Nursing Care Plan NCP

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

Assessment Nursing Scientific Analysis Goal and Nursing Rationale Evaluation

Diagnosis Outcomes Interventions
O: Deficient fluid The nursing Short term: Independent: Short term:
Onset of crampy volume r/t diagnosis is After 5 hrs. of Establish rapport  It is important to After 5 hrs. of
hypogastric pain antepartum deficient fluid nursing to the patient. build trust and nursing
radiating to hemorrhage volume r/t interventions, the relationship to interventions,
Lumbosacral area, PS: antepartum patient will be the patient to the patient will
9/10. Associated with hemorrhage since able to: understand and be able to:
mucoid bloody the patient is communicate
discharge noted and noted with A – Normovolemic well. It also A–
persistence of mucoid bloody as evidenced by improves patient Normovolemic
symptoms. discharge, thus, HR 60 to 100 beats care. as evidenced by
OE: awake, afebrile, the need for fluid per minute, and HR 60 to 100
NRD balance is a normal skin Assess the  To know any beats per
VS: BP: 110/70 priority. turgor. patient’s vital deviations from minute, and
mmHg signs. normal range. normal skin
HR: 104 bpm B – Explain turgor.
RR: 21 cpm measures that can -GOAL MET
Temp: 36.2°C be taken to treat
O2 Sat: 98% or prevent fluid Monitor for  Sources of fluid B – Explain
Weight: 49kg volume loss. possible sources loss may include measures that
Abdomen: of fluid loss and diarrhea, can be taken to
FH: 28cm C – Apply patient’s intake vomiting, wound treat or prevent
EFW: 2680 g alertness and and output. drainage, severe fluid volume
FHT: 135 bpm monitoring if blood loss. It loss.
IE: 6 cm, 90% eff., bleeding persists. provides -GOAL MET
St-2, IBOW, Cephalic information
A: G1P0, PU, 38 ¹/₇ D – Describe about overall C – Apply
weeks AOG Cephalic symptoms that fluid balance, alertness and
in Active Labor indicate the need renal function monitoring if
to consult with ,and bowel bleeding
health care disease control, persists.
provider. as well as -GOAL MET
guidelines for
fluid D – Describe
replacement. symptoms that
indicate the
Monitor vital  Establish need to consult
signs after drug baseline data with health care
administration. and note provider.
changes if -GOAL MET
adverse
reactions occur.

Observe for  Indicates

client’s mucous excessive fluid
membranes, loss or resultant
decreased skin of dehydration.
turgor and look
for signs of
dehydration.

Change the  Turning

position of the positions
patient reduces
frequently, if pressure on
necessary. fragile skin and
tissues.

Emphasize the  Increasing the

relevance of patient’s
maintaining knowledge level
proper nutrition will assist in
and hydration to preventing and
the patient. managing the
 fluid volume
loss.
Dependent:
Administer  Restore and rule
appropriate out any
medications underlying
mandated by conditions.
physician’s
orders.
Provide  Fluids may be
supplemental IV given in this
fluids as manner if client
indicated by is unable to take
physician’s oral fluids.
orders.

Collaborative:
 Refer the patient  Continuity of
to home health care is
nurse or private facilitated
nurse in able to through the use
assist patient, as of community
appropriate. resources.
 Nursing Care Plan NCP

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

Assessment Nursing Scientific Analysis Goal and Nursing Rationale Evaluation

Diagnosis Outcomes Interventions
O: Acute pain r/t Acute pain is a Short term: Independent: Short term:
Patient reported active phase of type of pain that After 7 hrs. of  Assess current  Allows the nurse After 7 hrs. of
onset of crampy labor amb pt’s typically lasts less nursing knowledge of to develop an nursing
hypogastric pain report of pain than 3 to 6 interventions, the obstetric pain individualized interventions,
radiating to months, patient will be control teaching plan the patient was
Lumbosacral area, PS: or pain that is able to: measures. for the patient. able to:
9/10. Associated with directly related  Assess anxiety  Allows for early
mucoid bloody to soft tissue A – Make an level and intervention to A – Make an
discharge noted and damage. informed decision implement decrease anxiety informed
persistence of regarding on pain measures to levels. High decision
symptoms. control measures. reduce anxiety levels of anxiety regarding on
OE: awake, afebrile, as needed. can increase the pain control
NRD B – Patient will perception of measures.
VS: BP: 110/70 engage in pain, decrease -GOAL MET
mmHg nonpharmacologic ability to
HR: 104 bpm measures to tolerate pain, B – Engage in
RR: 21 cpm reduce discomfort and decrease nonpharmacolo
Temp: 36.2°C or pain. comprehension gic measures to
O2 Sat: 98% of verbal reduce
Weight: 49kg C – Patient will instruction. discomfort or
Abdomen: report satisfactory  Initiate  These pain.
FH: 28cm pain control at a teaching/reinfor nonpharmacolo -GOAL MET
EFW: 2680 g level less than 3 to cing of gic comfort
FHT: 135 bpm 4 on a rating scale nonpharmacolo measures work C – Report
IE: 6 cm, 90% eff., of 0 to 10 by the gic comfort by providing satisfactory pain
 St-2, IBOW, Cephalic use of childbirth measures that diversion during control at a level
A: G1P0, PU, 38 ¹/₇ techniques can be used uterine less than 3 to 4
weeks AOG Cephalic learned and/or during labor if contractions. It on a rating scale
in Active Labor comfort needed (e.g., promotes of 0 to 10 by the
measures/analges use of focal relaxation and use of childbirth
ics/anesthetics point, visual enhances well- techniques
given. imagery, being of the learned and/or
breathing and patient. comfort
relaxation measures/analg
techniques). esics/anesthetic
 Provide positive  Positive s given.
reinforcement reinforcement -GOAL MET
and and
encouragement encouragement
to patient and provide the
support persons. patient and
support person
a sense of
control and self-
confidence.
 Monitor  Establish
maternal and baseline data
fetal vital signs. and note
changes.

Dependent:  Administering IV
 Administer drug during
medications by uterine
IV during contractions
contractions or decreases
IM, as indicated amount of
by physician’s medication that
orders. immediately
reaches fetus.
References:
 Dickerman, R. (2020). Acute Pain Definition. Spine-health. Retrieve from: https://www.spine-health.com/glossary/acute-pain#:~:text=Acute

%20pain%20is%20a%20type,as%20the%20injured%20tissues%20heal.

FDAR CHART

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DATE AND TIME FOCUS DATE, ACTION AND RESPONSE

D: Received patient

FDAR CHART

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DATE AND TIME FOCUS DATE, ACTION AND RESPONSE

 DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  Stimulates uterine  Induction of labor at Hypersensitive to  CNS: maternal— 1. Check physician’s
Oxytocin smooth muscle, term. drug when vaginal COMA, SEI-ZURES; orders.
producing uterine  Facilitation of delivery is advised fetal, INTRACRANIAL
Brand name: contractions similar threatened Cephalopelvic HEMORRHAGE. 2. Observe 10 rights of
Pitocin to those in abortion. disproportion is  Resp: fetal— drug administration.
spontaneous labor.  Post-partum control present ASPHYXIA,hypoxia
Classification:  Has vasopressor of bleeding after When delivery  CV: maternal— 3. Assess character,
Oxytocics and antidiuretic expulsion of the requires conversion hypotension; fetal, frequency, and
effects. placenta. as in transverse lie arrhythmias. duration of uterine
Route:  GI: nausea and contractions; resting
IV vomiting uterine
 F and E: maternal— tone; and fetal heart
Dosage: hypochloremia, rate frequently
10 mg hyponatremia, throughout
water intoxication. administration.

4. Monitor maternal BP
and pulse frequently
and fetal heart rate
continuously
throughout
administration.

5. Monitor patient for

signs and
symptoms (drowsiness,
listlessness, confusion,
headache, anuria) and
notify physician or
other health care
professional if they
occur.

6. Monitor patient
extremely closely
during first and second
stages of labor because
of risk of cervical
laceration, uterine
rupture and maternal
and fetal death.

7. Watch and take note

for any signs and
symptoms.

8. Advise patient to
expect contractions
similar to menstrual
cramps after
administration has
started.

9. Document that the

drug has been given.
References:

Vallerand, A., H., Sanoski, & Deglin, J. H. (2015). Oxytocin.  Nurse’s Med Deck (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/oxytocin.pdf

DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  Inhibits the action Treatment of the  Hypersensitivity, CNS: headache, 1. Check physician’s
Cefalexin of histamine at following infections Cross-sensitivity may malaise, vertigo orders.
theH2 receptor site caused by occur; some oral EENT: blurred vision 2. Observe 10 rights of
Brand name: located primarily in susceptible liquids contain alcohol GI: constipation, drug administration
Canelin gastric parietal organisms: Skin and and should be avoided diarrhea, nausea and 3. Do skin testing
cells, resulting skin structure in patients with vomiting 4. Verify correct IV
Classification: ininhibition of infections, known intolerance OTHER: anaphylaxis, concentration and
Anti-infective agent gastric acid Respiratory tract  Safe use during angioedema, burning rate of infusion
secretion infections, Otitis pregnancy (category and itching at 5. Allow 1 hour
Route:  Indirectly reduces media, Urinary tract B) or lactation is not injection site between any other
Oral pepsin secretion infections, Bone established. antacid and ranitidine
but appears to have infections.  Use cautiously 6. Avoid excessive
Dosage: minimal effect on inpatients with alcohol
500 mg 1cap fasting and hepatic dysfunction. 7. Assess patient for
postprandial serum  Adjust dosage epigastric or
Frequency: gastrin inpatients with abdominal pain and
TID x 7 days concentrations or impaired renal frank or occult blood
secretion of gastric function in the stool, emesis,
intrinsic factor or or gastric aspirate
mucus. 8. Nurse should know
that it may cause
false-positive results
for urine protein;
test with
sulfosalicylic acid
9. Inform patient that
it may cause
drowsiness or
dizziness
10.Inform patient that
increased fluid and
fiber intake may
minimize
constipation
11.Advise patient to
report onset of
black, tarry stools;
fever, sore throat;
diarrhea; dizziness;
rash; confusion; or
hallucinations to
health care
professional
promptly
12.Inform patient that
medication may
temporarily cause
stools and tongue to
appear gray black.
13. Instruct patients to
monitor for and
 report occurrence
of drug-induced
adverse reaction.

References:

Vallerand, A., H., Sanoski, & Deglin, J. H. (2015). Cephalexin.  Nurse’s Med Deck  (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/cephalexin.pdf

DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  Inhibits the enzyme  Relief of signs and  Hypersensitivity  CNS: dizziness, 1. Check physician’s
Celecoxib COX-2. This enzyme symptoms of  Cross-sensitivity headache, insomnia orders.
is required for the osteoarthritis, may exist with
Brand name: synthesis of rheumatoid other NSAIDs,  CV: HF, 2. Observe 10 rights of
Coxto prostaglandins. arthritis, ankylosing including aspirin MYOCARDIAL drug administration.
 Has analgesic, anti- spondylitis, and  History of allergic- INFARCTION,
Classification: inflammatory, and juvenile rheumatoid type reactions to STROKE, 3. Assess patient for
Nonsteroidal anti antipyretic arthritis. sulfonamides THROMBOSIS, allergy to sulfonamides,
inflammatory agent, properties.  Management of  History of asthma, edema, aspirin, or NSAIDs.
Antirheumatics acute pain including urticaria, or allergic- hypertension Patients with these
primary type reactions to allergies should not
Route: dysmenorrhea. aspirin or other  Derm: EXFOLIATIVE receive celecoxib.
Oral NSAIDs DERMATITIS,
 Advanced renal STEVENS-JOHNSON 4. Assess patient for
Dosage: disease SYNDROME, TOXIC skin rash frequently
200 mg 1 cap  Severe hepatic EPIDERMAL during therapy.
dysfunction NECROLYSIS, rash Discontinue at first sign
Frequency:  Coronary artery of rash.
BID bypass graft (CABG)  F and E:
surgery hyperkalemia 5. Instruct patient to
take celecoxib exactly
 GI: GI BLEEDING, as directed. Do not take
abdominal pain, more than prescribed
diarrhea, dyspepsia, dose. Increasing doses
flatulence, nausea does not appear to
increase effectiveness.

6. Advise patient to
notify health care
professional promptly if
signs or symptoms of GI
toxicity (abdominal
pain, black stools),
cardiovascular effects
(chest pain, shortness
of breath, weakness,
slurring of speech), skin
rash, unexplained
weight gain, or edema
occurs.

7. Instruct patient in
correct technique for
monitoring BP and to
notify health care
professional if
significant changes
 occur.

8. Document that the

drug has been given.

References:

Vallerand, A., H., Sanoski, & Deglin, J. H. (2015). Celecoxib.  Nurse’s Med Deck  (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/celecoxib.pdf

DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  The active  Natural health   When taken by 1. Check physician’s
Moringa component, supplement for mouth: Moringa orders.
malunggay nursing mothers is LIKELY SAFE when
Brand name: (Moringa oleifera), especially those the leaves, fruit, and 2. Observe 10 rights of
Feralac has gained with inadequate seeds are eaten as drug administration.
acceptance as a lactation. food. Moringa leaf
Classification: health food and seeds 3.
Supplements supplement to help are POSSIBLY
stimulate the SAFE when taken by
Route: secretion and flow mouth as medicine,
Oral of milk. short term. 
  It has been used by  Pregnancy:
Dosage: generations of It's POSSIBLY
500 mg 1 cap nursing mothers UNSAFE to use the
especially those root, bark, or flowers
Frequency: with inadequate of moringa if you are
OD lactation. pregnant.

References:

Vallerand, A., H., Sanoski, & Deglin, J. H. (2015). Celecoxib.  Nurse’s Med Deck  (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/celecoxib.pdf

DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  Senna’s metabolite  Treatment of  Hypersensitivity  F and E: electrolyte 1. Check physician’s
Senna acts as a local irritant constipation  Abdominal pain, imbalances, orders.
on the colon associated with dry, nausea, or vomiting, dehydration.
Brand name: stimulating hard stools and especially when  GI: abdominal 2. Observe 10 rights of
Senokot Forte peristalsis. decreased intestinal associated with cramps, nausea, drug administration.
 Docusate promotes motility. fever or other signs vomiting, diarrhea.
Classification: incorporation of  Prevention of of an acute  Derm: rashes. 3. Assess for abdominal
Stimulant laxatives water into stool, opioid induced abdomen  GU: urine distention, presence of
resulting in softer constipation.  Concomitant use of discoloration. bowel sounds, and
Route: fecal mass. mineral oil. usual pattern of
Oral  Therapeutic Effects: bowel function.
Softening and
Dosage: passage of stool. 4. Assess color,
500 mg 1 cap consistency, and
amount of stool
Frequency: produced.
OD HS
5. Administer with a full
glass of water or juice
preferably in the
evening.

6. Do not administer
within 2 hr of other
laxatives, especially
mineral oil. May cause
increased absorption.

7. Advise patients that

laxatives should be
used only for short-
term therapy.

8. Encourage patients
to use other forms of
bowel regulation, such
as increasing
bulk in the diet,
increasing fluid intake
(6–8 full glasses/day).

9. Advise patient not to

use laxatives when
abdominal pain,
nausea, vomiting, or
 fever is present.

References:

Vallerand, A., H., Sanoski, & Deglin, J. H. (2015). Docusate sodium senna.  Nurse’s Med Deck  (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/docusatesodiumsenna.pdf

DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name: An essential mineral  For relief of mild to  Known  In recommended doses, 1. Check physician’s
MV + Iron found in moderate pain in hypersensitivity adverse reactions are orders.
hemoglobin, patients ≥ 14 years (e.g., anaphylactic extremely rare
Brand name: myoglobin, of age, when reactions and  GU: urine discoloration 2. Observe 10 rights
Foralivit andmany enzymes. therapy will not serious skin (preparations with B of drug
Enters the exceed one week reactions) vitamins). administration.
Classification: bloodstream and is (7 days).  History of  asthma,  Misc: allergic reactions to
Vitamins & transported to the  For treatment of or other allergic- preservatives, additives, or 3. Assess patient for
Minerals (Pre & organs of the primary type reactions after colorants. signs of nutritional
Post Natal); reticuloendothelial dysmenorrhea. taking aspirin or deficiency, possible
Antianemics system (liver, other NSAIDs. cause of anemia
spleen, bone and need for patient
Route: marrow) where it teaching.
Oral becomes part of
iron stores. 4.Instruct the patient
Dosage: that oral preparations
500 mg 1 cap are most effectively
absorbed if
Frequency: administered 1hr
OD before or 2hr
after meals. If gastric
irritation occurs,
administer with
meals.

5. Advise the patient

to take tablets and
capsules with a full
glass of water or juice.

6. Encourage patient
to comply with
medication regimen.
Take missed doses as
soon
as remembered
within 12 hr,
otherwise, return to
regular dosing
schedule. Do not
double doses.

7. Advise patient that

stools may become
dark green or black.
References:

Multum, C. (August 23, 2019). Multivitamins and minerals. Drugs.com. Retrieve from: https://www.drugs.com/mtm/multivitamins-and-

minerals.html

Vallerand, A., H., Sanoski, & Deglin, J. H. (2015). Multiple vitamins.  Nurse’s Med Deck  (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/multiplevitamins.pdf

DRUG STUDY

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

DRUG ORDER MECHANISM OF INDICATIONS CONTRAINDICATIONS ADVERSE EFFECT NURSING

ACTION RESPONSIBILITY
PRECAUTION
Generic Name:  Inhibits the action Treatment of the  Hypersensitivity, CNS: headache, 1. Check physician’s
Cefalexin of histamine at following infections Cross-sensitivity may malaise, vertigo orders.
theH2 receptor site caused by occur; some oral EENT: blurred vision 2. Observe 10 rights of
Brand name: located primarily in susceptible liquids contain alcohol GI: constipation, drug administration
Canelin gastric parietal organisms: Skin and and should be avoided diarrhea, nausea and 3. Do skin testing
 cells, resulting skin structure in patients with vomiting 4. Verify correct IV
Classification: ininhibition of infections, known intolerance OTHER: anaphylaxis, concentration and
Anti-infective agent gastric acid Respiratory tract  Safe use during angioedema, burning rate of infusion
secretion infections, Otitis pregnancy (category and itching at 5. Allow 1 hour
Route:  Indirectly reduces media, Urinary tract B) or lactation is not injection site between any other
Oral pepsin secretion infections, Bone established. antacid and ranitidine
but appears to have infections.  Use cautiously 6. Avoid excessive
Dosage: minimal effect on inpatients with alcohol
500 mg 1cap fasting and hepatic dysfunction. 13. Assess patient
postprandial serum  Adjust dosage for epigastric or
Frequency: gastrin inpatients with abdominal pain and
TID x 6 days concentrations or impaired renal frank or occult blood
secretion of gastric function in the stool, emesis,
intrinsic factor or or gastric aspirate
mucus. 14.Nurse should know
that it may cause
false-positive results
for urine protein;
test with
sulfosalicylic acid
15.Inform patient that
it may cause
drowsiness or
dizziness
16.Inform patient that
increased fluid and
fiber intake may
minimize
constipation
17.Advise patient to
report onset of
black, tarry stools;
fever, sore throat;
diarrhea; dizziness;
rash; confusion; or
hallucinations to
health care
professional
promptly
 18.Inform patient that
medication may
temporarily cause
stools and tongue to
appear gray black.
13. Instruct patients to
monitor for and
report occurrence
of drug-induced
adverse reaction.

References:

Vallerand, A., H., Sanoski, & Deglin, J. H. (2017). Cephalexin.  Nurse’s Med Deck  (14th ed.). F.A. Davis Company. Retrieve from:

https://davisplus.fadavis.com/3976/meddeck/pdf/cephalexin.pdf

CEPHALOCAUDAL ASSESSMENT

CLINICAL INSTRUCTOR : Adriel Arman V. Pizarra, DHCM, MAN, RN

CASE STUDY NO. 2 – Kristinelou Marie N. Reyna
CLIENT NAME : Jennifer T. Lee AGE : 23 SEX : F
REASON FOR ADMISSION : Labor Pain
ADMITTING IMPRESSION: G1P0, Pregnancy Uterine, 38 ¹/₇ weeks AOG, Cephalic in Active Labor
PHYSICIAN : Dr. Montefalcon

HEAD AND FACE FINDINGS

Skin, Head and Face, Eyes, Ears, Nose Skin: The patient’s skin is fair in color. Patient’s skin has no lesions,
edema or abrasions. Warm to touch, poor turgor.
Head: Patient’s head is symmetrically round. Patient’s hair is long ash
brown, looks clean and dry.
 Eyes: Pupils are equally round, reactive to light and accommodation. No
visual disturbances.
Ears: Bilaterally symmetrical in both sides, no pus or blood. Normal voice
tones are audible to patient.
Nose: Slightly turned up, rounded nose tip symmetric along midline. Has
no discharges, no nasal flaring, both nares are patent. Nasal
turbinates are intact without deformities and presence of nodules.

NECK FINDINGS

Neck, Thyroid Gland Neck is symmetrical with head in central position. Able to move head
without discomfort or noticeable limits. Thyroid gland is not visible in
inspection, gland ascends during swallowing, no palpable masses.

CHEST FINDINGS
Anterior: Chest is symmetric upon expansion, Without lesions, skin intact.
Thorax, Anterior and Posterior and Lateral Quiet, rhythmic and effortless breathing, bronchovesicular and
vesicular breath sounds observed.
Posterior: Posterior thorax is asymmetric, muscle development is equal.
Chest is symmetric upon expansion. No masses or tenderness
upon palpation.

ABDOMEN FINDINGS

Abdominal movements, Auscultation of bowel sounds The patient’s abdomen skin color is uniform, no lesions, no scars.
Intermittent gurgling sounds observed. No friction rubs/audbile bruits
noted. Guarding movements observed. Patient reports hypogastric
pain radiating to lumbosacral area. PS: 9/10, 10 being the highest and
1 being the lowest.

UPPER EXTREMITIES FINDINGS

Muscles, Bones and Joints, The patient’s muscles are bilaterally symmetric, has no contractures
and tremors. The bones are uniform in structure, no deformities,
tenderness or edema. Joints are not tender, has smooth movement and
 no nodules.

LOWER EXTREMITIES FINDINGS

Both extremities are equal in size, have the same contour with
prominences of joints, slight edema observed. Color is even,
temperature is warm and even,

MENTAL STATUS / GROSS MOTOR FUNCTION FINDINGS

Language, Orientation, Attention span, Level of Consciousness,

Walking gait,

ANATOMY AND PHYSIOLOGY

VAGINA

The part of the female genitals behind the bladder and in front of the rectum that forms a canal. This extends from the uterus to the vulva.

CERVIX

The lower part of the uterus that extends into the vagina. The cervix is made up of mostly fibrous tissue and muscle. It is circular in shape.

UTERUS

The uterus, or womb, is a hollow, pear-shaped organ ln a woman's lower stomach between the bladder and the rectum. It sheds its lining each
month during menstruation. A fertilized egg (ovum) becomes implanted in the uterus, and the fetus develops. The inner layer, called the
endometrium, is the most active layer and responds to cyclic ovarian hormone changes. The middle layer, or myometrium, makes up most of the
uterine volume and is the muscular layer. The outer layer of the uterus, the serosa or perimetrium, is a thin layer of tissue that envelop the
uterus.

OVARIES

The ovaries are the female pelvic reproductive organs that house the ova and are also responsible for the production of sex hormones. They are
paired organs located on either side of the uterus within the broad ligament below the uterine (fallopian) tubes.

FALLOPIAN TUBES

Also called oviduct or uterine tube, either of a pair of long narrow ducts located in the human female abdominal cavity that transport male
sperm cells to the egg, provide a suitable environment for fertilization. Varies from 8-14 cm in length. Ovaries produced during puberty are
about 400,000 egg cells.
 ANATOMY AND PHYSIOLOGY DURING PREGNANCY

UTERUS

 The uterus leaves the pelvic and ascends to the abdominal cavity and the abdominal  content
displaced in response to the increased size of the uterus which is 5 times more than normal
this increases in the size of uterus associated with an increase of blood supply to the uterus
and uterine muscle activity.
 Increases in size till the 38 weeks after that the funds level starts to descend preparing for
delivery.
 Its weight increases from 50mg to 1000mg after that it doesn't get heavier any more and
only stretches to accommodate the fetus size, and associated with an increase in the
thickness and length of the fundus.

CERVIX

 The enlarged mucus glands of the cervix during pregnancy secretes a mucus plug called
“operculum”, act as a seal for the uterus and protect it from ascending infection, and act as a
barrier between the vagina and cervix. Later in pregnancy before delivery, there is a softening
of the cervix in response to the increasing uterine contractions.

VAGINA

 During pregnancy there is an increase in the blood supply to the vagina, its color change from
pink to purple, and becomes more elastic in the second trimester.

VAGINAL DISCHARGE

 During pregnancy, leukorrhea production increases due to increased estrogen and blood
flow to the vaginal area.
 However, this increase doesn't typically become noticeable until the 8 th week—after other,
more definitive signs of early pregnancy, such as a missed period.
 In first trimester of pregnancy, vaginal discharge increases in an effort to remove dead cells
and bacteria from the uterus and vagina to help prevent infections.