UNIVERSITY OF PERPETUAL HELP SYSTEM OF LAGUNA DR. JOSE G. TAMAYO MEDICAL UNIVERSITY STO.

NIO, BIAN, LAGUNA COLLEGE OF NURSING

(Case study)
In partial fulfillment of the requirements in NCM 102 submitted by: BSN- 2B ACADEMIC YEAR 2010-2011

Almacen, Bryan Joseph V.

Buenavista, Gladys Ann

Gonzalez, Catherine Anne H.

Noscal, Eugenio jr. B

Reyes, Karla Jane D

Sison, Hannah Louella

Trinidad, Paul Andre P

.

Turallo, Jonathan D.

I. II. III. IV. V. VI. VII.

Introduction Patients Profile Patients History Nursing Assessment Anatomy and Physiology Pathophysiology Medical Management a. Laboratory and Diagnostic Test b. Drug Study VIII. Surgical Management

IX. Nursing Care Plan a. Ineffective airway clearance b. Pain c. Anxiety d. Anticipatory Grieving

A. Definition Stillbirth is the birth of a baby who is born without any signs of life at or after 24 weeks pregnancy. The baby may have died during pregnancy (called intrauterine death), labor or birth. WHO defines stillbirth with a birth weight of at least 1000g or a gestational age of at least 28 weeks (third-trimester stillbirth).

B. Causes Maternal Factors: 1. Women who suffer from pre eclampsia also increase the risk of placental abruption by 50%. Women who have experienced a stillbirth in a previous pregnancy should receive careful, regular prenatal care to ensure another stillbirth does not occur.

2. Risk factors for stillbirth that can be identified before a woman becomes pregnant, having a prior stillborn baby, having prior miscarriages and not having other children were all associated with added risk.

3. Women with diabetes had 2.5 times the risk of stillbirth and women aged 40 and older had 2.4 times the risk of stillbirth as women aged 20 to 34.

4. Having an AB blood type, smoking in the three months before pregnancy, overweight/obesity and a history of drug addiction were also associated with higher risks.

One of the common reasons for stillbirths is placental abruption. This is when the placenta begins to strip away from the uterine wall, causing heavy bleeding and deprivation of oxygen to the fetus. Chromosomal abnormalities are another cause of stillbirths. While they are the most common factor for miscarriages in the first trimester, a miscarriage due to a chromosomal abnormality can occur at any time during a pregnancy.

Other causes of stillbirth include gestational growth problems, environmental factors, genetic defects, and bacterial infections (such as listeriosis) in the mother. Additionally, the risk of a stillbirth increases with the maternal age.

C. Signs and Symptoms

If you are pregnant, it is important that you be able to recognize the signs of a possible stillbirth. By catching the symptoms early on, it may be possible to prevent a stillbirth from occurring. Warning signs include: Lack of movement from your baby Significant decrease in baby's movement Vaginal bleeding

Patients Profile:
Address: Age: Civil Status:

M. A.C.
Silang, Cavite 32 yrs. Old Married

Religion:
Occupation:

Catholic
Housewife

Admission Date:
Time: Attending Physician:

February 14, 2012

2:13 pm Dr. R.G.

Admitting Diagnosis: Pregnancy Uterine, Pre Gestational Diabetes Mellitus, Chronic Hypertensive Vascular Disease with Super Imposed Eclampsia

Room Number:
Hospital:

201-A
Jonelta OB ward

Date of Discharge: February, 19, 2012

Final Diagnosis: G5P4 (0410) Pre Uterine Delivery, Pre-term, Breech, Stillbirth, baby girl 800gms, Fetal Congenital Anomaly, Pre Gestational Diabetes Mellitus, Chronic Hypertensive Vascular Disease with a Super Imposed Eclampsia

Poor OB history, (Pre-term, stillbirth, neonatal death) Caesarian Section, Hysterectomy under spinal Anesthesia

I. CHIEF COMPLAINT Elevated blood pressure 200/100 mmHg Vital Signs: BP: 200/100 PR: 89 bpm RR: 18 cpm T: 36 C
FHT 140 Left lower quadrant

II. HISTORY OF PRESENT ILLNESS: Patient came in OPD Jonelta OB clinic for her scheduled regular prenatal checkup. Asymptomatic, no headache, no blurring of vision, no vaginal bleeding, no hypogastric pain, with good fetal movement. Upon physical examination BP revealed 200/100 mmHg, patient was advised for admission.

III. Past Medical History (-) DM (-) HPN (-) Asthma (+) Hospitalization
IV. Family History (+) HPN Father (+) Cancer (breast) Mother (-) DM (-) PTB

V. PERSONAL AND SOCIAL HISTORY: Non- alcoholic beverage drinker Non- cigarette smoker
VI. MENSTRUAL/ SEXUAL HISTORY Age of menarche: 11 y/o Menstrual flow regular, consuming 2 pads per day, moderately soaked, lasting for 3 days, uses feminine wash (Betadine) 1st coitus 26y/o One sexual partner

VII. Immunization History Immunization- complete Tetanus Toxoid- complete VIII. Contraceptive History Uses pills from 2009-2011 Stopped due to desired pregnancy

IX. OBSTETRICAL HISTORY G5T0P4A1L 0

X. PAST PREGNANCIES
Pregnancy Pregnancy Year Gestation Sex Method Where Order Outcome Completed of Delivery
G1 G2 G3 G4 G5 Stillbirth Spontaneous Abortion Stillbirth Stillbirth Present Pregnancy 2006 2007 2008 2009 Preterm 2 Months Preterm Preterm M M F NSVD No curettage NSVD LTCS Hospital Hospital Home

XI. PRESENT PREGNANCY: LMP: July 16, 2011 EDC: April 23, 2012 AOG: 27 1/7 weeks
XII. PRENATAL HISTORY: 7 to 12 weeks AOG Ferrous Sulfate and multivitamins given. 13 weeks AOG Diagnosed with UTI, antibiotic was given, name of medication unrecalled, taken for 7 days.

14 weeks diagnosed with GDM, CHVD Medical management - CBG monitoring Diet modification Possible insulin therapy Aspirin once daily was started 16 weeks diagnosed with Bacterial Vaginosis and Cervicovaginitis Given Metronidazole 500mg/ tab BID x7days Albothyl vaginal suppository every other night for 7 doses

18 to 19 weeks Quickening noted. 21 to 22 weeks Ultrasound revealed single, live, intrauterine pregnancy.

PHYSICAL EXAMINATION ( CEPHALO-CAUDAL APPROACH)

VITAL SIGNS: Temperature: 36.5C Blood Pressure: 170/100 mmHg Pulse Rate: 89 bpm Respiratory Rate: 18 cpm

FEMALE INTERNAL STRUCTURE

FEMALE EXTERNAL STRUCTURE

Fetal Development
A. B.

D.

C.

E.

F.

H.

G.

I.

PATHOPHYSIOLOGY
Modifiable Factors Hypertension (uncontrolled) Presence of UTI Non-Modifiable Factors GDM (controlled) CHVD Poor Obstetric History (Preterm, Stillbirth, Neonatal death)

Vasoconstriction of uterine blood vessels caused by hypertension

Increased maternal and fetal glucose levels caused by gestational diabetes mellitus

Compromised maternal fetal gas exchange

Excess energy expenditure associated with conversion of excess glucose to fat Depletion of fetal oxygen levels Fetal Hypoxia Intrauterine Growth Retardation

Inadequate oxygen supply to fetus

Increased fetal heart rate Release of meconium into amniotic fluid

Respiratory Distress of Fetus

Decrease in fetal movements

Absence of fetal heart tone

Fetal Death

Absence of fetal movements

STILLBIRTH

I. Medical Management 1. Diet a. NPO - This was indicated for decreasing the workload of the stomach. It is a preparatory procedure for the operation.

b. Low salt, Low fat Diet A diet prescribed in the treatment of type 2 diabetes mellitus. It usually contains limited amounts of simple sugars or readily digestible carbohydrates and amounts of proteins, complex carbohydrates, fiber, and unsaturated fats similar to those recommended for the general public.

 Dietary regulation depends on the severity of the disease and on the type and extent of insulin therapy. The diet should be designed to prevent wide fluctuation in the amount of glucose in the blood, to preserve pancreatic function, and to prevent chronic diabetic complications.

2. Intravenous Fluids a. D5 NSS to normalize the sugar and body fluids. 3. Foley Catheter a. Indwelling Foley Catheter used to maintain a continuous out flow of urine for patients undergoing surgical procedures that cause a delay in bladder sensation.

4. Monitor Fetal Heart Tone and Uterine Contractions q 15mins and q 4hours. 5. Monitor Vital Signs and Urine Output q 1hour. 6. CBG Monitoring q4hours.
7. Insulin Regimen For CBG > 200mg/dL Give 4 units of Humulin R SQ

8. Laboratory Tests CBC with Platelet Count Urinalysis CT (Clotting Time) BT (Bleeding Time) PT test (Prothrombine Time) PTT test (Partial Thromboplastin)

BUN (Blood Urea Nitrogen) and Creatinine test SGPT (Serum Glutamic- Pyruvic transaminase SGOT (Serum Glutamic- Oxaloacetic Transaminase) LDH (Lactate Dehydrogenase) BUA (Blood Uric Acid) HGT (Hemo Glucose Test) CBG (Capillary Blood Glucose)

9. Diagnostic Test a. Pelvic Ultrasound (Sonography) 10. Medications Pre-operative Medications 1. ANTI-HYPERTENSIVE DRUGS Hydralazine 5mg IV PRN for BP > 140/100mmHg Methyldopa 500mg 1 tab q 8hours

2. ANTI INFLAMMATORY DRUG Dexamethazone 12 mg IM q 12hours 3. ANTI INFECTIVE/ ANTIBIOTIC DRUGS Cefuroxime 500 mg tab, 1 tab BID 4. ANTI CONVULSANT DRUG Magnesium Sulfate loading dose 4 grams SIVP 5 grams deep IM on each buttocks 5. ANALGESICS Nubain 5mg + Phenergan 25mg IM 6. ANTI HISTAMINES Promethazine HCL 25mg IM q4 or PRN 7. PRENATAL MULTIVITAMINS

Post Operative Medications 1. ANALGESICS Ketorolac 30mg TIV q8hours x 3 doses (-)ANST Tramadol 50mg q6 x 4doses refer if BP < 90/60mmHg 2. ANTI ULCER DRUG Ranitidine 50mg TIV q8hours x 3 doses while on NPO (1st dose given)

3. ANTI - INFECTIVE/ ANTIBIOTIC DRUGS Ampicillin 500mg q6hours ( ) ANST 4. ANTI HYPERTENSIVE DRUGS Hydralazine 5mg IV PRN for BP > 140/100mmHg

11. Cesarean Section Choice of cesarean section is indicated for stillbirth (fetus died in the uterus), the mother may not have contractions and undergo childbirth. The incision is made horizontally across the lower end of the uterus (called a low transverse incision) preferred for less bleeding and stronger healing. Surgery done due to cases of Gestational Diabetes Mellitus, hypertension and bacterial infection.

II. Surgical Management Pre-operative Informed Consent (Operative Permit/Surgical Consent) Physical Preparations Deep breathing exercise diaphragmatic Preparing the skin - Have full bath to reduce microorganism in the skin.

Preparing the G.I Tract - NPO, cleansing enema as required. Preparing for Anesthesia - Avoid alcohol and cigarette smoking for at least 24 hours before surgery. Promoting rest and sleep - Administer sedatives as ordered.

Psychosocial Preparations
Fear of anesthesia Fear of pain Fear of death Fear of disturbance and body image Worries for the outcome of the surgery. Explore clients feelings. Allow clients to speak openly about fears/concerns. Give accurate information regarding surgery.

Intra-operative Positions During Surgery Side Lying for induction of spinal anesthesia. Supine for abdominal surgery. Spinal Anesthesia

 Hysterotomy (uterotomy) is any procedure that involves making a cut into a females uterus. This uterine incision may be essential in a number of medical procedures, including Caesarian section. -Hysterotomy by a Cesarean Section was done due to Bacterial Vaginosis and Cervicovaginitis. The uterus accessed through the abdominal muscles. Surgical cuts are made on the lower portion of the uterus.

Post-operative Vital Signs Examine operative site and check dressing. Daily wound care Apply Abdominal Binder

 Perineal Hygiene Flat on bed without pillow x 8hours Encourage walking exercise NPO Watch out for signs and symptoms of respiratory distress hypertension, tachycardia, etc.

 Keep uterus well contracted at all time. For adequate blood glucose (CBG) and BP control Keep patient warm and comfortable
III. COLLABORATIVE MANAGEMENT Referral to Internal Medicine CBG Monitoring(Pre op Intra op Post op) Hook to Oxygen via Oxygen Mask Hook to Cardiac Monitor And Pulse Oximeter

URINALYSIS RESULT

A urinalysis is a chemical screening of urine for medical purposes. This is a common method for diagnosing any number of medical problems. Doctors will test urine for signs of infection, drug use, red blood cells, protein, glucose and many other medical disorders.

RESULT

NORMAL VALUES

INTERPRETATION

Color

Dark yellow

Pale yellow to amber

Normal

Transparency

Hazy

Clear to slightly Hazy

Presence of bacteria in urine

Reaction(ph)

Acidic 6.0

4.5-8.0

Normal

Protein

++++

Negative

Indication of infection,

diabetes, hypertension

RESULT

NORMAL VALUES

INTERPRETATION

Glucose

NONE

Negative

--

Ketones

NONE

Negative

--

Specific gravity

1.010

1.015-1.025

--

Diacetic Acid

--

RESULT

NORMAL VALUES

INTERPRETATION

Urobilinogen

NONE

0.1-1.0

--

Blood

NONE

Negative

--

Pus cells

10-15/HPF

5-10/HPF

Presence of infection

RBC

1-3/HPF

0-5/HPF

NORMAL

RESULT

NORMAL

INTERPRETATION

VALUES

Epithelial cells

NONE

Few

Crystals

a. A. Urates
b. A. Phosphates

Moderate

--

Mucus threads

--

Bacteria

Moderate

--

Casts

HGT RESULT

Hemo Glucose Test allows a person to know their blood glucose level at any time and helps prevent the immediate and potentially serious consequences of very high or very low blood glucose. Monitoring also enables tighter blood glucose control, which decreases the long-term risks of diabetic complications

RESULT
78mg/dl

NORMAL VALUE INTERPRETATION

74-106mg/dl NORMAL

COMPLETE BLOOD COUNT (CBC) The complete blood count (CBC) screening test has many applications, and it can help identify a wide variety of diseases. It is used to measure red blood cell and white blood cell count, total amount of hemoglobin in the blood, hematocrit (the amount of blood composed of red blood cells) and mean corpuscular volume (the size of red blood cells). Results can help detect problems such as dehydration or loss of blood, abnormalities in blood cell production and life span, as well as acute or chronic infection, allergies, and problems with clotting.

RESULT

NORMAL

INTERPRETATION

VALUES

Hemoglobin

161

120-170 gm/L

NORMAL

Hematocrit

.48

.37-.47

NORMAL

RBC count

5.76

4-5.5 X10^12/l

Destruction of blood

vessels
WBC count 13.4 X10^9/l Presence of infection

RESULT

NORMAL VALUES

INTERPRETATION

Segmenters

0.67

0.50-0.70

NORMAL

Lymphocytes

0.33

0.20-0.40

NORMAL

Monocytes

NONE

0-0.05

--

Eosinophile

NONE

0-0.04

--

RESULT

NORMAL VALUES

INTERPRETATIO N

Basophile

NONE

0-0.01

--

Stabs

NONE

0-0.04

--

MCV

84.8

80-98 Fl

NORMAL

MCH

28.0

26-32 Pg

NORMAL

RESULT

NORMAL VALUES

INTERPRETATION

MCHC Bleeding time Erythrocyte sedimentation rate(ESR)

330 3 NONE

320-360 g/L 1-5 Min 0-20 Mm/hr

NORMAL NORMAL --

Reticulocyte count Clotting time Remarks: 6

0.5-1.5 % 2-6 Min

-NORMAL --

CLINICAL CHEMISTRY RESULT Clinical Chemistry is defined as the study of substance in biological fluids most specially blood, the methods and principles of determination the intrinsic and extrinsic precautions, the normal levels and he significance of the abnormal values.

RESULT

NORMAL VALUES

CONVENTIONAL REFERENCE VALUES

INTERPRETA TION

ALT

28.00U/L

10-40

28.00IU/L

10-40

--

AST

33.00U/L

10-42

33.00IU/L

10-42

--

BUN

4.03mmol/L

2.5-6.4

11.29mh/dL

7-18

--

RESULT

NORMAL VALUES

CONVENTIONAL REFERENCE VALUES

INTERPRETA TION

CREATININE

60.08umol/L

37-96

0.68mg/dL

0.42-1.09

NORMAL

LACTOSE DEHYDROGENASE

878.00U/L

266-500

878.00IU/L

266-500

Indicates Hypertension

URIC ACID

425.94umol/L

155-428

7.16mg/dL

2.6-7.2

NORMAL

PROTHROMBINE TIME CONTROL TEST

RESULT
9.4 seconds

NORMAL VALUE
10.5-13.4 seconds

INTERPRETATION
--

PARTIAL THROMBOPLASTIN TIME

RESULT

NORMAL VALUE

INTERPRETATION

27.2 seconds

25.4-38.4 seconds

NORMAL

SECOND AND THIRD TRIMESTER ULTRASOUND REPORT Obstetrical ultrasound is also known as prenatal, pregnancy or fetal ultrasound. It keeps track of the growth and development of an unborn baby in the womb. The procedure is often a standard part of prenatal care, as it yields a variety of information regarding the health of the mother and of the fetus, as well as regarding the progress of pregnancy.

Name: M.A.C. Age: 32 years old Referring Physician: M. D. A. Date Requested: February 14, 2012 Examination Done: Early Obstetrical ultrasound GENERAL SURVEY
Number of fetuses Singleton

Presentation
FHB Amniotic fluid index

Breech
129bpm 14.13cm

Placenta: Location
Grade Distance to internal OS

Posterior
II High

BIOMENTRY
Biparietal diameter
Head circumference Abdominal circumference Femoral length Average ultrasonic age Ultrasonic EDC Estimated fetal weight

6.25cm 25 wks 2days

23.08cm 25 wks1day 20.82cm 25wks 3days 4.34cm 24wks 2days 25wks 5/29/2012 751gms

Fetal Anatomic Survey

Lateral vent(<1cm) Trans cereberallar diameter Cisterna magna(<1cm) Post nuchal fold(<0.06) 4 chamber hear Stomach .78 More than N With minimal pericardial effusion Spine 3vessel cord Minimal ascitis With scalp Edema

Bladder

Clinical diagnosis: Pregnancy Uterine 25 weeks by fetal biometry, breech, live, singleton with findings of: Increase Nuchal fold, scalp edema, minimal ascitis and pericardial effusion. Possible club foot, right, cardiomegaly and hepatomegaly. (R/o fetal hydrops) Normohydramnios, high lying posterior placenta. Estimated fetal weight below the 10th% for age (27 weeks). Follow up after 3 weeks.

DRUG NAME Generic Name Albothyl

MECHANISM OF ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATIO N

NURSING CONSIDERATION

Classification Anti-Infectives

Dosage 90mg

Route Suppository

Frequency 1 suppository every other night for 7 days

Albothyl has a selective effect on dead or pathologically altered tissue, producing coagulation with subsequent elimination. Healthy squamous epithelium is not affected due to its broad antimicrobial spectrum, Albothyl destroys pathogenic germs of the vagina (bacteria, trichomonas, and fungi), and enhances the growth of Lactobacilli (Doderleins bacilli) responsible for maintaining the physiologicalacidity of the vagina. In vitroperiodic investigations on different pathogens have revealed no changes in sensitivity

Gynecology: Vaginitis, vaginal and cervical discharge (due to bacterial, monilial or trichomonal infections), ectopia of the portio vaginalis with inflammatory processes and esorio vera, cervicitis, hemostasis, after biopsies and removal of cervical polyps, external urethral erosions, papilomas, condyloma acuminatum, pressure sores, after electrocautery in order to accelerate the healing process and cauterization of rhagades in mastitis.

Local irritation is occasionally observed at the beginning of the treatment with Albothyl, but usually subsides rapidly. When treating oral mucosa, it must be remembered that the high acidity of Albothyl could cause damage to the dental enamel. The following additional undesirable effects have been reported for use if preparations containing policresulen: Urticaria, systemic allergic reactions (eg. Angioedema, generalized urticaria) up to anaphylaxis, vaginal candidiasis, etc

Use in pregnancy and lactation: During pregnancy, particularly in advance stages swabbing of the endocervix should be avoided. Swabbing of the ectocervix and adjoining parts of the vagina should only be undertaken when specially indicated, and then only with extreme caution. During pregnancy, Albothyl should be administered only if absolutely necessary, taking into account all the possible risks for mother and child.

DRUG NAME Generic Name Metronidazole Brand name Flagyl Classification Antibiotic/ Antiprotozoal Dosage 5mg Route IV Frequency BID

MECHANISM OF ACTION Undergoes intracellular chemical reduction during anaerobic metabolism. After metronidazole is reduced, it damages DNAs helical structure and break its strands which inhibits bacterial nucleic acid synthesis and causes cell death.

INDICATION To treat systemic anaerobic infections caused by Bacteroides fragilis, Clostridium perfrinegens, Eubacterium, Fusobacterium, Peptococcus, and Veilonella species.

ADVERSE REACTION CNS: Aseptic meningitis (parenteral form), ataxia, confusion, dizziness, encelopathy, fever, headache, incoordination, insomnia, irritability, light headedness, peripheral, neuropathy, seizures ( high doses), syncope, weakness, vertigo EENT: Dry mouth, lacrimation (topical form), metallic taste, nasal congestion, optic nueropathym pharyngitis GI: Abdominal cramps or pain, anorexia, diarrhea, nausea, pancreatitis,vomitin g HEME: Leukopenia

CONTRAINDICATION Breast-feeding, hypersensitivity to metronidazole or its components, trichomoniasis, during first trimester of pregnancy.

NURSING CONSIDERATION Give I.V. Drug by slow infusion over 1 hr; dont give by direct I.V. Injection

Discontinue primary I.V. infusion during metronidazole infusion.

Monitor patient with severe liver disease because slowed metronidazole metabolism may cause drug to accumulate in body and increase the risk of adverse effects If skin irritation occurs, apply topical metronidazole gel less frequently or discontinue it as ordered.

To treat amebiasis (Entamoeba histolytica) To treat trichomoniasis (Trichomonas vaginalis) To prevent perioperative bowel infection To treat acne in patients with rosacea To treat bacterial vaginosis

DRUG NAME

MECHANISM OF ACTION Increase Synthesis of glycogen in the liver

INDICATION

ADVERSE REACTION Hyperglycemia, Hypokalemia, Injection site reaction pruritus, rash

CONTRAINDICATI ON Hypersensitivity to insulin

NURSING CONSIDERATION Ensure uniform dispersion of insulin suspensions by rolling the vial between hands, avoid vigorous shaking. Give maintenance dose subcutaneously, rotating injections sites regularly to decrease incidence of lipodystrophy. Do not give insulin injection concentrated IV; severe anaphylactic reactions can occur. Store insulin in a cool place away from direct sunlight. Monitor urine and serum glucose levels frequently to determine effectiveness of drug and dosage. Monitor insulin needs during times of trauma or severe stress; dosage adjustments may be needed.

Generic Name Insulin Regular Brand Name Humulin R

-Diabetic Coma -Diabetic Acidosis -Client suffering from labile diabetes

Classification Insulin Product

Dosage 4 units

Stock Dose 100 units/ml (vial)

Route SQ

Frequency

DRUG NAME

MECHANISM OF ACTION

INDICATION
-CHF -Hypertension - To manage essential hypertension, alone or with other antihypertensive.

ADVERSE REACTION Vasomotor reaction GI disturbance Anemia CNS: Chills, fever, headache, peripheral neuritis CV: Angina, edema, orthostatic hypotension, palpitations, tachycardia EENT: Lacrimation, nasal congestion GI: Anorexia, constipation, diarrhea, nausea, vomiting RESP: Dyspnea SKIN: Blisters, flushing, pruritus, rash, urticaria Other: Lupus-like symptoms, especially with high doses; lymphadenopathy

CONTRAINDICATION
Coronary artery disease, hypersensitivity to hydralazine or its components, mitral valve Disease Idiopathic SLE and related disease.

NURSING CONSIDERATION
Monitor blood pressure and pulse rate regularly and weigh patient daily during therapy. Check blood pressure with patient in lying, sitting, and standing positions, and watch for signs of orthostatic hypotension. Expect orthostatic hypotension to be most common in the morning, during hot weather, and with exercise. WARNING Expect to discontinue drug immediately if patient has lupus-like symptoms, such as arthralgia, fever, myalgia, pharyngitis, and splenomegaly. Expect prescriber to withdraw hydralazine gradually to avoid a rapid increase in blood pressure.

Generic Name May act in a manner Hydralazine Chloride that resembles organic nitrates and sodium Brand Name nitroprusside, except Apresoline that hydralazine is Classification Antihypertensive selective for arteries. It exerts a direct Dosage vasodilating effect on 5mg vascular smooth muscle. Stock Dose Interferes with calcium 20mg/ml (vial) movement in vascular Route smooth muscle by IV altering cellular Frequency calcium metabolism. PRN dilates arteries, not veins, which minimizes orthostatic hypotension and increases cardiac output and cerebral blood flow

causes reflex autonomic response that increases heart rate, cardiac output, and left ventricular ejection fraction has a positive inotropic effect on the heart.

DRUG NAME

MECHANISM OF ACTION Binds to intracellular glucocorticoid receptors and suppresses inflammatory and immune responses by: Inhibiting neutrophil and monocyte accumulation at inflammation site and suppressing phagocytic and bactericidal action. Stabilizing lysosomal membranes. Suppressing antigen response of macrophages and helper T cells Inhibiting synthesis of inflammatory response mediators, such as cytokines, interleukins, and prostaglandins.

INDICATION

ADVERSE REACTION GI disturbance, atrophy CNS: Depression, emotional lability, euphoria, fever, headache, increased ICP with papilledema, insomnia, lightheadedness, malaise, neuritis, neuropathy, paresthesia, psychosis, seizures, syncope, tiredness, vertigo, weakness CV: Arrhythmias, bradycardia, edema, fat embolism, heart failure, hypercholesterolemia, hyperlipidemia, hypertension, myocardial rupture, tachycardia, thromboembolism, thrombophlebitis, vasculitis

CONTRAINDICATION

NURSING CONSIDERATION Use dexamethasone cautiously in patients with congestive heart failure, hypertension, or renal insufficiency because drug can cause sodium retention, which may lead to edema and hypokalemia. Also use cautiously in patients who have had intestinal sugery and in those with peptic ulcer, diverticulitis, or ulcerative colitis because of the risk of perforation. Give once-daily dose of dexamethasone in the morning to coincide with the bodys natural cortisol secretion. Give oral drug with food to decrease GI distress. Be aware that dosage forms with a concentration of 24 mg/ml are for I.V. use only. Shake I.M. solution before injecting deep into large muscle mass.

Generic Name Dexamethasone Brand Name Decadron Classification Anti-inflammatory Dosage 12mg Stock Dose 10mg/ml (vial) Route IM Frequency Q12

-Hypercalcemia associated with cancer -Short term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (pemphigus), status asthmaticus and autoimmune disorders.

Administration of live-virus vaccine to patient or family member, hypersensitivity to dexamethasone or its components (including sulfites), idiopathic thrombocytopenic purpura (I.M. administration), systemic fungal infections systemic therapy peptic ulcers, systemic fungal infection

DRUG NAME Generic Name Cefuroxime Brand Name Kefox Classification Antibiotic Dosage 500mg Stock Dose 500mg (tablet) Route Oral Frequency BID

MECHANISM OF ACTION Interferes with bacterial cell wall synthesis by inhibiting the final step in the crosslinking of peptidoglycan strands. Peptidoglycan makes the cell membrane rigid and protective without it, bacterial cells rupture and die.

INDICATION UTI, and disused for surgical prophylaxis, reducing or eliminating infection. It is effective for the treatment of penicilllinase producing Neisseriagonorhoea (PPNG). Effectively treats bone and joint infections, bronchitis, meningitis, gonorrhea, otitis media, pharyngitis/tonsillitis, sinusitis, lower respiratory tract infections, skin and soft tissue infections.

ADVERSE REACTION CNS: Chills, fever, headache, seizures CV: Edema EENT: Hearing loss, oral candidiasis GI: Abdominal cramps, diarrhea, elevated liver function test results, hepatic failure, hepatomegaly, nausea, pseudomembranous colitis, vomiting GU: Elevated BUN level, nephrotoxicity, renal failure, vaginal candidiasis HEME: Eosinophilia, hemolytic anemia, hypoprothrombinemia, neutropenia, thrombocytopenia, unusual bleeding MS: Arthralgia RESP: Dyspnea SKIN: Ecchymosis, erythema, erythema multiforme, pruritus, rash, Stevens -Johnson syndrome Other: Anaphylaxis; injection site edema, pain, and redness; superinfection

CONTRAINDICATION Hypersensitivity to cephalosporins or their Components. To patient who take probenecid

NURSING CONSIDERATION Use cefuroxime cautiously in patients hypersensitive to penicillin because crosssensitivity has occurred in about 10% of such patients. If possible, obtain culture and sensitivity results, as ordered, before giving drug. Give oral form with food to decrease GI distress, as needed. Remember that oral formstablets and suspensionarent bioequivalent. For I.V. use, reconstitute using manufacturers instructions according to type of preparation available. Solution ranges in color from light yellow to amber. For I.M. use, add 3 or 3.6 ml sterile water for injection to each 750-mg vial to yield 220 mg/ml.

DRUG NAME

MECHANISM OF ACTION

INDICATION

ADVERSE REACTION Severe allergic reaction (rash; hives; itching; difficulty in breathing; tightness in the chest; swelling of the mouth, face lips or tongue); dizziness, flushing; irregular heartbeat muscle paralysis; severe drowsiness;

CONTRAINDICATION

NURSING CONSIDERATION Checked magnesium level after repeated doses. Normal magnesium level: 4-7 mg/dL Monitor patients fluid intake and output. Be alert for adverse reaction. Watch out for signs of magnesium toxicity: -urine output <30cc/hr -respiratory rate <1220cpm -(+) deep tendon reflexes Prepare antidote at bedside table: Calcium Gluconate

Replaces and maintain magnesium level; as anticonvulsant, Brand Name reduces muscle contraction by interfering with release of Classification acetylcholine at Anti-convulsant myoneural junction. Raises magnesium levels, alleviates Dosage Loading dose: 4g seizures, and restores normal SIVP sinus rhythm And 5g Deep IM Route SIVP And Deep IM Frequency Q6

Generic Name Magnesium sulfate

Mild/ severe hypomagnesemia. Magnesium supplementation. Hypomagnesemic seizure. Paroxysmal atrial tachycardia in patients unresponsive to other therapies. To manage pre term labor. Severe acute asthma unresponsive to conventional therapy.

Contraindicated in patients with myocardial damage, mark myocardial disease, or heart block. IV form is contraindicated in patients with preeclampsia during the 2 hrs preceding delivery. And to those patient with renal impairment. Use magnesium sulfate cautiously in patients with impaired kidney function.

DRUG NAME

MECHANISM OF ACTION Is decarboxylated in the body to produce alphamethylnorepinephrine, a metabolite that stimulates central inhibitory alphaadrenergic receptors. This action may reduce blood pressure by decreasing sympathetic stimulation of heart and peripheral vascular system.

INDICATION

ADVERSE REACTION CNS: Decreased concentration, depression, dizziness, drowsiness, fever, headache, involuntary motor activity, memory loss (transient), nightmares, paresthesia, parkinsonism, sedation, vertigo, weakness CV: Angina, bradycardia, edema, heart failure, myocarditis, orthostatic hypotension.

CONTRAINDICATION

NURSING CONSIDERATION

Generic Name Methyldopa Brand Name Amlodomet Classification Antihypertensive Dosage 500mg tab Stock dose 500mg (tablet) Route Oral Frequency Q8

-To manage hypertension -to treat hypertensive crisis

Active hepatic disease, hypersensitivity to methyldopa or its components, impaired hepatic function from previous methyldopa therapy, use within 14 days of MAO inhibitor.

Expect to monitor CBC and differential results before and periodically during methyldopa therapy. Monitor blood pressure regularly during therapy. Monitor results of Coombs test; a positive result after several months of treatment indicates that patient has hemolytic anemia. Expect to discontinue drug. Assess for weight gain and edema. If they develop, give a diuretic, as prescribed. Notify prescriber if patient has signs of heart failure (dyspnea, edema, hypertension) or involuntary, rapid, jerky movements. Be aware that hypertension may return within 48 hours after stopping drug.

DRUG NAME Generic Name Nalbuphine

MECHANISM OF ACTION

INDICATION
Relief of moderate to severe pain Preoperative analgesia, as a supplement to surgical anesthesia, and for obstetric analgesia during labor and delivery

ADVERSE REACTION

CONTRAINDICATION

NURSING CONSIDERATION Use nalbuphine cautiously in patients taking other drugs that can cause respiratory depression. Keep resuscitation equipment and naloxone readily available to reverse nalbuphines effects, if needed. For direct I.V. injection through an I.V. line with a compatible infusing solution, give drug slowly no more than 10 mg over 3 to 5 minutes. Inject into free-flowing normal saline solution, D5W, or lactated Ringers solution.

Binds with and stimulates mu and Brand Name kappa opiate Nubain receptors in the Classification spinal cord and Narcotic agonist- higher levels in the antagonist CNS. analgesic In this way, nalbuphine alters Dosage the perception of 5mg and emotional Stock Dose response to pain. 10mg (vial)

Route IM
Frequency Q4

CNS: Confusion, Hypersensitivity to depression, nalbuphine or its dizziness, components euphoria, fatigue, hallucinations, headache, nervousness, restlessness, seizures, syncope, tiredness, weakness CV: Hypertension, hypotension, tachycardia EENT: Blurred vision, diplopia, dry mouth GI: Abdominal cramps, anorexia, constipation, nausea, vomiting RESP: Dyspnea, pulmonary edema, respiratory depression, wheezing

DRUG NAME

MECHANISM OF ACTION Selectively blocks H1 receptors, diminishing the effects of histamine on cells of the upper respiratory tract and eyes and decreasing the sneezing, mucus production, itching and tearing that accompany allergic reactions. blocks cholinergic receptors in the vomiting center that are believed to mediate the nausea and vomiting caused by gastric irritation.

INDICATION

ADVERSE REACTION CNS: Akathisia, CNS stimulation,confusion, dizziness,drowsiness, dystonia, euphoria, excitation, fatigue, hallucinations,hysteri a, incoordination, insomnia, irritability, nervousness, neuroleptic malignant syndrome,paradoxica l stimulation, pseudoparkinsonism, restlessness,seizures , syncope, tardive dyskinesia, tremor CV: Bradycardia, hypertension, hypotension, tachycardia EENT: Blurred vision; diplopia; dry mouth, nose, and throat;nasal congestion; tinnitus; vision changes ENDO: Hyperglycemiaation

CONTRAINDICATION

NURSING CONSIDERATION Monitor BP, pulse and respiratory rate frequently. Assess level of sedation after administration. Assess patient for nausea and vomiting before and after administration. Administer each 25mg slowly over at least 1hr. Do not give rectal suppository or tabs to children younger than 2years old because of risk of fetal respiratory depressions. Give IM injections deep into muscles. Do not administer SQ, tissue necrosis may occur. Arteriospasms and gangrene of artery may occur when administered intra-arterially. Reduce dosage of barbiturates given concurrently within promethazine by least half.

Generic Name promethazine HCl Brand Name Phenergan Classification Anti-emetics, antihistamine, sedative hypnotic Dosage 25mg Stock Dose 25mg/ml (vial) Route IM Frequency Q4 or PRN

Preoperative sedation and surgery and obstetrics, allergic conditions of the upper respiratory tract and skin, sedation, allergic rhinitis, uticaria, insomnia.

Hypersensitivity, comatose patient, prostatic hypertrophy, bladder neck obstruction, narrow angle glaucoma

POST-OPERATIVE MEDICATIONS

DRUG NAME

MECHANISM OF ACTION

INDICATION

ADVERSE REACTION

CONTRAINDICATION

NURSING CONSIDERATION

Generic Name Ketorolac Brand Name Toradol

Classification Nonsteroidal antiinflammatory agents, nonopioid analagesics Dosage 30mg Stock Dose 30mg/ml (ampule) Route IV Frequency Q8

Inhibits prostaglandin synthesis, producing peripherally mediated analgesia. Also has antipyretic and anti-inflammatory properties,

-Short term management of pain (not to exceed 5 days total for all routes combined

CNS: Aseptic meningitis, cerebral hemorrhage, coma, dizziness, drowsiness, headache, psychosis, seizures, stroke CV: Edema, fluid retention, hypertension EENT: Laryngeal edema, stomatitis ENDO: Hyperglycemia GI: Abdominal pain; acute pancreatitis; bloating; constipation; diarrhea; diverticulitis; flatulence; GI bleeding, perforation, or ulceration; hepatitis; hepatic failure; jaundice; indigestion; nausea; perforation of stomach or intestines; vomiting; worsening of inflammatory bowel disease

Hypersensitivity Cross-sensitivity with other NSAIDs may exist preoperative use Known alcohol intolerance

Assess pain (note type, location, and intensity) prior to and 1-2 hr following administration. Ketorolac therapy should always be given initially by the IM or IV route. Oral therapy should be used only as a continuation of parenteral therapy. Caution patient to avoid concurrent use of alcohol, aspirin, NSAIDs, acetaminophen, or other OTC medications without consulting health care professional.
Advise patient to consult if rash, itching, visual disturbances, tinnitus, weight gain, edema, black stools, persistent headche, or influenza-like syndromes (chills,fever,muscles aches, pain) occur. Effectiveness of therapy can be demonstrated by decrease in severity of pain. Patients who do not respond to one NSAIDs may respond to another.

DRUG NAME Generic Name Tramadol Brand Name Classification Analgesics Dosage 50mg Defer is BP is >/= 90/60 Stock Dose 50mg/ml (vial) Route IV Frequency Q6 for 4 doses

MECHANISM OF ACTION
binds to -opiate receptors and inhibits reuptake of norepinephrine and serotonin. It reduces intensity of pain stimuli incoming from sensory nerve endings, altering pain perception and emotional response to pain.

INDICATION Tramadol is used to treat moderate to moderately severe pain.

ADVERSE REACTION
- agitation, hallucinations, fever, fast heart rate, overactive reflexes, nausea, vomiting, diarrhea, loss of coordination, fainting; -seizure (convulsions); -a red, blistering, peeling skin rash -shallow breathing, weak pulse. -dizziness, spinning sensation; -constipation, upset stomach; -headache;

CONTRAINDICATION Alcohol intoxication; excessive use of centralacting analgesics, hypnotics, opioids, or other psychotropic drugs; hypersensitivity to tramadol or its components; use within 14 days of MAO inhibitor therapy.

NURSING CONSIDERATION
Defer if BP is </= 90/60 Assess onset, type, location, and duration of pain. Effect of medication is reduced if full pain recurs before next dose. Assess drug history especially carbamazepine, CNS depressant medication, MAOIs. Review past medical history, especially epilepsy or seizures.

Assess renal or hepatic function laboratory values.

Give without regards to meals Monitor pulse and blood pressure. Assist with ambulation if dizziness or vertigo occurs. Dry crackers or cola may relieve nausea. Palpate bladder for urinary retention. Monitor pattern of daily bowel activity and stool consistency. Sips of tepid water may relieve dry mouth. Assess for clinical improvement and record onset of relief from pain.

-drowsiness - feeling nervous or anxious.

DRUG NAME Generic Name Ranitidine Brand Name Quicran Classification Anti-ulcer agents Dosage 50mgx3doses Stock Dose 25mg/ml (ampule) Route IV Frequency Q8

MECHANISM OF ACTION Potent anti-ulcer drug that competitively and reversibly inhibits histamine action at H2receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin concentrations or secretion of gastric intrinsic factor or mucus

INDICATION Treatment and prevention of heartburn, acid indigestion , and sour stomach.

ADVERSE REACTION Depressed deep tendon reflex Seizures Arrhythmias Circulatory collapse Slow, weak pulse Respiratory paralysis

CONTRAINDICATION Contraindicated in patients with myocardial damage, mark myocardial disease, or heart block. IV form is contraindicated in patients with preeclampsia during the 2 hrs preceding delivery. And to those patient with renal impairment.

NURSING CONSIDERATION - Assess patient for epigastric or abdominal pain and frank or occult blood in the stool, emesis, or gastric aspirate. - Nurse should know that it may cause falsepositive results for urine protein; test with sulfosalicylic acid. - Inform patient that it may cause drowsiness or dizziness. -Inform patient that increased fluid and fiber intake may minimize constipation. - Advise patient to report onset of black, tarry stools; fever, sore throat; diarrhea; dizziness; rash; confusion; or hallucinations to health car professional promptly.

DRUG NAME

MECHANISM OF ACTION

INDICATION Respiratory tract or skin and skin-structure infection. GI infection, UTI. Bacterial meningitis or septicemia. Uncomplicated gonorrhea. To prevent endocarditis in patients having dental procedure.

ADVERSE REACTION Seizures Thrombophlebit is Nausea and vomiting Diarrhea Agranulocytosi s Anemia Leucopenia, Thrombocytope nia anaphylaxis

CONTRAINDICATION Contraindicated in patients hypersensitive to drug and other penicillins. Use cautiously in patients with other drug allergies, especially to cephalosporins and in those with mononucleosis

NURSING CONSIDERATION Obtain specimen for culture and sensitivity test before giving the first dose. Monitor patients hydration status. Be alert for adverse reaction.

Inhibits cell wall Generic synthesis Name during Ampicillin microorganism multiplication Brand Name Kills susceptible Liferzin bacteria, including nonClassificatio penicillinase n producing Antibiotic gram-positive Dosage bacteria and 500mg many gramStock Dose negative 250mg/5ml organism (vial) Route IV Frequency Q6

Patients Name: M.A.C. Age: 32y/o Case: Stillbirth Problem: Ineffective tissue perfusion r/t vasoconstriction of blood vessels Short term goal: After 4 hours of nursing intervention, clients blood pressure will decrease to normal range (110-120/7080) Long term goal: After 2 days of nursing intervention, patient will verbalize and will identify factors that improves or inhibits peripheral circulation.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Objective Cues: edema (nonpitting)lower extremities proteinuria Vital Signs: BP: 170/100mmHg PR: 89 bpm RR: 18 cpm Temp: 36C decreased touch sensation

Ineffective tissue perfusion related to vasoconstriction of blood vessels

Increased cardiac

Short term goal:

Independent: Monitor vital signs Elevate the head of the bed and have the client enough rest and sleep Rationale: It can help in decreasing the blood pressure. Change position at least every hour

Standard: The clients blood pressure should be able to stabilize at a normal range of (110-120/70-80)

output that injures the After 4 hours of endothelial cells of the arteries and the action of the prostaglandins. Vasoconstriction occurs and blood pressure increases. nursing intervention, clients blood pressure will decrease to normal range (110-120/7080)

Criteria: The patients blood pressure reached 120/80mmHg.

CUES

DIAGNOSIS

SCIENTIFIC REASON Source: http://nursingcrib.co m/ nursing-careplan/ineffectivetissue-perfusionrelated-tovasoconstriction-ofblood-vessels/

GOAL

INTERVENTION

EVALUATION

Long term goal: After 2 days of nursing intervention, patient will verbalize and will identify factors that improves or inhibits peripheral circulation.

Rationale: to promote or improve arterial blood flow Encourage range-ofmotion exercises Rationale:

to enhance blood circulation

Instruct client to avoid standing or sitting with legs dependent for long periods of time

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Rationale:

to promote or improve venous blood flow

Dependent: Give anticoagulants as ordered Rationale:

to prevent blood coagulation on peripheral blood vessels

Patients Name: M.A.C. Age: 32y/o Case: Stillbirth Problem: Pain r/t tissue trauma secondary to surgical incision Short-term Goal: After 4 hours of nursing intervention, pain scale will reduce from 6/10 to 4/10. Long-term Goal: After 1 day, patient will be able to tolerate the pain well and will verbalize relief of pain.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Subjective: Masakit pa ang tahi sa may tiyan ko. Objective: Facial grimace Guarding behavior Pain scale: 6/10Location: With incision in the hypogastric area

Pain related to tissue trauma secondary to surgical incision

Pain is caused by

Short-term Goal:

Independent: Anticipate need for analgesics. Rationale:

Standard: Patient should not be able to feel pain at all.

the damage done to After 4 hours of tissue by the incision, the procedure itself, the closing of the wound and any force that is applied during the procedure. Source: www. surgery. about.com /od/aftersurgery/a/ SurgeryPain.htm nursing intervention, pain scale will reduce from 6/10 to 4/10. Long-term Goal: After 3 days, patient will be able to tolerate the pain well and will verbalize relief of pain.

One can most effectively deal with pain by preventing it.

Instruct patient to report pain. Criteria: Patient tolerated the pain well and verbalized adequate relief of pain.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Quality: Sharp knife-like pain

Rationale:

So that relief measures may be instituted.

Respond immediately to complaint of pain. Rationale:

Onset: Gradual Duration: Continuous

Type: Superficial somatic pain

Vital signs: -Temperature: 36.5C -BP: 140/90 -PR: 85 bpm -RR: 23 cpm

Prompt responses to complaints may result in decreased anxiety in patient. Demonstrated concern for patients welfare

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

and comfort fosters development of a trusting relationship.

Provide rest periods to facilitate comfort, sleep and relaxation. Rationale:

The patients experiences of pain may become exaggerated as the result of fatigue. A quiet environment , a darkened room

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

are all measures geared toward facilitating rest.

Dependent: Give analgesics as ordered, evaluating effectiveness and

observing for any signs or symptoms of untoward effects. Rationale:

Pain medications are absorbed and metabolized differently by

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

patients, so their effectiveness must be evaluated from patient to patient.

Patients Name: M.A.C. Age: 32y/o Case: Stillbirth Problem: Mild anxiety r/t outcome of future pregnancies secondary to poor OB history Short-term goal: After 2 hours of nursing intervention, patient will appear calm, relax and will verbalize feelings of anxiety properly. Long-term goal: After 1 day, patient will be able to demonstrate positive coping methods. (e.g. positive visualization, reassuring selfstatements etc.)

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Subjective: Ayoko na ulit magbuntis, baka mamatay lang yung ipinagbubuntis ko. Objective: Increase in blood pressure (150/100) Feelings of helplessness Worry Fearfulness

Mild anxiety related to outcome of future pregnancies secondary to poor obstetrical history

For anxiety, women who have suffered adverse outcomes in previous pregnancies are at particular risk. Miscarriage, fetal death, and preterm birth reduce womens quality of life scores and significantly raise their anxiety scores during subsequent

Short-term goal: After 2 hours of nursing intervention, patient will appear calm, relax and will verbalize feelings of anxiety properly. Long-term goal: After 1 day, patient will be able to demonstrate positive coping methods. (e.g.

Independent: Acknowledge awareness of patients anxiety. Rationale: Acknowledgment of patients feelings validates the feelings and communicates acceptance of those feelings.

Standard: Patient should be able to express feelings of anxiety appropriately and should be able to show positive coping methods.

Criteria: Patient verbalized feelings of anxiety properly and

Maintain a calm and

showed healthy

CUES

DIAGNOSIS

SCIENTIFIC REASON pregnancies. One study found that health anxiety was only elevated in pregnant women who had experienced earlier complications during pregnancy. Source: http://psychcentral. com /lib/2010/anxietyin-pregnancy/

GOAL

INTERVENTION

EVALUATION

positive visualization, reassuring selfstatements etc.)

manner while interacting with the patient. Rationale: The patients feeling of stability increases in a clam and nonthreatening atmosphere. Reduce sensory stimuli by maintaining a quiet environment.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Rationale:

Anxiety may escalate with excessive conversation and noise.

Encourage patient to talk about anxious feelings. Avoid false reassurances. Rationale:

False reassurances can increase level of anxiety.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

developing anxietyreducing skills (relaxation, deep breathing, positive visualization, reassuring selfstatements, etc.) Rationale:

Utilizing anxietyreduction strategies enhances patients sense of personal mastery and confidence.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Dependent: Administer antianxiety medications as appropriate.

Patients Name: M.A.C. Age: 32y/o Case: Stillbirth Problem: Anticipatory Grieving related to perceived loss of baby Short-term goal: After 1 hour of nursing intervention, patient will be able to verbalize feelings and establishes and maintains functional support systems. Long-term goal: After 3 days, patient will have a grasp of the current situation and will find ways to cope up with the feelings of grief.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Subjective: Wala na rin kaming magagawa eh, hindi talaga para sa amin yung baby. Objective: Sorrow Teary-eyed Hopelessness

Anticipatory grieving related to perceived potential loss of significant other

Anticipatory grieving is a state in which

Short-term goal: After 1 hour of

Independent: Establish rapport with patient and significant other. Listen and encourage patient/significant other to verbalize feelings. Rationale: This opens lines of communication and facilitate successful resolution of grief.

Standard: Patient should be able have an acceptance bit by bit of the situation.

an individual grieves nursing intervention,

before an actual loss. It may apply to individuals who patient will be able to verbalize feelings and establishes and

have had a perinatal maintains functional loss of a body part or to patients who have received a terminal diagnosis for themselves or a loved one. support systems. Long-term goal: After 3 days, patient will have a grasp of the current situation and will

Criteria: Patient showed acceptance of the situation and is slowly recovering from the situation.

CUES

DIAGNOSIS

SCIENTIFIC REASON Source: http://thromboangiiti s. blogspot .com /2010/09/nursingcare-plan-grievinganticipatory.html

GOAL

INTERVENTION

EVALUATION

find ways to cope up with the feelings of grief.

information about health status without false reassurances or taking away hope. Rationale: Defensive retreat occurs week to months after loss. Patient attempts to maintain what has been lost. Provide information about support groups.

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

Rationale:

Participation in group activities with others who have experienced similar circumstances may help couple successfully work through grief process.
Utilize a visual method to identify the patients critical status, i.e.,

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

color-coded door marker. Rationale:

This will inform hospital personnel of the patients status in an effort to ensure that staff do not act o r respond inappropriately to crisis situation.
Collaborative: Refer to other resources:

CUES

DIAGNOSIS

SCIENTIFIC REASON

GOAL

INTERVENTION

EVALUATION

counseling, group therapy, etc. Rationale:

Patient/significant other may need additional help to deal with individual concerns.

Discharge plan Teach the patient to be aware of the signs and symptoms that could indicate postpartum complications: pain in the calf of the leg; increase in vaginal bleeding; foul odor of vaginal discharge; fever; burning with urination; persistent mood change; a hard reddened area on the breast. Explain that the patient should not have intercourse until after the postpartum check. Encourage the patient in a bereavement support group, even if the patient and significant other seem to be coping with the loss.