growling” can
be heard.
» Tympany predominates because of
the presence of air in the stomach
and intestines
» Percussion is dull at the liver’s lower
boarder.
» Soft abdomen, no tenderness, no
muscle guarding, no lumps, or
masses, or organomegaly.
» Liver’s edge feels firm and not tender.
UPPER
EXTREMITIES
» skin color varies (pinkish, tan, dark
Arms brown), symmetrical, fine hair evenly
tan, hair is evenly distributed and no distributed, presence/absence of
visible vein ; warm and no areas of visible veins.
tenderness. » Warm, dry and elastic, no areas of
tenderness. Muscle appears equal
with good muscle tone.
Palms and Dorsal
Surfaces
» Palms pinkish (dorsal surface), warm;
males – thick; females – softer;
elastic.

Nails
transparent, smooth and pink
nailbeds with white tips; complete
5/5 fingers in each hand with no
deformities; the pink color returns
immediately after applying pressure;
clean.
» Nails are transparent, smooth and
convex with pink nailbeds and white
translucent tips.
» Five fingers in each hand.
» As pressure is applied to the nailbed,
appears white or blanched, and pink
color returns immediately as pressure
is released.

Manipulation – the process of moving or attempting to move the part being examined. Limitation of
movements can be discovered.

Shoulders

can be able to do the movements

» Performs with relative ease.
without pain

Arms

can be able to do the movements » Performs with relative ease

without pain
» No relative difficulties

Elbows
able to bend and straighten with
ease. » Performs with relative ease.
Hands and wrists
able to extend and spread the
fingers, able to make a fist,
» Performs with relative ease
thumb across and knuckles

LOWER
EXTREMITIES

Legs » Skin color varies (pinkish, tan, dark

brown) skin is smooth, fine hair
skin is tan, smooth and hair is evenly
evenly distributed, absence of
distributed, with few visible veins,
varicose veins, muscles symmetrical,
muscle are symmetrical
length symmetrical.

» Muscles appear equal, warm and with

good muscle tone.

Toes

» Five toes in each foot; sole and dorsal

surface is smooth; with pink nail beds
and white translucent tips.
five toes in each foot, with pink
nailbed; with normal capillary refill.
» As pressure is applied, the nailbed
appears white or blanched; pink color
returns when pressure is released.

Legs (one leg at a

time)

can perform all the said

Performs with relative ease
movements

Knees

can bend and extend Performs with relative ease

Ankles

can perform all movements Performs with relative ease

Toes
can spread and wiggle Performs with relative ease

Diagnostic/Laboratory Examination

Examination Normal Values Findings Analysis

Urinalysis (11/24/19)
Physical
Examination
 Color Yellow Light Yellow Yellow color of urine in
pregnancy is considered
normal. It could be
because of something
she ate or because of
prenatal vitamins or she
need to drink more
water.

 Transparency Slightly Turbid Cloudy urine could just

be a result of hormonal
or dietary changes and
does not necessarily
mean anything. During
pregnancy women will
also have increase in
vaginal discharge
which can mix urine
causing it appear
cloudy.

Microscopic
Examination
 WBC 0 – 5/hpf 0 – 1/ HPP Normal

 RBC 0 – 5/hpf ≥ 50/ HPP

 Epithelical cells Occasional

 Bacteria Rare

 Mucua Threads Occasional

 Protein Negative Negative Normal

 pH 5.0 – 8.0 6.5 Normal

 Blood Negative +2 If pregnant and
see blood in
your urine, or your
doctor
detects blood during a
routine urine test, it
could be a sign of
a urinary tract infection
(UTI).

 Specific gravity 1.005 – 1.030 1.015 Normal

 Glucose Negative Negative Normal

Hematology I
(11/24/19)

 Hemoglobin mass 120.00 - 160.00 g/f 110 Decrease

concentration
Decrease
 Erythrocyte volume 0.37 – 0.45 0.34
fraction
4.50 – 11.00 x10 ˟ Normal
 Leukocytle 7.5
numerical
concentration
Leukocyte type
numerical
fraction
58.00 – 66.00% 74 Increase
 Neutrophil
21.00 – 38.00% 26 Normal
 Lymphocyte Decrease
 Red blood cell 4.20 - 5.40 x 10 / L 3.73
count Decrease
 Thrombocyte count 150.00 – 450.00 x 10˟ 135

.
ANATOMY and PHYSIOLOGY(affected system/ organ)

ANATOMY & PHYSIOLOGY

The female reproductive system consists of the ovaries, uterine tubes (or fallopian tubes), uterus,

vagina, external genitalia, and mammary glands. The internal reproductive organs of the female

are located within the pelvis, between the urinary bladder and the rectum. The uterus and the

vagina are in the midline , with an ovary to each side of the organ. The internal reproductive

organs are held in place within the pelvis with ligaments. The most conspicuous is the brad

ligament, which spreads out on both sides of the uterus and to which the ovaries and the uterine

tubes attach.

Pathophysiology of the disease

NURSING CARE plan

Assessment Diagnoses Planning Goal Nursing Rationale Evaluation plan
Interventions
Objective Moderate  After 5 hrs  Monitor  It Goal met
pain of nursing vital sign serves After 5 hrs of nursing
Vital Sign related to intervention as a intervention the client
T: surgical the client baselin was able to
BP : 110/70 incision will be able e data
Pulse : to to  Reported pain is
 Report pain  Perform check reduced from the
Subjective if there pain scale of 3/10
is reduce pain
Pain scale 5 from the assessme are any
out of 10 pain scale of nt each deviati
“ Masakit 5/10 to 3/10 time pain ons
pag occurs from
umuupo her
ako”  verbalize  Assist in vital  The patient has
methods different signs. received the right
that relief position  It drug for pain.
pain like sitting reduces
and side muscle
lying tension
position and
fatigue.
 The patient feel
 demonstrate  Encourage relieved somehow.
relaxation deep
methods breathing  To
 exercise alleviat
e the
pain

Risk for
infection  To reduce  Note risk  Patient didn’t show
related to client pain factors of early signs of
surgical and regain occurence  To infections
incision strength of the avoid
secondary infection infectio
to n
caesarian  Give pain
section reliever to
patient

 Keep her
surroundi
ng clean

Activity  Assist in  demonstrated an

intolerance  To sit and different  To increase in activity
due to walk with no position know tolerance.
moderate pain like sitting some
and side
lying
position

Drug Study (as applied to the client)

Name of Mechanism Dosage Indication Contraindication Adverse Nursing

drug of action Effect Considera
tion
Generic Nonsteroidal Dose: used to Contraindicated CNS: Because
Name: Anti- 75mg/min treat mild in patient Anxiety , NSAIDS
Diclofenac Inflammator (-)ANST to hypersensitive depression, impair the
Sodium y drug Isotonic moderate to drug and in dizziness, synthesis of
 NSS 50 cc pain, or those with drowsiness, renal
Brand Unknown, signs and hepatic insomnia, prostagland
Name: May inhibit symptoms porphyria or irritability, ins, they
Voltaren, prostaglandi of history of headache, can
Fenac n synthesis osteoarthrit Asthma, decrease
to produce is or urticarial, or CV: heart renal blood
anti- rheumatoid other allergic failure, flow and
inflammator arthritis. reactions after hypertensio lead to
y, Analgesic, Voltaren is taking aspirin n, edema , reversible
and also or other fluid renal
antipyretic indicated NSAIDSs. retention impairment
effects. for the , especially
treatment EENT : in patients
of tinnitus, with renal
ankylosing laryngeal or heart
spondylitis. edema, failure or
The swelling of liver
Cataflam the lips and dysfunction
brand of tongue, , in elderly
this blurred patients
medicine is vision, eye and in
also used to pain, night those
treat blindness, taking
menstrual epistaxis, diuretics.
cramps. reversible Monitor
hearing loss. these
patients
GI: closely.
abdominal
pain or
cramps,
diarrhea,
indigestion,
nausea,
abdominal
distention,
flatulence,
taste
disorder
peptic
ulceration,
bleeding
melena.
NAPROXEN Nonsteroidal 55 mg/ 1 used to >hypersensitivit CNS: Monitor GI
anti- tab P.O relieve pain y to drug or dizziness, status, Stay
inflammator after from other NSAIDs drowsiness, alert for
y dinner various >active GI headache, signs and
drug(NSAID), then TID conditions bleeding or vertigo, symptoms
nonopioid after meals such as ulcer disease light- of GI
analgesic, 6 doses headache, >asthma headedness bleeding
antipyretic, muscle >pregnancy(thir CV: In long
anti- aches, d pregnancy) palpitations, term use,
inflammator tendonitis, tachycardia assess CBC
y dental pain, EENT: visual with white
and disturbance cell
Unknown. menstrual s, tinnitus, differential
Thought to cramps. It auditory and
inhibit also GI: nausea, coagulation
prostaglandi reduces pai diarrhea studies,
n synthesis n, swelling, ,constipatio and
and joint n, monitor for
stiffness heartburn, visual and
caused abdominal hearing
by arthritis, pain, impairment
bursitis, stomatitis, Monitor
and gout GI cardiovascu
attacks. BLEEDING lar status
This SKIN: rash for
medication ,proritus, tachycardia
is known as skin ,
a eruptions palpitations
nonsteroid ,sweating , and
al anti- ,photosensit edema
inflammato ivity Monitor
ry drug OETHERS: blood
(NSAID). thirst , glucose
edema, level closely
Allergic on diabetic
reactions, patient.
including
anaphylaxis
TRANEXA Antihemorrh PRN used to >Hypersensitivit CNS: Patient
MIC ACID agic, treat y to drug dizziness, monitoring:
Antifibrinolyt heavy blee >Upper urinary malaise, >monitor
ic ding during tract bleeding headache, V/S, fluid
the >Disseminated delirium, intake and
Interferes menstrual intravascular hallucinatio output, and
with cycle coagulation ns, ECG
plasminogen (monthly >Neonates(injec weakness, >Assess for
activator periods) in table form) seizures signs and
substances women. CV: symptoms
and blocks Tranexamic hypotension of
action of acid is in a , ischemia, thrombophl
 fibrinolysin(p class of thrombophl ebitis and
lasmin) medication ebitis, pulmonary
s called cardiomyop embolism
antifibrinol athy, >Monitor
ytics. It bradycardia, neurologic
works to arrythmias status,
improve EENT: especially
blood conjunctival for signs of
clotting suffusion, impending
tinnitus, seizure
nasal >Monitor
congestion kidney and
GI: nausea, liver
vomiting, function
diarrhea, test results,
abdominal serum
pain, electrolytes
dyspepsia level, and
GU: CBC with
intrarenal white cell
obstruction, differential
renal failure >Evaluate
Hemetologi for blood
c: bleeding dyscrasias,
tendency, particularly
generalized bleeding
thrombosis, tendencies
agranulocyt
osis,
leucopenia,
thrombocyt
openia
Generic Analgesic ( Dose: To relieve Hypersensitivity Hematologi >Assess
name: Non-opioid) 1.2 gms mild to to c: patient’s
Paracetam Antipyretic moderate acetaminophen hemolytic fever or
ol Route: pain due to or anemia, pain: type
Paracetamol IV things such phenacetin; use leukopenia, of pain,
Brand may cause as with neutropenia location,
name: analgesia by headache, alcohol , intensity,
Biogesic inhibiting muscle and pancytopeni duration,
CNS joint pain, a, temperatur
prostaglandi backache thrombocyt e, and
n synthesis. and period openia. diaphoresis
The pains. It is Hepatic: .
mechanism also used to liver
of morphine bring down damage, >Assess
is believed to a high jaundice allergic
involve temperatur Metabolic: reactions:
decreased e. For this hypoglycemi rash,
permeability reason, a urticaria; if
 of the cell paracetamo Skin: rash, these
membrane l can be urticuria occur, drug
to sodium, given to may have
which results children to be
in after discontinue
diminished vaccination d.
transmission s to prevent
of pain post- >Teach
impulses immunizati patient to
therefore on pyrexia recognize
analgesia. (high signs of
temperatur chronic
e). overdose:
Paracetamo bleeding,
l is often bruising,
included in malaise,
cough, cold fever, sore
and flu throat.
remedies
>Tell
patient to
notify
prescriber
for pain/
fever
lasting for
more than
3 days.
Generic Second- 750 mg IV Pharyngitis, * Body as a Determine
Name: generation q8 tonsillitis, Contraindicated Whole: history of
CEFUROXI cephalospori infections in patients Thrombophlebi hypersensit
ME n that of the hypersensitive tis (IV site); ivity
inhibits cell- urinary and to drug. pain,burnin reactions to
Brand wall lower * Use cautiously g, cellulitis( cephalosph
Name: synthesis, respiratory in patients IM orins,
ZOLTAX promoting tracts, and hypersensitive site);superin penicillins
osmotic skin and to penicillin fections,pos and history
Classificati instability; skin- because of itiveCoombs of allergies
on: usually structure possibility of 'test. particularly
ANTIBIOTI bactericidal. infections cross-sensitivity to drugs
C caused by with other beta- GI: before
Streptococc lactam Diarrhea, therapy is
Frequency: us antibiotics. nausea, initiated.
BID pneumonia * Use with antibiotic-
e and S. caution in associated Report
Dosage: pyogenes, breast-feeding colitis. onselt of
1 tab 500 Haemophill women and in loose stools
mg usinfluenza patients with Skin:
e, history of colitis Rash, Absorption
Route: Staphyloco or renal pruritus, of
PO ccus sufficiency. urticaria. cefuroxime
aureus, is enhanced
Escherichia Urogenital: by food.
coli. Increased
serum Notify
cretonne prescriber
and BUN, about
decreased rashes or
creatinine superinfecti
clearance ons

Discharge Plan
MEDICATION Instructed the patient to take the prescribed
medications at home with the right amount of
dose at specific time of the day. (Then lagay mo
here mga meds)
ENVIRONMENT Instructed the patient to stay in calm and quiet
environment to promote faster healing through
comfort and relaxation - Home environment must
be free from slipping or accident hazards. •
instructed patient to report to physician for any
signs of infection • instructed pt to report any case
of haemorrhage or abnormal finding.
TREATMENT Instructed pt to have a follow up check up after 1
week upon discharge
Health Teachings Informed patient to avoid lifting heavy objects for
1-2 weeks Stressed the importance of perineal
cleanliness Encouraged client to have hot sitz bath
Instructed patient to increase intake of protein-
rich foods to promote faster wound healing
Instructed to promote adequate fluid intake
Discouraged patient to participate in strenuous
activities that might precipitate stress and trauma
to the wound Instructed patient to promote
breastfeeding.
Observable Signs and Symptoms Observe for dehiscence and evisceration
Instructed patient to report to physician any signs
of infection Instructed patient to report any case
of hemorrhage or abnormal bleeding
Diet Encouraged client to increase intake of fiber to
avoid constipation Instructed to increase fluid
intake Instructed to increase intake of nutritious
foods such as fruits and vegetables