ASIA PACIFIC COLLEGE OF ADVANCED

STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan
COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES

INTRODUCTION

Sexual Intercourse without using Contraceptive Presumptive Signs

Caused by many
Maturation of Egg cell pathological
Amenorrhea
states, including
pregnancy
The Egg Cell and Sperm Cell Unite
Due to the effects
Nausea and
of human
Vomiting
Fertilization chorionic

Increase of the
Implantation Urinary hormone
Frequency progesterone and

Pregnancy Pregnancy Symptoms Breast The dazzling

tenderness and hormonal duo of
changes estrogen and
progesterone
Uterine Due to uterine
Enlargement fibroids
Probable Signs
Quickening Fluttery sensation

Find the presence Due to extra fluid

(+) Pregnancy of HCG Weight in the body that
baby’s needed for
It is demonstrated circulation, the
as a softening in Due to hormonal
Hegar’s Sign Skin Changes
the consistency changes and
of the uterus
Due to the Fatigue Increased level of
separation of progesterone and
Abdominal underlying
connective tissue Positive Signs
as the uterus
Fetal heartbeat/Sounds
Diagnostic Procedure
Fetal Movement

CBC Ultrasound

Enlarged and gravid uterus;

Hemoglobin - 13.5 Cephalic presentation;
Hematocrit - 0.41
WBC - 9.6 Good cardiac contraction and active
Segmenters - 0.70 osmotic movements;
Lymphocytes - 0.29 No. of fetuses: 1;
Monocytes - 0.01 Fetal heart rate- 139 beats/minute;
Placenta location: posterior;
Amniotic fluid volume: 4.1cm;
LMP: March 18,2020;
EDD(LMP)- Dec.23,2020; EDD(AUA)-
Dec.24,2020;
Baby boy
 BIOGRAPHIC DATA

PERSONAL DATA
Name: Ms. I
Age: 15 years old
Gender: Female
Birthday: July 01, 2005
Religion: Roman Catholic
Marital Status: Single
Address: Alikabok Bayan Orani, Bataan
Nationality: Filipino
Education Level: Junior High School-Grade 10
Weight: 73 kg
Height: 5’0 ft
OB History: G1P0
(LMP)- March 18, 2020
(EDD)- December 24, 2020
Menarche: 11 years old
Days of menstruation: 7 days
Coitarche: 14 years old

CLINICAL DATA
Chief Complaint: Hip and back pain, edema and uti
Date of admission: At home
Admitting Diagnosis: Pregnancy Uterine 31 wks 5d by fetal biometry
Live singleton in cephalic presentation
Adequate amniotic fluid volume
Attending Physician: Mary Grace H. Del Rosario, MD.FPOGS.FPSUOG.OB-GYNE
SONOLOGIST
Ward: N/A
Final diagnosis: N/A
 NURSING HISTORY
A. History of Pregnancy
Sexual Intercourse without using
contraceptive

Maturation of Egg Cell

The Egg Cell and Sperm Cell unite

Fertilization Absence of Menstruation

Implantation April,2020- Use P.T

(Positive)
Pregnancy
July 16,2020- Check up
and Vaccine (Tetanus LMP-March 18,2020
IMPRESSION Diphtheria) EDD-December
Normal single live uterine 24,2020
July 31,2020-Pelvic
pregnancy with good
Ultrasound
somatic and cardiac activity
in cephalic DIAGNOSIS
presentation approximately October 27,2020- Pregnancy Uterine 31 wks by
19-weeks, 6-days AOG Ultrasound, Second fetal biometry
Adequate amniotic fluid and Third trimester Live singleton in cephalic
No previa presentation
Adequate amniotic fluid
volume

B. Past Health History

Ms. I is a 15 years old woman with the present history of pregnancy. She has a history of childhood
illness like cough and colds, fever, and pneumonia and no known allergies. Ms. I got her BCG vaccine
when she was an infant because of the BCG vaccine scar in her right arm. The patient does not remember
if she has a complete immunization. The client has a history of accidents wherein she slipped at her
school but it is not that bad according to her and a car accident. The client has taken the medicine
Obitron one capsule 2x a day for 30 days, Omegabloc one capsule once a day for 30 days, Duphaston 10
mg one tablet 3x a day for 30 days, Canesten 100 mg vaginal tablet, one tablet vaginally before bedtime
for 6 nights, Ferrous sulfate, she takes 30 mg per day. The client takes cephalexin and calcium carbonate
for her urinary tract infection. She has no history of hospitalization, surgery , foreign and domestic travel.

C. Present Health History

The patient experienced a back pain that aches 5 times a day and located at the back of the hip.
The pain lasted for about 2-3 minutes with the scale of 7 out of 10. Everytime she hunches something,
that’s when pain will occur. Then, rubbing her lower back is her non-pharmacological pain management.

The patient experienced voiding that is more than 10 times a day during her 7 months of
pregnancy. The patient verbalized that when she urinates it feels a burning sensation. She also has a
Urinary Tract Infection for the treatment, she takes Cephalexin as prescribed by the physician.
 PATHOPHYSIOLOGY

Urinalysis Laboratory Test

Color- pale yellow

pH- acidic
Sugar- negative
transparency- hazy
Specific gravity- 1.005
Protein- negative
EPI - many

Urinary Tract Infection

Medical
manageme Nursing management Nursing diagnosis
nt

*assess the presence of pain, frequency, urgency and

hesitancy and changes in urine.
*asses the patient pattern of elimination.
*encourage to eat foods rich in vit. C
*cephalexi Impaired Urinary
*advise to avoid drinking coffee, soft drinks, or tea.
n Elimination
*advice to perform hygienic measures like daily
*canesten
perineal care.
*Administer Cephalexin as prescribed by the
physician.
*Give canesten as prescribed by physician.

Pregnancy

Growing uterus

Sciatica

Back and hip pain

Nursing Management Nursing Diagnosis

*Perform comprehensive assessment of pain. Impaired Physical Mobility r/t hip

Determine via assessment the: pain aeb pregnancy
Onset
Location
Duration
Characteristic
Aggravating factors
Relieving factors
Treatment
 Pregnancy

Increase body fluids

Increase blood flow and

pressure of growing uterus

Uterus getting heavier

Baby grows

Slow blood flow from legs

to feet

Swelling

Nursing Management Edema Nursing Diagnosis

-Established rapport Fluid Volume Excess r/t

-Monitor and record vital signs pregnancy aeb presence of
-Advice patient to elevate feet when sitting down edema in feet and leg
-encourage manual mobility
-encourage to eat a low-salt diet
-monitor fluid intake

PATTERNS OF FUNCTIONING
PSYCHOLOGIC ASSESSMENT INTERPRETATI RELEVANT ANALYSIS
AL HEALTH ON THEORY

Coping Pattern “Wala namang This theory is Theory of Stressors

ganon kalaking related to the Human Caring
changes na client's personal by: Jean Watson
Caring
nangyari sa buhay practice of caring
Relationship
ko, kumbaga ano for a client is able The theory is
lang po pagiging to handle her stress focused on “the
batang ina yun po and difficulties centrality of Trusting herself
yung nagbago, because her partner human caring
pero hindi ko po to was there and that and on the Stress-free
tinuturing na she accepts her caring-to-caring
problema po. situation right now transpersonal
Maayos po kasi and being pregnant relationship and
ang pagsasama is not a problem to its healing
namin ng partner her. Whenever she potential for
ko at nandyan po is stressed out she both the one who
siya kasama ko. solves it by herself is caring and the
Relaxed naman po in a way of crying one who is being
ako kapag alone and she will cared for”
nastrestress be alright after that. (Watson, 1996).
Lumalayo kapag
nagagalit.
Kapag may
problema iiyak na
lang po at
magiging okay na
din po.”
-as verbalized by
the client.

Interaction “Noong una hindi This theory is 21 Nursing mistakes

Pattern tanggap nila mama related to the client Problems
na ako ay nabuntis situation because Theory
break the trust of
dahil na nga po sa she is able to by: Faye Glenn
her family
ako ay bata pa. meet and promote a Abdellah
Pero ngayon good
maayos naman na relationship with According to understanding
ulit kami at her family for her Faye Glenn
tanggap na nila.” - development and Abdellah’s love
as verbalized by will guide her on theory, “Nursing
the client her journey as a is based on an
teen mom. art and science Good
that moulds the relationship with
attitudes, her family
intellectual
competencies,
and technical
skills of the
individual nurse
into the desire
and ability to
help people, sick
or well, cope
with their health
needs.”

Cognitive Pattern “Okay ang This theory is Theory of Ability to

memory at mabilis related to the client Cognitive remember things
makatanda because she is able Development and memorize it
to understand the ( Formal
Walang iniinom na world properly and Operational
Can easily
gamot has a good memory Stage)
understand the
and sensory ability. by: Jean Piaget
words
Madali lang naman
po ako makaintindi The ability to
at wala namang systematically Good sensory
 pong problema sa plan for the
pananaw at future and
Good cognitive
pandinig.” reason about
development
-as verbalized by hypothetical
the client situations are
also critical
abilities that
emerge during
this stage.

Self Concept “Bata na buntis This theory is Adaptation fearful about

at mahilig mag- related to the client Model of giving birth
ayos. At tanggap because she is able Nursing
ko na din naman to adapt and accept by: Sister Calista
she keeps her
na meron na akong her new role Roy
positive emotion
magiging anak. At function. She
may takot din understands that Is a prominent
akong she will be going to nursing theory taking care of
nararamdaman sa be a mother and aiming to her self image
aking pagbubuntis has the explain or define
at kung gaano ka responsibility to the provision of She accepts her
sakit ang fulfill. The level of nursing science. situation.
manganak pero her adaptation is a In her theory,
pilit ko pong challenge for her Sister Callista
pinapatatag yung because of her fear Roy’s model
sarili ko. “ of what it feels to sees the
-as verbalized by give birth. individual as a
the client set of
interrelated
systems who
strives to
maintain a
balance between
various stimuli.

Emotional Pattern “Nagagalit at This theory is 21 Nursing Stressors/

umiiyak kapag ako related to the client Problem Problem
ay na i-stress, iyan because she is able Theory
po yung madalas to identify her by: Faye Glenn
Crying as her
kong unang emotions and Abdellah
coping
emosyon na facilitate her self
mechanism
napapakita. awareness as an According to
individual that Faye Glenn
Mabilis lang po crying for her is her Abdellah’s relieve pain that
akong mainis, coping mechanism theory, “Nursing she feels
mababaw po ang when problems is based on an
stress level ko po arise, because it art and science improve her
at di ko po kayang will boost her that moulds the wellbeing
i kontrol po iyon mood and improve attitudes,
kaya po umiiyak her well-being. intellectual
lang po ako. Para competencies,
sakin po kasi don and technical
po mas gumagaan skills of the
ang loob ko. “ individual nurse
-as verbalized by into the desire
the client and ability to
help people, sick
or well, cope
with their health
needs.

Sexuality “Magkasama na po This theory is Maslow’s Good

kami ng partner related to the client Hierarchy of relationship
ko po ngayon, sa because she is able Needs
isang araw po to satisfy herself by by: Abraham
love with each
isang beses ganon getting her Maslow
other
noong maliit pa po physiological needs
yung tiyan ko pero in being able to Maslow (1943)
 ngayong malaki na develop and grow initially stated satisfy each
po hindi na po as a person. that individuals other needs
namin nagagawa must satisfy
ang ganon dahil lower level
Good sexual life
mahirap na po. deficit needs
(pagtatalik) Pero before
noong mga unang progressing on
tatlong buwan at to meet higher
hanggang ika anim level growth
wala naman pong needs.
hirap kaya
nagagawa po
namin. “
-as verbalized by
the client

Wala po kaming
ginagamit na
contraceptive

Unang
pagbubuntis ko pa
lang po ito.

Kapag niregla po
ako inaabot ng
7days

SOCIO- ASSESSMENT INTERPRETATI RELEVANT ANALYSIS

CULTURAL ON THEORY
PATTERN

Cultural Pattern “Kapag may sakit This theory is Self Care Right choice of
po hindi po ako related to the client Theory medication
uminom ng mga because she is able by: Dorothea
gamot po na hindi to perform Orem
will not harm her
reseta ng doctor. individual self care
baby and her
Hindi naman po to maintain the Dorothea
body
ako nagkasakit health of her baby Orem’s Self-
noong buntis po inside her womb Care Deficit
ako, ubo lang po and to maintain her Theory focuses Maintain health
tapos oregano po health. on each of the baby and
yung iniinom ko “individual’s her health
po.” ability to
-as verbalized by perform self-
the client care, defined as
‘the practice of
activities that
individuals
initiate and
perform on their
own behalf in
maintaining life,
health, and well-
being.'”

Significant pattern “Nagsasama po This theory is Behavioral Caring for each

kami ng partner ko related to the client System Model other
po, maayos naman and her significant (Attachment or
po yung other because they Affiliative
Love
pagsasama namin have a good subsystem)
minsan nagiging relationship towards by: Dorothy
dahilan siya ng each other. Johnson Strong intimate
 stress ko, pero bond
maayos naman Attachment or
yung pakikitungo affiliative
niya sakin at subsystem is the
inaalagaan niya “social inclusion
naman ako.” intimacy and the
-as verbalized by formation and
the client attachment of a
strong social
bond.”

Recreational “Noong unang This theory is Behavioral Walking/ Doing

Pattern tatlong buwan ko related to the client System Model household
po mahilig po ako because she is able (Achievement chores
maglakad inaabot to achieve her Subsystem)
po ng 30 minutes. physical health by by: Dorothy
Reduces the risk
Naglilinis ng walking and doing Johnson
of complications
bahay din po. household chores.
Noong apat Walking reduces the The
hanggang anim na risk of Achievement Achieved
buwan po complications subsystem physical health
naglalakad at during pregnancy provokes
naglilinis pa din po and delivery. behavior that
ako ng bahay, tries to control
yung paglalakad the environment.
ko po nabawasan It attempts to
na ng konti kasi po manipulate the
hinihingal na po environment. Its
ako siguro po mga function is
20 minutes po. control or
Ganon pa naman mastery of an
din po yung aspect of self or
ginagawa ko environment to
ngayon nabawasan some standard
lang po sa of excellence.
paglalakad kasi
nga po hinihingal
na po ako sa laki
po ng tiyan ko,
mga 5- 10 minutes
po ang paglalakad
ko po. “
-as verbalized by
the client

Environmental “Noong tatlong This theory is Health Her partner

Pattern buwan ko po hindi related to the client Promotion understand what
pa po ako nakapag because she is able Model are dangerous
pa check up po sa to promote self care by: Nola Pender for her
doktor. and initiate the
Nakapagpacheck check up for her Health
Initiate self care
up po ako nung baby’s health. Her promotion is
apat na buwan na significant other defined as
po. Dalawang understands that it behavior Environmental
beses po akong is dangerous for her motivated by the wellness
pumunta sa kanya to inhale the smoke desire to
at pagkatapos po of cigarettes. increase well-
non sa Center being and
nalang po ako actualize human
pumupunta. health potential.
It is an approach
Naririgarilyo po to wellness.
ang partner ko at
umiinom pero
alam niya naman
po na bawal ko
pong malanghap
po ang usok na
galing sa sigarilyo.
 -as verbalized by
the client

Economic “Monthly income This theory is Health afford medical

Pattern po namin ay galing related to the client Promotion care
po sa mama ko, because she is able Model
pinapadalhan po to promote her by: Nola Pender
receive better
kami, 25k a month baby’s health and
health
po. Mga gastusin her health and does Health
po sa bahay galing not have any promotion is
po lahat kay problem with their defined as Economic status
mama, yung socioeconomic behavior stability
partner ko po status. She is able to motivated by the
nakapagbigay po provide the care that desire to
sakin ng pampa she and her baby increase well-
ultasound ko po needs to acquire. being and
noon: actualize human
health potential.
Wala naman po It is an approach
kaming problema to wellness
sa pera at
naibibigay naman
po yung mga
kailangan po para
po sa health.

Doctor’s visit,
ultrasound,
medicines ( 6, 000
pesos.)
Newborns clothes:
(950) yan palang
po ang nabibili
ko.” -as verbalized
by the client

SPIRITUAL ASSESSMENT INTERPRETATI RELEVANT ANALYSIS

PATTERN ON THEORY

Religious Belief “Roman Catholic This theory is Nursing Need strong belief to
po ang religion ko, related to the client Theory God
at malaking tulong because she has a
po sa akin ito at strong belief that by:Virginia
ease the problem
naniniwala din po God will help her Henderson
akong maka in any
tutulong po sa akin circumstances in The theory better life
kapag oras po ng her life. focuses on the
problema.” importance of
-as verbalized by increasing the
the client patient’s
independence to
hasten their
progress in the
hospital.
Henderson’s
theory
emphasizes on
the basic human
needs and how
nurses can assist
in meeting those
needs.
Values and valuing “Gusto ko po This theory is Adaptation New role in life
maging healthy and related to the Model of
baby ko at client’s way of Nursing
New
magampanan ko po thinking. She is by: Sister Calista
responsibilities
yung role ko as conscious of her Roy
mama niya po. situation and she
Magiging mabuting views her situation The Adaptation motherhood
nanay po ako at enthusiastically. Model of
aalagaan siya She held herself Nursing is a
ganon po sa paraan accountable to the prominent
po na alam kong view of nursing theory
tama at andyan responsibility aiming to explain
naman din po si which is becoming or define the
mama ko para po a mother. provision of
tulungan kami.” nursing science.
-as verbalized by In her theory,
the client. .Sister Callista
Roy’s model sees
the individual as
a set of
interrelated
systems who
strives to
maintain a
balance between
various stimuli.

LABORATORY
DATE LABORATORY ACTUAL NORMAL ANALYSIS
RESULT RESULT

10-16-20 Urinalysis Physical and Physical and Pregnancy

Chemical Chemical
Examination: Examination:
Hormonal and
chemical changes
Color: Light Straw to dark
Yellow yellow
Eating unhealthy
Transparency: foods (junk foods,
SL.HAZY Clear to hazy soft drinks)

Sugar: Urinary stasis and

NEGATIVE Negative vesicoureteral
reflux
Protein:
NEGATIVE Negative
Infections
pH: 6.0 5.0-7.0
Increase level of
Specific Gravity: WBC and
1.005 1.005-1.030 Epithelial cells

Microscopic Microscopic
Examination: Examination: Painful and urgent
urination
RBC: 0-2/hpf 0-3/hpf
Urinary tract
Mucus Thread: infection
MODERATE None-Few

Bacteria: Impaired Urinary

MODERATE None-Few Elimination
 WBC: 3-6/hpf 0-5/hpf

Epithelial Cells:
MANY None-Few

DATE LABORATORY ACTUAL NORMAL ANALYSIS

RESULT RESULT

12-04-20 Urinalysis Physical and Physical and Pregnancy

Chemical Chemical
Examination: Examination:
Hormonal and
chemical changes
Color: Pale Straw to dark
yellow yellow
Eating unhealthy
Sugar: foods (junk foods,
NEGATIVE Negative soft drinks

Transparency: Urinary stasis and

HAZY Clear to hazy vesicoureteral
Specific Gravity: reflux
1.005 1.005-1.030

Protein: Infections
NEGATIVE Negative
Microscopic Increase level of
Examination: Microscopic WBC, RBC and
Examination: Epithelial cells
RBC: 2-4/hpf
0-3/hpf
Bacteria: Painful and urgent
MODERATE urination
None-Few
WBC: 5-10hpf Urinary tract
0-5/hpf infection
Epithelial cells:
MANY
None-Few Impaired Urinary
Elimination

DATE LABORATORY ACTUAL NORMAL ANALYSIS

RESULT RESULT

12-04-20 CBC Hemoglobin: Hemoglobin: NORMAL

13.5 g/dL 11-16 g/dL

Hematocrit: Hematocrit: NORMAL

0.41% 0.37%-0.42%

WBC: WBC: NORMAL

9.6 9-15k/mm cubed

Segmenters:
Segmenters: 0.70 0.50-0.80 NORMAL

Lymphocytes: Lymphocytes:
0.29 0.14-0.44 NORMAL
 Monocytes: 0.01 Monocytes: BELOW
0.02-0.06 NORMAL

ULTRASOUND

PELVIC ULTRASOUND

REPORT OF ULTRASOUND EXAMINATION

Name: Ms.I Date: July 31,2020

Age/Sex: 15/F
Referring Physician: DRA. E GOMEZ
Indication: check-up

PELVIC ULTRASOUND

Within the enlarged and gravid uterus is a single, live fetus in cephalic presentation, exhibiting good
cardiac contraction and active somatic movements. Fetal heart rate is about 139 beats per minute.

The BPD, FL, AC and HC measure about 4.6, 2.9, 15.1 and 17.1 respectively equivalent to an
approximate volume of 19-weeks and 6-days . EFBW = 316 grams

The placenta is implanted posteriorly, high lying grade 1 change.

Amniotic fluid volume is well adequate AFI = 14.1 cm

EDC is about December 19, 2020

Impression:
Normal single live intrauterine pregnancy with good somatic and cardiac activity in cephalic
presentation approximately, 19-weeks 6-days AOG.
Adequate amniotic fluid volume
No previa

OBSTETRIC ULTRASOUND
SECOND AND THIRD TRIMESTER

Name: Ms. I Age: 15

Referred by: RHU Date: 10-27-2020
LMP: 3/18/2020 EDC: 12-23-2020
AOG: 31wks6d

Gen Survey: Placenta-location: posterior

No. of release: Singleton Grade: 2
Presentation: Cephalic Distance to int os: high lying
FHB: 130bpm
Amniotic Fluid volume: 4.1 cm (SVP) (4QP)

BIOMETRY FETAL ANATOMICAL SURVEY

BPD: 7.8 cm Lateral ventricles: /
OFD: 10.3 cm T. Cereb. Diameter:
HC: 29.1 cm Cisterna magna: /
AC: 28.5 cm Post. Nuchal fold:
FL: 5.8 cm 4-C Heart: /
Stomach: /
Ave: Ultrasonic age: 31wks5d Kidney: /
EDC: 12/24/2020 Spine: /
EFW: 1853g 3-vessel cord: /
Bladder: /

DIAGNOSIS:
Pregnancy Uterine 31wks5d by fetal biometry
Live singleton in cephalic presentation
Adequate amniotic fluid volume

DRUG STUDY

DRUG NAME INDICATION ACTION EFFECTS NSG INTERVENTION

Generic Name: Parenteral (calcium Calcium Side Effects: Independent

Calcium chloride, calcium carbonate -Constipation *Check on the usual
Carbonate gluconate): Acute ↓ pattern of elimination,
hypocalcemia (e.g., Assists in including frequency and
Brand Name: neonatal regulating consistency of stool.
Calcimate hypocalcemic release/storag Encourage the patient to
tetany, alkalosis), e of take in fluid 2000 to 3000
electrolyte hormones/ mL/day, if not
Classification:
depletion, cardiac neurotransmit contraindicated
Antacid, arrest (strengthens ters. medically.
Antihypocalcemic myocardial
, ↓
contractions), Neutralizes/ *Assist patients to take at
Antihyperkalemic, hyperkalemia Reduces least 20 g of dietary fiber
Antihypermagnes (reverses cardiac gastric acid (e.g., raw fruits, fresh
emic, depression), (increases vegetables, whole grains)
Antihyperphospha hypermagnesemia pH). per day.
temic (aids in reversing
CNS depression). *Urge patients for some
Dosage: Calcium carbonate: physical activity and
1.25g tablet Antacid, treatment/ exercise.
prevention of Health Teachings
Frequency: calcium deficiency, *Do not take within 1-2
Once a day hyperphosphatemia. hrs of other oral
Calcium citrate: medications, fiber
Antacid, treatment/ containing foods.
prevention of *Avoid excessive use of
calcium deficiency, alcohol, tobacco,
hyperphosphatemia. caffeine.
Calcium acetate:
Controls
hyperphosphatemia
in end-stage renal
disease.
Generic Name: Treatment of Cephalexin Side Effects: Independent
Cephalexin susceptible ↓ *Abdominal *Perform a
infections due to Binds to pain comprehensive
Brand Name: staphylococci, group bacterial cell assessment of pain.
Exel A streptococcus, K. membranes Determine via assessment
pneumoniae, E. coli, ↓ the location,
P. mirabilis, H. inhibits cell characteristics, onset,
Classification:
influenzae, M. wall duration, frequency,
Antibiotic catarrhalis including synthesis quality, and severity of
respiratory tract, pain.
Dosage: genitourinary tract,
500mg Capsule skin, soft tissue, *Evaluate the patient’s
bone infections; response to pain and
Frequency: otitis media; management strategies.
Once a day rheumatic fever
prophylaxis; follow- *Provide non
up to parenteral pharmacologic pain
therapy. management.

*Cognitive-behavioral
therapy (CBT) for pain
management.
 *Cutaneous stimulation
or physical
interventions
Health Teachings
*Doses should be evenly
spaced.

*Continue therapy for

full length of treatment

*May cause GI upset

(may take with food,
milk)

*Refrigerate oral
suspension
Generic Name: This medication is a Multivitamin Side Effects: Independent
Multivitamins+Iro multivitamin and s+Iron *Nausea *Provide an emesis basin
n iron product used to ↓ within easy reach of the
treat or prevent provide patient.
Brand Name: vitamin deficiency vitamins and
Obitron due to poor diet, iron that are *Eliminate strong odors
certain illnesses, or not taken in from the surrounding
during pregnancy. V through the (e.g., perfumes,
Classification:
itamins and iron are diet. dressings, emesis)
Vitamins important building ↓
blocks of the body *Tell patients to avoid
Dosage: used to treat
and help keep you in foods that might cause or
iron or
good health. exacerbate abdominal
vitamin
deficiencies cramping like caffeinated
Frequency: caused by beverages, chocolate,
Twice a day illness, orange juice.
pregnancy,
poor *Keep rooms well-
nutrition, ventilated. If possible,
digestive assist the patient to go
disorders, outside to get some fresh
and many air.
other Health Teachings
conditions. *Never take more than
the recommended dose of
multivitamins with iron.

*Avoid taking any other

multivitamin product
within 2 hours before or
after you take
multivitamins with iron.

*Taking similar vitamin

products together at the
same time can result in a
vitamin overdose or
serious side effects.
Generic Name: Fish oil Side Effects: Independent
Fish oil Provided as daily ↓ *Constipation *Check on the usual
supplements. A pattern of elimination,
Reducing
preparation of including frequency and
Brand Name: triglyceride
omega-3-acid ethyl consistency of stool.
Omegabloc levels
esters is licensed for
↓
prevention of *Encourage the patient to
Classification: recurrent events inhibition of
acyl- take in fluid 2000 to 3000
Antilipemic or after myocardial
CoA:1,2- mL/day, if not
lipid-regulating infarction in
diacylglycero contraindicated
agents addition to treatment
l acyl transfer medically.
of
hypertriglyceridemia se
Dosage: *Assist patients to take at
. ↓
1000mg least 20 g of dietary fiber
increased
(e.g., raw fruits, fresh
mitochondria
Frequency: vegetable, whole grains)
Once a day l and per day.
peroxisomal- *Urge patients for some
beta- physical activity and
oxidation in exercise.
the liver Health Teachings
↓ *Pregnant women likely
decreased have an increased need
lipogenesis in for essential omega-3
the liver fatty acids compared with
↓ women who are not
increased pregnant.
plasma
lipoprotein *Fish oil supplements,
lipase containing both EPA and
activity. DHA, and algae-derived
DHA-only oils are good,
mercury-safe means of
supplementing the diet of
a pregnant woman.

*Docosahexaenoic acid
(DHA) is a major
structural fat in the
human brain and eyes,
representing about 97%
of all omega-3 fats in the
brain and 93% of all
omega-3 fats in the
retina.

*DHA is particularly
important for fetal
development of the brain
and retina during the
third trimester and up to
18 months of life.

Generic Name: >Progesterone Dydrogestero CNS: DEPENDENT:

Deficiencies: ne is an Irregularities,
orally-active headache nau *Patients should monitor
DYDROGESTE Treatment of progesterone sea, breast visual disturbance,
RONE dysmenorrhea, ↓ tenderness, migraine, headache or
endometriosis, Produces a dizziness, embolic disorder.
secondary complete vomiting
Brand Name: amenorrhea, secretory *If an allergic reaction
irregular cycles, endometrium occurs, medicine has to
DUPHASTON dysfunctional in an be stopped and consulted
uterine bleeding, Estrogen- by a physician.
premenstrual primed uterus
Classification: syndrome, ↓
threatened Providing INDEPENDENT
Progestogen; miscarriage, habitual *Encourage patients to
protection
Progestin miscarriage, determine percentages by
against the
infertility due to increased risk reporting regular cycles.
luteal insufficiency for
Available and luteal support as *Assess patients to take
endometrial
Dosage: a part of an Assisted medication at least 18
hyperplasia
Reproductive and/ or day of the cycle until the
Technology (ART) carcinogenesi regular cycle turns to
Dydrogesterone treatment. normal in 25 days.
10mg film-coated s induced by
Tablet estrogens.
>Hormone ↓ Health Teaching:
replacement
Frequency: therapy: *Tell the patient to not
Dydrogestero
stop taking duphaston as
3x a Day ne has no
To counteract the per doctor’s prescribed
estrogenic,
effects of unopposed intake.
no
estrogen on the
androgenic,n
endometrium in *Avoid excessive use of
o
hormone alcohol, tobacco,
thermogenic,
 replacement therapy no anabolic caffeine.
for women with and no
disorders due to cortical *For fetal development
natural or surgical activity. of the brain and retina
induced menopause ↓ during the third trimester
with an intact uterus. Dydrogester and up to 18 months of
one is a life.
progestogen
that works by
regulating the
healthy
growth and
normal
shedding
↓
Treat
disorders
related to the
female
reproductive
cycle,
infertility,
irregular
menses and
uterine
bleeding.
↓
Improves the
conditions
that occur
due to
imbalance in
the hormonal
levels
Generic Name: >Superficial fungal Clotrimazole GI: lower INDEPENDENT:
infections ( tinea abdominal
corporis, tinea cruris cramps, >Caution the patient that
CLOTRIMAZO , tinea pedis, tinea is a nausea and frequent or persistent
LE versicolor, Fungistatic or vomiting yeast infections may
candidiasis) fungicidal. with suggest a more serious
lozenges. medical problem.
>Vulvovaginal
Brand candidiasis Depending >Checked patients using
Name: on Level. a sanitary napkin to
>Oropharyngeal Alters fungal protect clothing when
CANESTEN candidiasis cell-wall using vaginal
Tablet permeability. preparation.
>To prevent
Classification: oropharyngeal >Encourage patients to
candidiasis in Also it refrain from sexual
Antifungal patients produces intercourse during
medications immunocompromise osmotic intravaginal treatment.
called imidazoles d instability
By chemotherapy , >Assess the patient to not
radiotherapy, or use occlusive wrappings
corticosteroid or dressings.
Available therapy in the
Dosage: treatment of
leukemia, solid Health Teaching:
100mg Vaginal tumors, or renal
transplantation
Tablet (6) Vaginal
> Do not breastfeed while
Tablets
taking this drug.

Frequency: >Continue treatment for

the full course.
1 Tablet per day
>Notify prescriber if no
improvement occurs after
4 weeks.
 Generic Name: Ferrous SIDE INDEPENDENT:
>Iron Deficiency Sulfate EFFECT:
Ferrous Sulfate Slightly dark
>As a supplement stool, nausea >Keep monitoring
during pregnancy Provides and vomiting hemoglobin level,
Brand elemental hematocrit, and
Name: >Hemoglobin iron. reticulocyte count during
carries oxygen therapy.
Slow FE, Fer-In- through your blood
Sol, to tissues and It is Essential >Provide some foods in
Feratab, Iron, organs. Myoglobin component in taking drugs although
Mol-Iron, Feosol, helps your muscle the formation absorption may be
and cells store of decreased.
MyKidz Iron 10. oxygen. Ferrous Hemoglobin.
Sulfate is an >Check on the usual
Classification: essential body pattern of elimination,
mineral. Ferrous including frequency and
Hematinic sulfate is used to consistency of stool.
(IRON) products treat iron deficiency
anemia (a lack of
red blood cells Health Teaching:
Available caused by having
Dosage: too little iron in the >Tell the patient to report
body). constipation or any
changes in stool color or
200mg Tablet consistency.

> Do not intake tablets

with milk or antacids,
Frequency: preferably orange juice or
water only.
Take a 30 mg/
per day >Do not substitute one
iron salt for another
because amounts of
elemental iron vary.

>Do not to crush or chew

extended-release forms.

DISCHARGE PLANNING
CATEGORY DISCHARGE PLAN
M-Medication
● Advice patients to not skip medication that the Doctor ordered.

● Take Multivitamins
E-Exercise
● Enough Rest

● Elevate Feet several times a day during the day.

● Walking

T-Treatment
● Use of Drugs

● Avoid all alcohol and recreational drug use and limit caffeine.

● Quit smoking, if you smoke.

H-Health Teaching
● Encourage patient for Sodium Restriction

● Advice to continue medicine as prescribed

● Encourage high protein foods, calcium, magnesium zinc, vitamin

C and E.
● Encourage to eat Healthy foods like vegetables and fruits.

● Encourage to avoid rich in oils and fats

● Encourage the patient to limit her daily activity and Exercise.

O-OPD follow-up
● Observe carefully in Signs and Symptoms

● Give instructions about possible alarming symptoms, to urgently

inform ,when additional signs and symptoms occur.
● Provide clear information to the client

D-Diet
● High protein, Calcium and Iron

● Eat fresh green leafy vegetables and fresh fruits

● Adequate fluid intake

● Low fats and sodium diet, restriction if possible

 NURSING CARE PLAN

Assessm Nursing Dx. Analysis Goals ( Short/ Interventions Rationale Evaluati

ent Long-term) on

Subjectiv Excessive Pregnancy Short term Independent:

es: urination l goal: After 1
output Assess the Serve as a week of
“ Hormonal After 8 hours
related to patient pattern basis for nursing
madalas and chemical of nursing
infection and of elimination determining interventi
po akong changes intervention,
pregnancy as appropriate on, the
umihi, evidenced by l the patient will Encourage to intervention patient
more frequent Urinary achieve a eat foods rich s was able
than 10 voiding stasis and normal urinary in vitamin C to
times po vesicouretera elimination demonstr
akong l reflux pattern as To help ate
umiihi sa evidenced by improve behaviora
isang l the absence of Advise to renal blood l
araw, Infections frequent avoid drinking flow technique
tapos l voiding. coffee, soft s to
parang Increase drinks, or tea To prevent prevent
lagi po level of the UTI and
kong WBC and occurrence improved
naiihi at Epithelial of bacterial urinary
konti cells Long term Advise to growth eliminati
lang po goal: perform
l on as
yung hygienic evidence
Urinary tract After 1 week
lumalaba measures like d by the
infection of nursing
s na ihi daily perineal absence
intervention,
minsan l the patient will
care of
patak Excessive frequent
demonstrate
lang po urination Dependent: voiding
behavioural
at output techniques to Administer Proper
masakit
prevent urinary Cephalexin as perineal
po lalo
tract infection prescribed by care helps
na po
kapag the physician in
onti po minimizing
yung Give Canesten the risk of
ihing as prescribed contaminati
lumalaba by the on and re-
s.” physician infection

- as
verbalize
d by the
patient.

Objective
s:

- dysuria
- urgency
Assessme Nursing Dx. Analysis Goals Interventions Rationale Evaluatio
nt n
( Short/ Long-
term)
Subjective Impaired Pregnancy Short term Independent: After 8
s: physical goal: hours of
mobility l Perform Helps in nursing
related to After 4 hours of comprehensiv clarifying interventio
“sumasaki Release of nursing
pregnancy as e assessment pain n, the
t yung hormone intervention, the
evidenced by of pain. assessment patient was
balakang relaxin patient
back and hip Determine via able to
ko mga pain, demonstrate assessment demonstrat
limang grimace and l measures to the: e improved
beses sa restlessness Stretched increase physical
isang muscles and mobility Onset mobility
araw at ligaments and level
nahihirapa Location of pain as
n din ako
l evidenced
magkikilo Duration by
s lalo na Dysfunction
of the decrease
pag may Characteristic pain scale
aabutin sacroiliac
joints 3 or 4 out
ako. ”-as Long term Aggravating of 10
verbalized goal: factors
by the l
patient After 8 hours of Relieving
Pain in the
nursing factors
round
intervention, the
ligaments
patient Treatment
describes
Objective
l satisfactory pain
s: Symphisis control at a
pubis level less than 3
-Back and dysfunction or 4 on rating
hip pain scale of 0 to 10
-Grimace l
-
restlessne Back and
ss hip pain

l
Impaired
physical
mobility
Assessme Nursing Dx. Analysis Goals ( Short/ Interventions Rationale Evaluation
nt Long-term)

Subjectiv Fluid volume Pregnancy Short term Independent: after 8

es: excess related goal: hours of
to pregnancy l After 4 hours of
-Established -to assess nursing
as evidenced rapport precipitatin interventio
“Namama Increase nursing
by presence g and n the
ga ang body fluids intervention the
of edema in causative patient was
mga binti feet and legs patient will use factor able to
at paa ko” l the verbalizes
as Increase recommendatio -Monitor and -To obtain the
verbalized blood flow n that was record vital baseline awareness
by the and pressure provided from signs data of causative
patient. of growing the nurse to factors and
uterus manage the behaviors
edema like -Advice -this essential to
Objective reposition,
s:
l patient to prevent and fluid excess
exercise, and elevate feet lessen fluid
Uterus appropriate
getting when sitting accumulatio
clothing that down n in lower
-presence heavier will diminish extremities
of edema lower limb
in feet and l edema. -encourage -this
legs Baby grows manual movement
mobility can reduce
l Long term the buildup
goal: of fluid and
Slow blood
from legs to activate
BP: After8 hours of
feet muscle
130/90 nursing
pumping
mmhg intervention the
l patient
-encourage to -consuming
Swelling verbalizes
eat a low-salt too much
awareness of
diet salt can
causative
l retain more
factors and
Edema water,
behaviors
which
essential to
increases
l fluid excess
swelling.
Fluid
Volume
Excess
-monitor fluid -this
intake enhances
compliance
with the
regimen