LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING

As Partial Fulfillment
For NCM501205(RLE)

A Care Study on
DTS live birth, PROM associated with severe Pre-
Eclampsia and anemia 2nd degree to acute blood
loss

Submitted to:
Mrs. Lucy Estrada R.N. M.N.
On
January 14, 2009

Submitted by:
Baculio, Edzel
Group B11
 Table of Contents
I. Introduction…………………………………………………………………….. ..

a. Overview of the case……………………………………………………

b. Objective of the study……………………………………………….....

c. Scope and Limitation of the study……………………………………

d. Significance of the study……………………………………………….

II. Health History…………………………………………………………………….

a. Profile of patient………………………………………………………..

b. Family and personal health history…………………………………

IV. Medical Management…………………………………………………………..

a. Medical Orders and Rationale………………………………..………

b. Drug Study……………………………………………………………….

c. Diagnostic Tests………………………………………………………..

V. Pathophysiology with Anatomy & Physiology……………………………..

VI. Nursing Assessment (System Review & Nursing. Assessment II)…….

VII. Nursing Management…………………………………………………………..

a. Actual Nursing Management (SOAPIE)………………………….....

VIII. Referrals and Follow-up………………………………………………………

IX. Evaluation…………………………………………………………………………

X. Bibliography……………………………………………………………………….
I. INTRODUCTION

a. Overview of the Case

Childbirth is the culmination of a human pregnancy or gestation period

with the delivery of one or more newborn infants from a woman's uterus. The
process of normal human childbirth is categorized in three stages of labour: the
shortening and dilation of the cervix, descent and delivery of the infant, and
delivery of the placenta.

One of the abnormalities associated with pregnancy and labor is pre-

eclampsia. Pre-eclampsia is a medical condition where hypertension arises in
pregnancy (pregnancy-induced hypertension) in association with significant
amounts of protein in the urine. Because pre-eclampsia refers to a set of
symptoms rather than any causative factor, it is established that there are many
different causes for the syndrome. It also appears likely that there is a substance
or substances from the placenta that may cause endothelial dysfunction in the
maternal blood vessels of susceptible women. While blood pressure elevation is
the most visible sign of the disease, it involves generalized damage to the
maternal endothelium and kidneys and liver, with the release of vasopressive
factors only secondary to the original damage.

Pre-eclampsia may develop from 20 weeks gestation (it is considered

early onset before 32 weeks, which is associated with increased morbidity) and
its progress differs among patients; most cases are diagnosed pre-term. Apart
from abortion, Caesarean section, or induction of labor, and therefore delivery of
the placenta, there is no known cure. It may also occur up to six weeks post-
partum. It is the most common of the dangerous pregnancy complications; it may
affect both the mother and the fetus.

Another complication of labor that my patient experience is severe anemia

which was a result from loss of blood during the labor and delivery stage. Anemia
is defined as a qualitative or quantitative deficiency of hemoglobin, a molecule
found inside red blood cells (RBCs). Since hemoglobin normally carries oxygen
from the lungs to the tissues, anemia leads to hypoxia (lack of oxygen) in organs.
Since all human cells depend on oxygen for survival, varying degrees of anemia
can have a wide range of clinical consequences. Anemia is also caused by a lack
of iron in the body.
b. Objective of the study

This case study aims to improve the present condition of the patient and is
conducted to gain a thorough understanding about the client’s condition. We as
student nurses will not only learn about the condition itself, but how we as nurses
can provide a holistic care to this client by applying our knowledge on nursing
assessment, problem identification, nursing interventions, and evaluation related
to the condition. Furthermore, by gathering the subjective and objective data
regarding the case, it will allow us to have a proper and appropriate personalized
nursing care for the patient. This study also aims to improve our skills in the
clinical area, our interpersonal relationship with other health care givers, and to
gain more confidence in ourselves towards the task assigned to us.

c. Scope and limitation of the study

The study includes the collection of information specifically to the patients’

health condition primarily to my patient with severe pre-eclampsia and anemia.
The study also includes the assessment of the physiological and psychological
status, adequacy of support systems, and care given by the family as well as
other health care providers.

The scope of this study would include:

• Data collected via assessment, interviews with the patient, family

members, and clinical records.
• Actual and ideal problems and its appropriate nursing interventions that
would be applied throughout her stay in the hospital.
• Developing a plan of care that will reduce identified predicaments and
complications.
• Coordinating and delegating interventions within the plan of care to assist
the client to reach maximum functional health.
 • Further evaluating the effectiveness of nursing interventions that have
been applied to the client’s entire course of therapy.

An array of factors influencing the limitations of the this study includes:

• The lack of complete familial history obtained is due to lack of information

provided by client and family.
• The interaction, assessment and care were only limited to a total of 24
hours (2 clinical duties, 1 assessment day), with actual nursing
interventions done.
• Only 3 two of the members of this study were able to provide the actual
nursing intervention
• All carried out actual nursing interventions were only limited to the
procedures we the students were permitted to perform.

d. Significance of the study

The result of this study will provide valuable benefits to the following
groups of persons:

Patient:

In this study, the patient can receive a quality, personalized, and holistic
care coming from the student nurses. Through the daily assessments of
students, they can closely monitor the condition as well as the progress of the
patient.
Family of the Patient:

In this study, the family can be provided with more knowledge regarding
the patient’s condition. In addition, through demonstration and explanations, the
family can gain more knowledge and skill on the proper care of the patient.

Student Nurses:

The result of the study can possibly provide additional insights or

knowledge, about pre eclampsia and anemia , to the students. This study will
also provide a chance to test the student’s skills regarding proper patient
assessment in the clinical setting. Critical thinking will also be exercised in
relating the disease process and assessment to what has been learned from
research and theory.

II. HEALTH HISTORY

a. Profile of Patient

Name : Ms. RD

Age : 24 Y.O.

Gender : Female

Address: P4 Poblacion pamulong Bukidnon

Date of Birth: 3/23/1984

Height: 5’1

Weight: 57 kilograms

Nationality: Filipino

Religion: Roman Catholic

Occupation: Government employee

Date of Admission: 1/1/09

Time of Admission: 7:10 PM

Physician: Dr. Igar

Chief Complaints: Labor Pain

Admitting Diagnosis: PU 40 weeks AOG IL pre-eclampsia severe G1P0

Final Diagnosis: DTS alive baby girl, 3.1 kg cephalic G1P1(2001) PROM,
24H Severe pre-eclampsia, anemia 2nd degree to acute
Blood loss.

b. Family and Personal Health History

Upon interview, the patient had denied any history of other serious
diseases. She just claimed that she had some relative from his father’s side who
is experiencing hypertension. She also Claimed that this is her 2nd pregnancy and
her 1st hospitalization.
IV. MEDICAL MANAGEMENT

a. Medical Orders and Rationale

 DOCTOR’S ORDER RATIONALE
January 1, 2009

 Please admit
 Secure consent
 TPR q 4
 NPO
 Start IV D5LR iL @
20gtt/min
 Labs:
- U/A
- HBSA
- Crea
 Meds:
- Ampicillin 20mg
IVTTq 6h ANST
- Hydralazine 5mg
IVTT now then
report BP after
20mins then refer
- Hyosine –N-
Butylbonde amp
IVTT O.D. ANST
- MgSO4 4mg slow
IVTT now then
deep IM to both
buttocks
 Insert FBC attach to URO
bag
 Monitor FHT and BP hourly
and record.
 O2 inhalation at 2 LMP
 Refer accordingly

January 2, 2009

 Incorporate 10 “u” Oxytoxin

to IVF @ 10gtts/min
 FHT q 30mins, BP q 30mins
 Hydralazine 5mg IVTT now
 Nipedipine 30mg tab P.O.
now
 Fast drip 300cc D5LR now
 Meds:
- Cefuroxime
500mg BID P.O.
- FeSo4 tab BID
- Mefenamic acid
b. Drug Study

1. Captopril

Date: 1/05/09

Classifications: anti-hypertensive

Mechanisms of action: Ace inhibitor aids in conversion of angiotensin to

vasoconstrictor.

Specific Indication: Management of hypertension

Contraindications: Hypersensitivity of angiotensins

Side Effects: Dizziness fatigue and headache

Nursing Implications: Monitor BP, give drug 1 hour after meals

2. Methyldopa

Date: 1/3/09

Classifications: Anti-Hypertensive

Mechanisms of action: Stimulates the CNS which results in decrease blood

pressure

Specific Indication: Management of Hypertension

Contraindications: Hypersensitivity
Side Effects: Sedation, Nasal stiffing, Bradycardia, edma, and hemolytic
anemia

3. Ampicillin

Date: 1/1/09

Classifications: Anti-infectives

Mechanisms of action: Bind to bacterial cell wall resulting in cell death

Specific Indication: Prevention of Genito urinary infection

Contraindications: Hypersensitivity reaction

Side Effects: Seizures. Diarrhea, Nausea and vomiting urticaria and rashes.
Nursing Implications: Advise patient to report signs of allergy

4. Hydralazine

Date: 1/1/09

Classifications: Anti-Hypertensive

Mechanisms of action: Direct acting arteriolar vasoconstrictor

Specific Indication: Moderate to severe hypertension

Contraindications: Hypersensitivity reaction

Side Effects: Dizziness fatigue and headache

Nursing Implications: Monitor BP, give drug 1 hour after meals

5. Cefuroxime

Date: 1/2/09
 Classifications: Anti-bacterial

Mechanisms of action: Binds to bacterial cell wall causing cell death

Specific Indication: Prevention of UTI

Contraindications: History of hypersensitivity to cephlosphorins

Side Effects: Seizures. Diarrhea, Nausea and vomiting urticaria and rashes.

Nursing Implications: May be taken with food.

6. Ferrous Sulfate

Date: 1/2/09

Classifications: Anti-anemia

Mechanisms of action: An essential mineral found in hemoglobin. Support in

the production of iron.

Specific Indication: treatment for anemia

Contraindications: patients recurring BT.

Side Effects: Diarrhea, Nausea and vomiting, GI irritation.

Nursing Implications: May be taken with meals to reduce GI dicompfort.

7. Mefenamic acid

Date: 1/2/09

Classifications: Analgesics

Mechanisms of action: Inhibits prostaglandin synthesis which helps relieve

pain

Specific Indication: relief of mild to moderate pain

Contraindications: GI ulcerations and inflammation

Side Effects: GI disturbance and head aches

 Nursing Implications: Should be taken with food

WBC 33.4 5.0-10.0L Normal

HGB 7.6 11.7-14.5 g/dl Anemia
HCT 22.8 34.-44.3 vol Normal
Platelet Adequate
Segmenters 87 43.4-76.2% Normal
Lymphocytes 13 17.4-46.2%

Color Light yellow Clear-yellow Normal

Transparency Clear Clear Normal
Sugar Negative Negative Normal
Albumin Negative Negative Normal
Sp. Grav 1.010 1.010-1.025 Normal
Pus cells 5.7 0-1 Possible UTI
RBC 5—9 0-1 Possible UTI
Epithelium few

WBC 19.7 5.0-10.0L Normal

HGB 10.9 11.7-14.5 g/dl Anemia
HCT 32.0 34.-44.3 vol Anemia
Platelet adequate Normal
Segmenters 84 43.4-76.2% Normal
Lymphocytes 16 17.4-46.2% Normal

c. Diagnostic Tests
CBC-1/5/09

Urine analysis-1/1/09

Creatinine 0.5 0.5-0.9 mg/dl Normal

CBC-1/11/09
 HBSAg Non-reactive Non-reactive Normal

Blood type “B”

1/8/09
HGB 7.3 11.7-14.5 g/dl Anemia
HCT 22.0 34.-44.3 vol anemia

Ultrasound

Impression:
-Pregnancy uterine 31 wks 1 day by fetal biometry cephalic presentation,
low singleton fetus

-Estimated fetal wt. 4 Lbs

-Good cardiac activity (FHB 129 Bpm)
-Active fetal movement

Creatinine 0.7 0.5-0.9 mg/dl Normal

V. PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

a. Anatomy and Physiology

Many women do not know the signs of labor and do not understand the
labor and delivery process. It can be a very emotional and frightening
experience unless you are prepared for it. The best thing to do is to talk to your
health care provider and educate yourself in other ways.

It is important to know the signs of labor and learn about the different
options available for giving birth so you feel confident and comfortable with your
experience. Signs of true labor can include contractions at regular and
increasingly shorter intervals that also become stronger in intensity, lower back
pain that does not go away, your water (amniotic sac) breaks, you experience a
bloody, brownish or blood-tinged mucous discharge, and your cervix begins
dilating (opening up) and becoming thinner and softer.
 It is important to know that you have several options available such as
where you will have your baby (home birth, birthing center or hospital), who will
assist in the delivery (midwife, doctor, doula, significant other), what kind of
delivery you have (vaginal, C-section, episiotomy, water birth), what kind of pain
management (drugs, hypnosis, natural) and even post delivery options.

Before you reach the last few weeks of pregnancy, it is a good idea to
review your birth plan and pain relief issues with your doctor or midwife and visit
the hospital you have selected or the birthing center where you plan to deliver.
Don't get short on time and remember that your due date is only an estimate of
the date of delivery and that most women do not deliver on the estimated due
date.
Pre-eclampsia

Preeclampsia is a disorder of widespread vascular endothelial malfunction

and vasospasm that occurs after 20 weeks' gestation. It is clinically defined
by hypertension and proteinuria.

Preeclampsia is part of a spectrum of disorders that includes gestational

hypertension, severe preeclampsia, and eclampsia. Although each of these
disorders can appear in isolation, they are thought of as progressive
manifestations of a single process and are believed to share a common etiology.

The diagnostic criteria for preeclampsia focus on measurement of elevated blood

pressure and proteinuria that develop after 20 weeks' gestation. Consensus is
lacking among the various national and international organizations about the
values that define the disorder, but a reasonable limit in a woman who
was normotensive prior to 20 weeks' gestation is a systolic blood pressure (BP)
greater than 140 mm Hg and a diastolic BP greater than 90 mm Hg on 2
successive measurements 4-6 hours apart. Preeclampsia in a patient with
preexisting essential hypertension is diagnosed if systolic BP has increased by
30 mm Hg or if diastolic BP has increased by 15 mm Hg.

Anemia during pregnancy

Anemia affects 20% of all females of childbearing age in the United States.
Because of the subtlety of the symptoms, women are often unaware that they
have this disorder, as they attribute the symptoms to the stresses of their daily
lives. Possible problems for the fetus include increased risk of growth retardation,
prematurity, intrauterine death, rupture of the amnion and infection.

During pregnancy, women should be especially aware of the symptoms of

anemia, as an adult female loses an average of two milligrams of iron daily.
Therefore, she must intake a similar quantity of iron in order to make up for this
loss. Additionally, a woman loses approximately 500 milligrams of iron with each
pregnancy, compared to a loss of 4-100 milligrams of iron with each period.
Possible consequences for the mother include cardiovascular symptoms,
reduced physical and mental performance, reduced immune function, fatigue,
reduced peripartal blood reserves and increased need for blood transfusion in
the postpartum period.

Pre-eclampsia Pathophysiology

Placental Hypoperfusion

Unclear Pathway of blood vessel Abnormal Formation of spiral

arterioles
Release Systemic vasoactive
Compound Leads to Vasoconstriction

Hypertension
 NURSING SYSTEM REVIEW CHART
Name: Datuin, Rio A. a
Vital Signs:
Pulse: 84 bpm ; RR: 23 cpm ; BP: 180/120 mmhg ; Temp: 36.6 C ; Height: 5’1 ; Weight: 56 kg
EENT:
[ ] impaired vision [ ] blind
[ ] pain redden [ ] drainage Sleep deprvation
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth Pale orbital area
Assess eyes ears nose throat for abnormality Frequent yawning
[x] no problem

RESP:
[ ] asymmetric [ ] tachypnea [ ] barrel chest Linea nigra: straea
[ ] apnea [ ] rales [ ] cough
[ ] bradypnea [ ] shallow [ ] rhonchi gravidarum
[ ] sputum [ ] diminished [ ] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [ ] cyanotic Acute pain on
Assess resp. rate, rhythm, depth, pattern, breath sounds, episiotomy site
comfort
[X] no problem
Minimal vaginal
CARDIOVASCULAR:
[ ] arrhythmia [ ] tachycardia [ ]numbness discharge
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain

Assess heart sounds, rate rhythm, pulse, blood

Pressure, circ., fluid retention, comfort
[x] no problem

GASTROINTESTINAL TRACT:
[ ] obese [ ] distention [ ] mass
[ ] dyspagea [ ] rigidity [ ] pain Fatigue: Pallor and weak
Assess abdomen, bowel habits, swallowing, bowel in appearance
sounds, comfort
[x] no problem
BT of FWB type B
GENITO – URINARY AND GYNE
[ ] pain [ ] urine color [ ] vaginal bleeding regulated at 15gtts/min
[ ] hematuria [X] discharge [ ] nocturia

Assess urine frequency, control, color, odor, comfort, PNSS 1liter at KVO
gyne bleeding, discharge
[x] no problem

NEURO:
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethargic [ ] comatose [ ] vertigo [ ] treamors
[ ] confused [ ] vision [ ] grip
Diaphoritic
Assess motor function, sensation, LOC, strength,
grip, gait, coordination, orientation, speech Warm Skin
[x] no problem
moist
MUSCULOSKELETAL and SKIN:
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae
[ ] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [ ] cool [ ] deformity
[ ] wound [ ] rash [ ] skin color [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis
[X] diaphoretic [X]moist

Assess mobility, motion, gait, alignment, joint function

skin color, texture, turgor, integrity
NURSING ASSESSMENT 1
[ X] no problem
SUBJECTIVE OBJECTIVE
COMMUNICATION:
[ ] hearing loss Comments: “wala [ ] glasses [ ] languages
man koy problema sa
[ ] visual changes
akong mata og [ ] contact lenses [ ] hearing aide
[X ] denied dalungan” as
verbalized by the
patient.
Pupil size: 3-3mm [ ] speech

difficulties

Reaction:Pupils Equally Round, Reactive

to Light and Accommodation

OXYGENATION: Resp. [X] regular [ ] irregular

[ ] dyspnea Comments: “wala Describe: Regular respiratory pattern rr:23

[ ] smoking history man koy ubo, unya dili

pud ko gapanigarilyo” R: Symmetric lung expansion to left

[ ] cough
as verbalzed by the L: Symmetric lung expansion to right
[ ] sputum
patient
[X] denied
CIRCULATION:

[ ] chest pain Comments: “wala Heart Rhythm [x] regular [ ] irregular

[ ] leg pain
man nag sakit akong Ankle Edema
[ ] numbness of
dughan” as verbalized Pulse Car Rad. DP Fem*
extremities
[x ] denied by the patient. R + 84 + _____ -

L + + + +

NUTRITION:

Diet: breastfed and Comments: “wala [ ]dentures [x]none

semi solid foods man koy problema sa

[]N[]V akong gana sa pag Full Partial with

Character kaon” as verbalzed by patient

[ ] recent change in he patient.

weight appetite Upper [] [] []

[ ] swallowing

Difficulty Lower [] [] []

[X] denied
ELIMINATION: Comments: Bowel sound is

Usual bowel pattern [ ] urinary frequency Hyper active bowel audible

once a day 5 times a day sounds

[ ] constipation [ ] urgency Abdominal

Remedy [ ] dysuria Urine is yellow in Distention

NONE [ ] hematuria color concentrated Present [ ] yes [x] no

[ ] incontinence and has an Urine* (color,

Date of last BM [ ] polyuria unpleasant odor consistency, odor)

Jan. 7, 1009 [ ] foley in place The client’s urine is

[x ] denied yellowish in color

[ ] diarrhea and in moderate

character amount

MGT. OF HEALTH & ILLNESS: Briefly describe the patient’s ability to

[] alcohol [ ] denied follow treatments (diet, meds, etc.) for

(amount & frequency) chronic health problems (if present).

N/A

[ ] SBE Last Pap Smear: N/A The patient is strictly following and took
LMP: march 2008
 the prescribed medications.

NURSING ASSESSMENT 2

SUBJECTIVE OBJECTIVE
SKIN INTEGRITY:
[ ] dry
Comments: [ ] dry [ ] cold [ ] pale
[ ] other “Dili man ga
katol akong [ ] flushed [X] warm
[x ] denied panit” as
verbalized by [X] moist [ ] cyanotic
he patient
*rashes, ulcers, decubitus (describe size,

location, drainage): No ulcers or rashes

observed
ACTIVITY/ SAFETY:

[ ] convulsion Comments: [ ] LOC and orientation the patient is

[ ] dizziness “maka lihok conscious, coherent, cooperative as to

[ ] limited motion of man ko og the place, person and time.

Joints tarong” as Gait: [ ] walker [ ] cane [ ] other

verbalized by

Limitation in the patient. [ ] steady [ ] unsteady

Ability to [ ] sensory and motor losses in face or

[ ] ambulate extremities

[ ] bathe self no sensory and motor losses in face or

[ ] other extremities

[X] denied [ ] ROM limitations: none

COMFORT/SLEEP/AWAKE:

[X] pain “medyo nay [X] facial grimaces

Comments:
sakit sa akong [X] guarding
(location)
tinahian og ga [ ] other signs of
Frequency
mata-mata ko [ ] side rail release form signed (60 +
Remedies
karon tungod years)
[ ] nocturia
kai nay bata.” N/A
[ ] sleep difficulties
As verbalized
[ ] denied
by the patient

COPING: Observed non-verbal behavior: The

Occupation: Government employee patient cooperates with the interview and

Members of household: 3 elaborates the subject when answering.

Most supportive person: Mr. Jonathan

Datuin( Husband) The person and her phone number that

can be reached anytime: none

VII. NURSING MANAGEMENT
a. Actual Nursing Management (SOAPIE)
SOAPIE 1
S “Medyo naay sakit aking tinahian” as verbalized by the patient.
O Subjective cues: verbalization of pain
Pointing to painful area
Objective cues: Facial grimace
Guarding
A Acute pain related to perineal sutures secondary to episiotomy repair.
P Short term goal: at the end of 15 mins, the patient will be able to learn
relaxation technique relieve of pain.
Long term goal: At the end of the entire shift, the patient will be able to
report of a relief in pain.
I Independent interventions:
1. Instructed patient to turn to sides every two hour
-To avoid prolong sitting
 2. Encouraged the patient diversional actvities like talking to her
watchers and play simple puzzle games
-To divert patients attention from pain
3. Encourage relaxation technique such as deep breathing exercise.
-To reduce pain
4. Instructed the patient to limit physical activity.
-To reduce the risk of occurance of pain or avoid the increase
pain intensity.
Dependent interventions:
5. Administer Pain reliever as prescibed by the physician such as
Mefenamic acid.
- To relieve of pain
E At the end of the shift the patient were able to verbalized a relief of pain.
 Soapie 2
S “akong nahibalan, pagka admit nako nag taas jud akong BP” as
verbalized by the patient.
O Objective cue: Elevated BP=150/100
A Risk for decreased cardiac output related to hypertension as evidenced
by elevated BP readings.
P Short term: At the of 1 hour, the patient will have a decrease in BP.
Long term goal: At the end of the shift, the patient will be able to learn
what are the appropriate measures in controlling BP.
I Independent:
1. Monitored BP every hour.
- To determine BP elevation
2. assisted client in performing physical activity.
-To reduce stress which can stimulate the increase of BP
3. Provided adequate bed rest.
- To gain energy and relieve from stressful stimuli
4. Encouraged the patient to limit intake of food high in fat,sugar
and salt.
- To reduce the risk of increasing the BP
5. Encouraged the patient to avoid strenuous activities.
-To reduce the risk of further increasing the BP.
6. Encouraged the patient about relaxation techniques such as
deep breathing exercise.
-To reduce anxiety.
Dependent:
7. Administer Anti-hypertensive drugs prescribed by the physician
such as Methyldopa and captopril.

E At the end of the shift, the patient was be able to learn what are the
appropriate measures in controlling BP.
 SOAPIE 3

S “Luya gihapon ko karon gikan sa akong pag panganak” as verbalized by

the patient.
O Subjective Cues: Verbalized of body weakness
Patient claimed of sleep deprivation
Objective cues: Presence of eye bags
Pallor at orbital area
Appeared weak
Frequent yawning/ drowsy
A 1. Fatigue related to anemia secondary to excessive blood loss from
labor and delivery.
2. Fatigue related to sleep deprivation
P Short term goal: At the end of 8 hours, the patient will be able to gain
energy and verbalized of reduced fatigue
Long term goal: At the end of 24 hours, The patient will be able to
perform daily activities and show signs of absence of fatigue.
I Independent intervention:
1. Provided adequate bed rest
-To restore and gain energy
2. Limit physical and strenuous activities
-To conserve energy
3. Encouraged the patient to consume a nutritious diet such as
eating fruits and vegetables
- To provide adequate nutrition.

E At the end of 8 hours, the patient was will be able to sleep and gain
energy and verbalized of reduced fatigue

VIII. REFERRALS AND FOLLOW-UP

 • Explain to patient the importance of compliance of medication
such as Cefuroxime,Ferrous sulfate, metyledopa, captopril and
MEDICATION mefenamic acid.

• Encourage patient to take medication properly and in timely

manner.
• Encourage patient to ambulate (slowly)
• Teach and encourage patient the effective breathing and
EXERCISE coughing
• Teach patient the relaxation techniques
• Position patient in Semi or Fowler position
• Thought the patient about the importance of breast feeding
TREATMENT

• Encourage patient to visit physician at least one’s a week or

visit the near health center in their community for follow-up
check-up.
• Encourage patient to continue and comply medication given
OUTPATIENT and prescribed by the physician.
• Teach and encourage patient to eat foods high in vitamin C
and minerals such as fruits (eg: oranges) and green leafy
DIET vegetables.
• Encourage patient to eat a diet rich in calcium and vitamin D.

IX. EVALUATION
 Generally the prognosis of our client was Poor; the intervention that was
implemented to our patient had made less improvement to the condition of my
patient.
As a student nurse during our clinical exposure with this patient, the
knowledge that we had gained during the 24 hours (2 days clinical exposure and
1 assessment day) in assessing and caring for the patient had enhanced our
understanding about Elective health nursing, not only that we had implemented
interventions but the feeling of fulfillment by being accepted as a health care
provider and touch others’ lives in our own little ways somehow made a
difference.
The concept of Team nursing is not all about fulfilling thee requirements to
pass the subject, or just intervening the problems identified as required. But it is a
random act of kindness without expecting something in return, it is more of
touching other people’s lives, where there is compassion determination and
motivation towards oneself and the patient’s significant others to act upon the
task to promote health and prevent disease.
This exposure had already helped improved our well-studied skills in the
clinical area. It has also enabled us to develop interpersonal relation with people
whom we worked with. Team building and organizing is a good quality of a nurse
that should be develops to have a good flow of activity during duty hours.
Through this we were able to understand deeply the essence of nursing.

X. BIBLIOGRAPHY
Black, Joyce M. 1993. Medical-Surgical Nursing- A Psychologic Approach. 4th ed.
W.B Saunders Company: Philadelphia, Pennsylvania,USA.

Smeltzer, Suzanne C.et al.2004. Medical Surgical Nursing. - 11th ed.Lippincott

Williams and Wilkins: Philadelphia

Doenges, Marilynn E.2006. Nurse’s Pocket Guide. F.ADavis Company:

Philadelphia.

Davis, F.A. Taber’s Cyclopedic Medical Dictionary. 19th ed. F.A. Davis Company:
Philadelphia.

www.wikipedia.com