CASE PRESENTATION

Presented by:
BSN 141 / Group 161 - A
 I. BIOGRAPHIC DATA
 Name: Ms. MNI
 Address: 126 Carnation A Premium Ext. Project 8, Quezon
City
 Age: 20
 Gender: Female
 Religion: Roman Catholic
 Marital Status: Single
 Occupation: Waitress
 Chief Complaint: Labor Pains
 Diagnosis: G1 P0 Pregnancy Uterine Full Term, 38 weeks
AOG, Cephalic in Labor
 II. NURSING HISTORY
 
 Obstetrical History
 Ms. MNI’s had her first prenatal check-up when she was 4 months pregnant; she
had her monthly check-up since then.
 According to the patient, she had 2 tetanus toxoid shots, 1 on July and the other
one was on August 2010.  
 The patient admitted that when she was pregnant she craved for fruits and meat
especially chicken and that she didn’t eat vegetables that much. She said that she
was a light eater. She also said that she drank 1 glass of milk and 8 glasses of water
a day. According to her she took ascorbic acid, ferrous sulfate, calcium vitamins.
 Ms. MNI admitted that up until the sixth month of her pregnancy, she often lacked
sleep due to her shift at work as a waitress which is 5pm – 3 am. She also admitted
that her only exercise when she was pregnant was walk.
 The patient last menstrual period was on March 5, 2010. Her expected date of
confinement is December 12, 2010. Her AOG is 38 weeks.
 Past Health History 
Five months prior to her pregnancy, the patient
claimed that she fell off the stairs. She was brought to
a nearby hospital. She was hurt but according to her,
the accident didn’t do anything to her pregnancy. 
 History of Present illness
On November 27, at 7:00 am she started having labor
pains. His husband decided to take her to CSV lying-in
clinic. They were admitted at 11:35 am.
 Family History
According to the patient, she doesn’t know any
hereditary diseases present in her family. 
 III. PATTERNS OF FUNCTIONING
 A. Psychological Health 
 Coping Pattern
  According to the client, stress is normal to be felt and he feels stress in association with his
work as a waitress. She told us that whenever she would feel stress, she takes naps and
listens to music that somehow relieves her stress. She does not smoke and doesn’t drink
alcohol because she knows that it’s bad for her pregnancy.
 
 Analysis:
Coping mechanisms are behaviours used to decrease stress and anxiety. Many coping
behaviours are learned based on one’s family, past experiences, and socio-cultural influences
and expectations. Typical behaviours include crying, laughing, sleeping, cursing, physical
activity, exercise, smoking, drinking, lack of eye contact, withdrawal, and limiting relationships
to those with similar values and interests. (Fundamentals of Nursing: The Art and Science of
Nursing Care/Carol Taylor, Carol Lillis, Priscilla LeMone—5 th ed. page 855).
 
 Interpretation:
Ms. MNI is able to cope to stress in a good way. She doesn’t involve herself into vices that may
do damage to pregnancy.
 Cognitive Perceptual Pattern
The client has clear vision and doesn’t have any problem in hearing or in taste.
Also Ms. NMI doesn’t have difficulty in learning or understanding.
 
 Analysis:
Cognitive development refers to the manner in which people learn to think,
reason, and use language. It involves a person’s intelligence, perceptual ability
to process information. Cognitive development represents a progression of
mental abilities from illogical to logical thinking, from simple to complex
problem solving and from understanding concrete ideas to understanding
abstract concept. (Fundamentals of Nursing by Kozier, et al..page 359).
Cognitive-Perceptual: No sensory deficits, pupil 3 mm, equal, brisk reaction,
must be oriented to time, place, and person, responsive, responds
appropriately to verbal and physical stimuli, and recent and remote memory
intact. (Fundamentals of Nursing by Kozier, et al..page 273)
 
 Interpretation:
The client doesn’t have any problems with his cognition and perception.
 Self-Concept
The patient has positive outlook in life. Other than the financial
instabilities, she is happy and contended especially now that she has
her baby

 Analysis:
Self concept is developed through a very complex process that
involves many variables. The four components of self-concept
frequently considered by nurses are identify, body image, self esteem
and role performance. Self concept is a Psychic representation of an
individual, the central core of “I” around which all perceptions and
experiences are organized. (Fundamentals of Nursing, 5th Edition by:
Patricia A. Potter & Anne Griffin Perry, page 541)
 
 Interpretation:
The client does have a positive outlook in life even though they are
not financially stable.
 Emotional Patterns
The client is happy with his life together with her boyfriend and family,
especially now that there’s an additional member of their family. Ms. MNI
said that he is not experiencing any conflict with his family and the people
around her. She said that her boyfriend’s family is very supportive to her.
 
 Analysis:
Individuals and groups, though interpersonal relationships can provide
comfort and assistance, encouragement and information. Social support
fosters successful coping and promotes satisfying and effective living.
(Pender, 2002)
Social support systems contribute to health by creating an environment
that encourages healthy behaviors, promotes self-esteem and wellness
and provides feedback that person’s actions will lead to desirable
outcomes. (Fundamentals of Nursing by Kozier et. al.)
 Interpretation:
The support that she is receiving contributes to her positive outlook in life.
 Sexuality
When the client was asked if she was contented and happy about being a woman, she
answered “yes”. She is also happy having a partner. Due to her pregnancy, she
admitted she admitted that she became less active in sex.
 
 Analysis:
As a person grows and develops, so does his or her sexuality. Each stage of
development brings changes in sexual functioning and the role of sexuality in
relationships. (Fundamentals of Nursing by Potter and Perry pg. 567)
  Sexuality is the degree to which a person exhibits and experiences maleness or
femaleness physically, emotionally and mentally. Sexuality is a learned behaviour in
how one behaves in relationships with others. Because our sexuality is so basic to our
sense of self, nurses need to value sexuality as a critical element of health and well-
being in general and must be skilled in identifying and meeting problems related to
several self-concept, body image, and sexual identity. Sexual identity encompasses a
person's self-identity, biologic sex, gender identity, gender role behaviour or
orientation, and sexual orientation or preference.(Fundamentals of Nursing by Kozier)
 
 Interpretation:
The client was happy being a woman, because she has partner in life.
 B. Socio-Cultural Patterns
Cultural Patterns
Ms. MNI said that she follows many Filipino values such as giving respect
to elders. Every year, they are having family gatherings and reunions, she
said that they do not forget to participate and attend on it. Her family also
celebrates birthdays, Christmas, New Year, etc.
Analysis
Culture may be defined as a shared system of beliefs, values, and
behavioral expectations that provides social structure for daily living.
Culture defines roles and interactions with others as well as with families
and communities. And is a parent in the attitudes and institutions unique
to particular group. Culture includes the beliefs, habits, likes and dislikes
and customs and rituals learned from ones family. (Fundamentals of
Nursing by Taylor pg. 40)
 Interpretation
Normal. The client is valuing some cultural practices.
 Significant Relationships
 Ms. MNI considers his baby, partner, relatives, and friends as
the significant people in her life. Their family didn’t have any
major conflict. She said that his partner is his companion
especially in hard times.
 Analysis
 According to Maslow’s Hierarchy of needs, Love and
belongingness is the third level of needs which includes
giving and receiving affection, attaining a place in a group
and maintaining the feeling of belongingness (Fundamentals
of Nursing by Kozier pg.197)
 Interpretation
 The client gives importance to the significant people in
her life and doesn’t have any conflict with her family.
Whenever she needs help, she is consults it to her family.
 Recreation Patterns
 The client likes listening to music. She said that they
find time to relax like watching movies or strolling in mall.
 Analysis
 The individual needs both self-esteem and esteem
from others. When the need for self-esteem is satisfied,
the individual strives for self-actualization, the innate
need to develop one’s maximum potential and realize
one’s abilities and qualities. (Fundamentals of Nursing by
Kozier pg.197)
 Interpretation
 Recreational activities are important in enhancing
person’s self esteem and self actualization. In the case of
the client, its music.
 Environment
 The client said that they are residing in an
apartment in Quezon City. It belongs to his boyfriends
family. He said that the house is fully ventilated,
comfortable and organized. The house is enough for
the family. It is free of vectors or any rodents.
 Analysis: The environment affects health and the level
of wellness. (Fundamentals of nursing by Kozier pg.177)
 Interpretation
 The client’s environment is a comfortable place for
her.
 Economic
 According to the client, there is an adequate income
for them. Her sister-in-law provides for their needs since
both she and her partner don’t have jobs at the time.
 Analysis
 According to Maslow’s Heirarchy of needs,
Physiologic needs is ranked as the most essential for
survival. This includes water, shelter, rest, sleep, activity,
and temperature maintenance. (Fundamentals of Nursing
by Kozierpg. 197)
  
 Interpretation
 The client and her family have an adequate income
that is somehow enough to support their needs.
 C. SPIRITUAL PATTERNS
 Religious Beliefs and Practices
 The client is Roman Catholic. She goes to mass twice a
month. She said she has strong faith in the power of God.
 Analysis
 Spirituality is a concept that is unique to each individual.
Individual’s definitions of their own spirituality or influenced
by their culture development, life experiences, beliefs, and
ideas about life. (Fundamentals of Nursing, 5th Edition by:
Patricia A. Potter & Anne Griffin Perry, page 591)
 Interpretation
 The client has strong faith in God.
  
 ACTIVITIES BEFORE DURING ANALYSIS AND
OF DAILY HOSPITALIZATION HOSPITALIZATION INTERPRETATION
LIVING

Nutrition Mrs. MNI preferred eating Mrs. MNI eats the Interpretation: The client lacks
meat and fruits when she food that was served nutritional intake needed to
was still pregnant. She is in CVS. Her meal nourish her child.
not fond of eating was rice and corned Analysis: During pregnancy,
vegetables. She beef and vegetables. women must eat adequately to
verbalized “Hindi ko alam supply enough nutrients to the
kung saan ko siya fetus so the fetus can grow. In
pinaglihi siguro sa manok addition, adequate protein
kasi mahilig ako sa intake may help prevent
chicken noon. Tsaka complications of pregnancy
ayoko ng gulay nung such as pregnancy-induced
buntis pa ako. Puro karne hypertension or preterm labor.
lang kinakain ko.” Deficiencies or overuse of
vitamins may contribute to
birth defects.
-Maternal & Child Health
Nursing 3rd Ed. pp. 277
ACTIVITIES BEFORE DURING ANALYSIS AND
OF DAILY HOSPITALIZATION HOSPITALIZATION INTERPRETATION
LIVING

Mrs. MNI said that she She has just urinated Interpretation: The client has
has normal urination and once after giving difficulty urinating and
Elimination bowel movement. She birth. She doesn’t feel defecating because of her
urinated atleast 4x a day any urge to urinate ephiseoraphy.
ang defecates without any and just urinated in Analysis: During a vaginal
difficulty everyday. compliance with the birth, the fetal head exerts a
nurses’ advice. She great deal of pressure on the
hasn’t defecated yet. bladder and the urethra as it
passes on the bladder’s
underside. The pressure may
leave the bladder with a
transient loss of tone, and
edema surrounding the urethra
makes voiding difficult.
Although a bladder fills rapidly
and becomes distended, the
woman may have no
sensationof having to void.
- Maternal & Child Health
Nursing pp. 216
 ACTIVITIES BEFORE DURING ANALYSIS AND
OF DAILY HOSPITALIZATION HOSPITALIZATION INTERPRETATION
LIVING

Exercise Mrs. MNI said that she She just gave birth of Interpretation: The client was able
considers her work as her her baby and since her to manage exercising by walking
major exercise. She works at ephiseoraphy is painful, everyday even though she is
night in a restaurant bar and she just prefers lying in working.
goes home by 3am. She took bed while nourishing her Analysis: The woman should limit
advantage of having at least a baby. strenuous activities for the first
30 min walk by then. week at home. Beginning the
second week, if her lochial
discharge is normal, she may start
to increase her activity. She should
have muscle strengthening
exercises. Some women find that
carrying out perineal exercises
three or four times a day greatly
relieves episiotomy discomfort. The
exercise consists of contracting
and relaxing the muscles of the
perineum five to ten times in
succession as if trying to stop
voiding(Kegel’s exercises). This
improves circulation to the area
and so helps decrease edema.
Kegel’s exercises, when repeated
in greater numbers, help the
woman regain her prepregnant
muscle tone and form.
- Maternal & Child Health Nursing
pp. 594
ACTIVITIES BEFORE DURING ANALYSIS AND
OF DAILY HOSPITALIZATION HOSPITALIZATION INTERPRETATION
LIVING

She takes a bath twice She hasn’t taken Interpretation: The client
Hygiene a day. She said she is her bath since she has a poor hygiene.
uncomfortable if she gave birth. She has Analysis: The woman may
can’t take a bath that not changed her take either tub baths or
often. She changes clothing either. showers. She should
clothes twice. She Because of no urge continue to apply any
brushes her teeth 3x a to urinate, she cream or ointment as
day and. forgot to change ordered for the perineal
her pad too. As areaand cleanse her
verbalized “Hindi perineum from front to
pa din naman puno back. Any perineal stitches
yung pad kaya ok will be absorbed within 10
lang.” days. She should not use
vaginal douches until she
returns for her post partal
check up.
- Maternal & Child Health
Nursing pp. 604
ACTIVITIES BEFORE DURING ANALYSIS AND
OF DAILY HOSPITALIZATION HOSPITALIZATION INTERPRETATION
LIVING

Mrs. MNI said that she Mrs. MNI is having Interpretation: The client is
Sleep and is very unsatisfied with a hard time falling unable to have enough rest
Rest her sleeping pattern. asleep in CVS and sleep due to
Because of her nature since there are a unfavorable environment
of work, she is having a lot of patients in the and the pain she is
difficulty getting a long ward. She experiencing on her
sleep. She works at verbalized “Paputol ephiseoraphy.
6pm and goes home by putol din ang tulog Analysis: Rest and Sleep
3am. She usually ko dahil kay baby”. are essential for health.
sleeps at 6am and Puyat na puyat
People who are ill
wakes up in the talaga ako simula
afternoon. She is easily kagabi.” frequently require more rest
awakened by disturbing and sleep than usual same
noises in the with those pregnant women
environment. That’s who needs more rest
why she always ends
up very sleepy at work. - Fundamentals of Nursing
by Taylor pp. 1106
GENERIC/T DOSAGE/FREQ CLASSIFICATION INDICATION CONTRAINDICATION SIDE NURSING
RADE UENCY EFFECTS RESPONSIBILITIES
NAME
Generic Local Anesthetic rapid acting local Contraindicated in Adverse -assess patient’s
Name: anesthetic for patients Effects: condition
Lidocane procedures hypersensitive to amide- CNS: before starting
Brand ranging from type Confusion, therapy and
Name: infiltration to local anesthetics and in tremor, regularly
Xylocaine regional nerve those lethargy, thereafter to
Xylocard block with Adams –Stoke somnolence, monitor the
Dilocaine syndrome. stupor, drug’s
Wolff-Parkinsons-White restlessness effectiveness
Syndrome, or severe anxiety, -monitor
degrees hallucinations, patient’s
of SA, AV, or nervousness, response, esp.
intraventricular seizure. ECG, blood
block in the absence of CV: pressure and
pacemaker. hypotension, electrolytes
bradychardia, -check for
new or therapeutic
worsened level
arrhythmias -be alert for
EENT: adverse effect
tinnitus, blurred reactions and
or double drug interaction
vision. -assess patient’s
Respiratory: family about
Respiratory the drug
depression and therapy
arrest -Teach client to report
difficulty speaking, thick
Skin: soreness tongue, numbness,
at injection site tingling,
Other: difficulty breathing, pain
anaphylaxis, or numbness at site,
Side Effects: swelling or pain at site
sensation of
cold, vomiting
GENERI DOSAGE/ CLASSIFICATI INDICATION CONTRAINDICATI SIDE NURSING
C/TRAD FREQUEN ON ON EFFECTS RESPONSIBILITI
E NAME CY ES
Trade Injection: 0. Oxytocic -Routine -Hypersensitivity to CNS: -Be aware that
name: 2 mg/ml management drug dizziness, drug isn't routinely
methyler Tablets: 0.2 after delivery -Hypertension headache, givenI.V. because
gonovin mg of the -Toxemia hallucination, of risk of severe
e placenta. -Pregnancy (except seizures, CVA hypertension and
maleate -Treatment of during third stage of (withI.V. use) cerebrovascular
Generic postpartum labor) CV: accident (CVA).
name: atony and hypertension, -Monitor blood
Metherg hemorrhage; Use cautiously in: hypotension, pressure and
ine subinvolution -severe hepatic or transient uterine
of the uterus. renal disease, chest pain, contractions
-Uterine vascular disease, palpitations, during
stimulation jaundice, sepsis thrombophlebi administration.
during the -patients in second tis -Know that if used
second stage stage of labor. during third stage
of labor EENT: of labor, drug
following the tinnitus, nasal increases risk of
delivery of congestion hemorrhage and
the anterior infection.
shoulder, GI: nausea, -When givingI.V.,
under strict vomiting, closely monitor
medical diarrhea blood pressure,
supervision. pulse, uterine
GU: hematuria contractions, and
Musculoskelet bleeding.
al: leg cramps -Monitor patient for
adverse effects
Respiratory:
dyspnea
Skin:
diaphoresis,
GENERIC/T DOSAGE/ CLASSIFICATION INDICATION CONTRAINDICATION SIDE NURSING
RADE FREQUENCY EFFECTS RESPONSIBILITIES
NAME
Generic Injection: 10 Posterior pituitary Antepartum: to -Hypersensitivity to drug CNS: seizures, -Continuously monitor
name: units/ml ampule hormone initiate or coma, neonatal contractions, fetal and
oxytocin or vial improve uterine -Cephalopelvic brain damage, maternal heart rate, and
Trade name: Uterine-active contractions to disproportion subarachnoid maternal blood pressure
Pitocin agent achieveearly hemorrhage and ECG. Discontinue
Oxytocic vaginal delivery; -Fetal distress when infusion if uterine
stimulation or delivery is not imminent CV: premature hyperactivity occurs.
reinforcement ventricular - Monitor patient extremely
of labor in -Prolonged use in uterine contractions, closely during first and
selected cases inertia or severe toxemia arrhythmias, second stages of labor
of neonatal because of risk of cervical
uterine inertia; -Hypertonic or hyperactive bradycardia laceration, uterine rupture,
management of uterine pattern and maternal
inevitable or GI: nausea, and fetal death.
incomplete -Unfavorable fetal position vomiting
abortion; 2nd or presentation that's -When giving drug to control
trimester undeliverable without GU: postpartal postpartal bleeding, monitor
abortion conversion hemorrhage; and record vaginal
Postpartum: to -Labor induction or pelvic bleeding.
produce uterine augmentation when hematoma;
contractions vaginal delivery is uterine -Assess fluid intake and
during the third contraindicated (as in hypertonicity, output. Watch for signs and
stage of labor invasive cervical cancer, spasm, or symptoms of water
to active genital herpes, or tetanic intoxication.
control total placenta previa) contraction;
postpartum Use cautiously in: abruptio
bleeding or -previous cervical or placentae;
hemorrhage uterine surgery, history of uterine rupture
Lactation uterine sepsis (with
defieciency -breastfeeding patients. excessive
doses)
Hematologic:
afibrinogenemi
a
Hepatic:
neonatal
jaundice
GENERIC/T DOSAGE/ CLASSIFICATION INDICATION CONTRAINDICATION SIDE NURSING
RADE FREQUENCY EFFECTS RESPONSIBILITIES
NAME
Generic 500mg Antibiotic Used for Hypersensitivity - Nausea C - Antibiotic
Name: Frequency: treating to ampicillin, any - Vomiting H -  Pain as well as
Ampicillin Q6° bacterial component of the - Loss of inflammation and its
Brand name: Route: infection formulation, or appetite signs and symptoms -
Omnipen, IVTT other penicillins - Diarrhea redness, swelling, fever,
Polycillin, - Abdominal and pain are reduced.
Principen pain E  - Every 6 hours
- Rash C -  Instruct client to
- Itching report any adverse
- Headache reaction to the physician
- Confusion or nurse. Tell patient
- Dizziness that Antibiotic
medicines can cause
diarrhea, which may be
a sign of a new
infection.
K -  Do not take the
medication in larger
amounts, or take it for
longer than
recommended
by your doctor.
-Tell patient that
medication may cause
nausea or vomiting
(small, frequent
meals, frequent
mouth care, sucking
lozenges, or chewing
gum may help); or
diarrhea (buttermilk,
boiled milk, or yogurt
may help).
-Instruct client to
maintain adequate
hydration (2-3 L/day
of fluids) unless
instructed to restrict
fluid intake.
 GENERIC/ DOSAGE/ CLASSIFICATIO INDICATIO CONTRAINDICATIO SIDE NURSING
TRADE FREQUEN N N N EFFECTS RESPONSIBILITI
NAME CY ES
Trade name Dosage: Antibiotic -Infections Contraindicated with -Observe 10
: Amoxil 200 mg. due to allergens to rights in
Frequency: susceptible penicillins, giving
Generic TID strains of cephalosphorins or medications.
name: H. other -Culture infected
Amoxicillin influenza, allergens. area
[Link], P. Use cautiously with prior to treatment;
mirabilis, N. renal reculture area if
gonorrhea, disorders, lactation response is not
S. as
pneumonia expected.
& -Give in oral
streptococc preparations
i. only; amoxicillin
- is not
Helicobacte affected by food.
r pylori -Continue therapy
infection in for at
combinatio least 2 days after
n signs
with other of infection have
agents. appeared;
-Post – continuation
exposure for 10 full days is
prophylaxis recommended.
against -Use
Bacillus corticosteroids or
anthracis. anti histamines
-Unlabeled for skin
use: reactions
Chlamydia
GENERIC/ DOSAGE/ CLASSIFICATI INDICATIO CONTRAINDICATI SIDE NURSING
TRADE FREQUENC ON N ON EFFECTS RESPONSIBILITI
NAME Y ES

Generic -To prevent -Contraindicated CNS: -When giving

name: vitamin c in patients with faintness, for urine
Vitamin C deficiency allergy to dizziness. acidification,
(ascorbic in tartrazine or GI: diarrhea, check urine pH
acid) patients sulfites. heartburn, to ensure
Trade with -Contraindicated nausea, efficacy.
name: poor in large doses in vomiting. -Stress proper
Cecon nutritional pregnant women GU: acid nutritional habits
habits or urine to prevent
increased recurrence of
requirement deficiency.
s. -Inform patient
-to acidify that vitamin c is
urine readily absorbed
from citrus fruits,  
tomatoes,
potatoes, and
leafy vegetables.
 GENERIC/ DOSAGE/ CLASSIFICATION INDICATION CONTRAINDICATION SIDE NURSING
TRADE NAME FREQUENCY EFFECTS RESPONSIBILITIES

Generic name: 500 mg PO NSAIDS For mild to Containdicated Headache, -Take with food,
mefenamic every 6 moderate, to patient with nervousness, milk, or antacids
acid hours PRN severe pain hypersensitivity dizziness, -While using
Trade name: associated to NSAIDs itching, rash, this medication,
po- with including aspirin or any fluid retention, do not use
Mefenamic; muscular, component abdominal alcohol,
Nu-Mefenamic; rheumatic, of the cramps, excessive
PMS-Mefenamic traumatic, formulation; heartburn, amounts of
Acid; Ponstan; dental,post- pregnancy (3rd indigestion, vitamin C, or
Ponstel; operative trimester) nausea, salicylate-
Revalan and post- vomiting, containing foods
partum diarrhea, (curry powder,
patient constipation. prunes, raisins,
tea, or licorice),
other
prescription or
OTC medications
containing
aspirin or
salicylate, or
other NSAIDs
without
consulting
prescriber.
-Advise
patient to eat
foods to prevent
GI effects.

-Encourage
patient to report
abnormalities.

-Instruct
patient to
increase fluid
intake.
GENERIC/ DOSAGE/ CLASSIFICATIO INDICATIO CONTRAINDICATIO SIDE NURSING
TRADE FREQUEN N N N EFFECTS RESPONSIBILITI
NAME CY ES
Generic 200 mg PO Multivitamins Megaloblasti Hemosiderosis, Constipatio 1. Instruct patient
name: OD c, hemochromatosis, n, not to take iron
Ferrous macrocytic peptic ulcer, gastricirritati with cheese,
Sulfate and Fe regional enteritis, on,nausea, yogurt, eggs, tea,
Trade deficiency and ulcerative abdominal coffee, and
name: anemia, colitis. Haemolytic cramps, cereals for these
Sorbiter anemia due anemia, anorexia, may interfere
to pyridoxine- diarrhea, with iron
pregnancy responsive anemia, dark- absorption.
or and cirrhosis of the colored 2. Instruct patient
malabsorpti liver. Use in those stools. to swallow it
o with normal iron without chewing.
n syndrome balance. 3. Encourage
anemia of patient not to
nutritional crush the drug.
origin -Encourage
patient to report
for any
abnormalities.
-Advise patient
not to take oral
iron with
antacids or Ca
supplements.
-Tell the patient
that iron turns
stool black
or dark green.
 GENERIC/ DOSAGE/ CLASSIFICATION INDICATION CONTRAINDICATION SIDE NURSING
TRADE FREQUENCY EFFECTS RESPONSIBILITIES
NAME
Generic 1 amp every8 Anti-spasmodic Acute GI, biliary -Myasthenia gravis -Xerostomia Assessment:
Name: hours and -Megacolon -Tachycardia -Monitor intake and
Hyoscine genitourinary -Hypersensitivity -Urinary output ratio;
Trade spasm, -Parenteral: glaucoma retention retention commonly
Names include biliary -hyperthrophy of the -When causes
(Philippines): and renal prostate with urinary administered decreased urinary
Ascopen, colic, retention, mechanical IV: output
Buscopan, dysmenorrhea. stenosis of GIT, visual -Assess for urinary
Buscopan Parenterally tachycardia accommodatio hesitancy,
Plus, also as an aid n retention; palpate
Drugmaker in diagnostic disturbances, bladder if
s Biotech and dizziness, retention occurs
Hyoscine-N- therapeutic agranulocytosi -Assess for
Butylbromid procedures s, constipation
e, e.g. pancytopenia, -Assess mental status
Spasmosan, gastroduodenal and Interventions:
Spastrine, endoscopy, bronchospasm -Administer parenteral
Xspas radiology dose with
patient recumbent to
prevent
postural hypotension
-Administer 3-4x/daily
-Give by directIV after
diluting with
sterile water; give
slowly
Teaching Points:
-Tell patient to avoid
activities
requiring alertness;
dizziness may
occur
-Inform the patient that
the drug
passes into the breast
milk and
decreases milk flow;
 GENERI DOSAGE/ CLASSIFICA INDICATI CONTRAINDIC SIDE NURSING
C/ FREQUENC TION ON ATION EFFECTS RESPONSIBIL
TRADE Y ITIES
NAME
Tetanus Adults and Immunizing -For -NOT indicated NS: slight -Intramuscular
toxoid children age agent booster for primary fever, injections
immu should be
7 injection nization. headache, given with
and older: only -hypersensitivit seizures, great
0.5ml for y to any malaise, care in patients
component of suffering from
(adsorbed) persons the vaccine, encephalopa thrombocytope
I.M. 4 7 including thy. nia
to 8 weeks years of thimerosal, a CV: or other
apart age mercury tachycardia, coagulation
derivative, is disorders
for two or older acontraindica hypotension, -Special care
doses; against tion for flushing. should
then give tetanus. further use of Musculoske be taken to
this vaccine. ensure
third -For the letal: that the
dose 6 to 12 preventio aches, pains. injection
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NURSING PROBLEMS CUES JUSTIFICATION
IDENTIFIED
Acute pain related to OBJECTIVE: The problem is a health deficit since there
incision as manifested is already the presence of muscle pain as
 Tolerated pain
by episiotomy manifested by her episiotomy
 The client is unable to have enough
rest and sleep due to unfavorable It requires attention since according
environment and the pain she is to Maslow’s hierarchy of needs pain
experiencing on her episiotomy avoidance is included in the physiologic
 She just gave birth of her baby and needs level. They are the literal requirements
since her ephiseoraphy is painful, for human survival. If these requirements are
she just prefers lying in bed while not met (with the exception of clothing and
nourishing her baby shelter), the human body simply cannot
 The client has difficulty urinating and continue to function. If pain is present in the
defecating because of her client when coughing there will be alterations
ephiseoraphy. or complications that may arise.

An episiotomy is a surgical incision

into the perineum, the area between the
bottom of the vaginal opening and the anus,
in order to increase the size of the vaginal
opening during childbirth. Episiotomy pain
should subside within two weeks but
discomfort may continue for 3-6 months. The
following remedies can help relieve pain,
promote healing, and prevent episiotomy
problems.

Reference: Fundamentals of Nursing by

Kozier
 Risk for OBJECTIVE: The problem is a health
Imbalance deficit since the client has lost
 lost her appetite
nutrition: less her appetite.
 The client lacks
than body nutritional intake needed It requires immediate
requirements to nourish her child. attention since according to
related to loss of Maslow’s hierarchy of needs
appetite food is included in the
physiologic needs level. They
are the literal requirements for
human survival. If these
requirements are not met (with
the exception of clothing and
shelter), the human body
simply cannot continue to
function.
Reference: Fundamentals of
Nursing by Kozier
 Risk for infection  She hasn’t taken her bath since The problem is a health threat
related to inadequate she gave birth. since despite of her having inadequate
primary defenses as  She has not changed her primary defenses as manifested by her
manifested by clothing either. episiotomy, she still has poor hygiene.
episiotomy  Because of no urge to urinate,
It requires immediate attention
she forgot to change her pad
since according to Maslow’s hierarchy
too.
of needs homeostasis is included in the
 As verbalized “Hindi pa din
physiologic needs level. They are the
naman puno yung pad kaya ok
literal requirements for human survival.
lang.”
If these requirements are not met (with
the exception of clothing and shelter),
the human body simply cannot continue
to function.

If delivery requires an episiotomy,

care must be taken in the days
following delivery to prevent
infection or tearing of the
episiotomy stitches. Proper
hygiene is essential; the site must
be kept as clean as possible.
Reference: Fundamentals of Nursing
by Kozier