GENERAL SANTOS DOCTORS’ MEDICAL SCHOOL FOUNDATION, INC.

Bulaong Subdivision, Barangay West, General Santos City 9500

Tel No.: (083) 302-3507, Telefax No.: (083) 552-9793

GRAND CASE PRESENTATION

OLIGOHYDRAMNIOS
In Partial Fulfilment of the Requirements In NCM 116n
Related Learning Experience

Presented to:
Nancy A. Sarmiento, RN, MAN
Mark Arthur Penafiel RN, LPT
Nelba C. Tangog, RN, MANc
Sherad A. Lee, RN, RM, MN

Submitted by:
FERRANDO, Andrea Samantha Sushyne C.
ELESTERIO, Michell Andre T.
TORREFIEL, Robert James H.
ACAMAD, Alyanna Aliah K.
ESBERTO, Jam Noreen C.
VENTURA, Blyzy Myryz T.
CAMACHO, Jessamae A.
ROMA, Danna Nicole M.
ER-ER, Pamela Olivia O
TORRES, Rose Jane A.
MASABPI, Aisha A.
DE PABLO, Aira B.
DELMO, Kyla

MAY 2022
 TABLE OF CONTENTS

Cover Page i

Table of Contents ii

Acknowledgement 3

Chapter I: Introduction 4

Chapter II: Demographic Profile 7

Chapter III: Physical Assessment & Gordons’ FHP 8

Chapter IV: Review of Anatomy & Pathophysiology 19

Chapter V: Diagnostic Procedures 24

Chapter VI: Nursing Care Plan 26

Chapter VII: Drug Study 45

Chapter VIII: Discharge Planning 64

Chapter IX: Bibliography 68

Chapter X: Appendix 74
 ACKNOWLEDGEMENT

This undertaking may not have been possible without the involvement and

support of those individuals who extended their support in so many ways. Their

efforts are sincerely valued and will always be remembered with gratitude.

The group would like to thank the Clinical Instructor Mr. Mark Peñafiel. for

his untiring support throughout the conduct of this case study. Truly, his

enthusiasm and concern to the group has led to the group's success of completing

the case.

To Dr. Grace Joy Gerada-Nietes, Dean of General Santos Doctors Medical

School Foundation, Inc., for the motivation and to bring only the best from the

students;

To Mrs. Nancy A. Sarmiento, level 3 head coordinator for ensuring that the

students are on track in developing the student’s skills and knowledge especially

during the virtual classes and duty; To Mrs. Nelba C. Tangog and Mrs. Sherad A.

Lee, our other RLE coordinators for leading us, our million thanks to your guidance

to help us in keeping and finishing our course despite the many challenges along

the way;

To the parents and guardians who were determined to let the students finish

their studies, thank you for the sacrifices, love and financial support and;

Above all, to Almighty God, for being the source of knowledge, passion of

service to humanity, and strength amidst the hardships especially in adapting to

the "new normal" of learning due to COVID 19 pandemic.

3
 CHAPTER I

INTRODUCTION

Oligohydramnios is defined as reduction in amniotic fluid less than 500ml.

Normally, the amniotic fluid ranges from 800 to 1,200 ml at term. Between the 28

weeks and 40 weeks, the total pockets of amniotic fluid seen by ultrasonography

average to 12 to 15 cm, an amount smaller than 5 to 6 cm indicates

oligohydramnios. Because of this, a decrease in amniotic fluid volume puts the

fetus at risk for fetal death, intrauterine growth restriction, limb contractures

(oligohydramnios begins early in the pregnancy), delayed or incomplete lung

maturation (oligohydramnios begins early in the pregnancy), inability of the fetus

to tolerate labor, requiring for cesarean delivery. (Silbert-Flagg, J. and Pilliteri, A.,

8th Edition, pg 179, 195 & Dulay, A., 2020).

The importance of amniotic fluid is it is essential for the fetus for its normal

growth and development. It protects the fetus from physical trauma, allows for fetal

lung development, and acts as an infection barrier. The volume of amniotic fluid in

the gestational sac is a result of a balance between fluid production and fluid

movement out of the sac. Lung secretions, as well as hydrostatic and osmotic

transport of maternal plasma through the fetal membranes, account for the majority

of amniotic fluid production during the first 20 weeks. Around 16 weeks, the fetal

kidneys begins to operate, thus the fetal urine production steadily increases,

eventually taking over the majority of amniotic fluid production until the pregnancy

reaches term (Shanks, A., and Keilman, C., 2021). For instance, a disturbance of

4
kidney function, may cause an abnormal low level of amniotic fluid called

oligohydramnios.

Oligohydramnios is a complication in approximately 4.4% of all pregnancies

according to Willacy, H. (2021). Oligohydramnios is more common in pregnancies

beyond term, as the AFV normally decreases at term. It complicates as many as

12% of pregnancies that last beyond 41 weeks. Moreover, Friedman, P. and

Ogunyemi, D. (2018) mentioned that pulmonary hypoplasia is the primary cause

of mortality in pregnancies complicated by second-trimester oligohydramnios.

Because amniotic fluid is necessary for the normal development and expansion of

the pulmonary system, a lack of it at critical periods of lung development is linked

to a poor outcome. Meanwhile, in the Philippines, as stated by the study of

Dalmacion G., et al (2018), the prevalence of oligohydramnios in Paranaque and

Tagum city accounts to 0.6% neonatal deaths.

As stated, the aforementioned statistics, oligohydramnios is rare, however

the impact of this condition can contribute to mortality in pregnancies. With that,

the student nurses would like to raise awareness by applying nursing interventions

regarding to this situation. The goals that the student nurses will follow are: (1) To

obtain knowledge about oligohydramnios; (2) To understand and conceptualize

the pathophysiology of the condition; (3) To implement nursing care to help ensure

both a safe fetal environment and a safe pregnancy outcome; and (4) To utilize the

information in raising awareness.

5
General Objectives:

For the student nurses to grasp new concepts regarding pregnancy

condition called Oligohydramnios and to comprehend its nature and management.

As well as discuss the overall health condition of the patient chosen for this grand

case presentation.

Specific Objectives

The student nurses will be able to:

1. Define and obtain background knowledge about Oligohydramnios;

2. Present demographic profile of patient;

3. Analyze and interpret the results of the physical assessment;

4. Review the anatomy and physiology and trace and discuss the

pathophysiology of Oligohydramnios;

5. Interpret course in the ward and diagnostic procedures;

6. Prioritize nursing problems and develop an effective nursing care plan.

7. Formulate drug study of the prescribed medications and;

8. Create appropriate discharge plan for patient.

6
 CHAPTER II

DEMOGRAPHIC PROFILE

Patient’s Full Name: S.C.

Age and Sex: 26 years old/Female

Birthdate: No data available

Religion: Roman Catholic

Address: Brgy. Calumpang, General Santos City

Marital Status: Married

Educational Level: No data available

Occupation: No data available

Recent Travel: No data available

Immunization: No data available

Medication: Dexamethasone 6mg IM q12, Cefuroxime 750mg IVTT q8,

Ketorolac 50mg IVTT q8, Tramadol 50mg IVTT q8 prn for severe pain, Ranitidine

50mg IVTT q8 prn x2 more doses, Metoclopramide Hydrochloride 10mg IVTT

Admitting diagnosis: PU 34 weeks, CNIL oligohydramnios, G1P0

Allergies: None

Chief Complaints: Oligohydramnios

PAST MEDICAL HISTORY: No comorbidity

PRESENT MEDICAL HISTORY: 26 years old, G1P0, PU 34 weeks cephalic not

in labor few hours prior, consult with attending showed oligohydramnios, no bloody

or clear discharge vaginal.

7
 CHAPTER III

PHYSICAL ASSESSMENT

Physical Examination according to Chart/Records (April 11, 2022 - 6:50PM)

• HEENT: Symmetric chest exam, clear breath sounds
• CHEST/LUNGS: A dynamic precordium
• CVS: Regular rate & rhythm
• GU (IE): IE at 6:55pm Cervix close, no blood on gloved finger
• SKIN/EXTREMITIES: Full + equal pulses, Warm
• NEURO EXAMINATION: GCS 15
VITAL SIGNS (APRIL 12, 2022 at 4:00AM)

BP: 110/70 mmHg Temp: 36 ºC RR: 19 cpm PR: 83 bpm

General Appearance: The patient is conscious and appears to be in moderate distress, oriented in time, date, and place.
Inspection Palpation Percussion Auscultation Interpretation
Skin >Noted Not Performed Not Performed Not Performed >Linea nigra maybe present and
hyperpigmented area normally appears during pregnancy.
specifically in the > A pregnant woman's body goes
abdomen. A dark, through hormonal changes during
vertical line on the belly pregnancy, causing estrogen levels to
rise. Higher estrogen levels may
> Upon inspection increase the likelihood of developing
notice palms of the palmar erythema.
hand is red.

8
HEEN > Patient has black and Not Performed Not Performed Not Performed > The iris is typically round, flat, and
straight hair evenly colored. The pupils, round with a
> Pupils are equal and regular border, is centered in the iris.
round, reactive to light > Ears are equal in size bilaterally
and accommodation (normally 4-7 cm). The tympanic
membrane should be pearly gray, shiny
> Tympanic membranes and translucent, with no bulging or
clear: Landmarks retraction.
visible. > Nasal mucosal swelling and redness
may result from increased estrogen
production in pregnant woman.
> No noted swelling of Epistaxis is common for pregnant
nasal mucosa and woman because it is a common variation
redness. No epistaxis of the increased vascular supply to the
noted upon inspection. nares during pregnancy.
Mouth > Throat is pink and no Not Performed Not Performed Not Performed > In all clients, tissue should be smooth
and redness or exudate. and moist without lesions.
Throat
Neck > Neck is symmetric, > Smooth, Not Performed Not Performed > In pregnant women smooth,
with head centered and nontender, nontender, small cervical nodes may be
without bulging masses. palpable and a slight enlargement of the
small thyroid may be noted during pregnancy.
cervical
nodes is
palpable.
No
enlargeme
nt of
thyroid.

9
Thorax > Upon inspection there Not Performed Not Performed > As the uterus expands, the diaphragm
Not Performed
and is an increased is displaced cephalad by as much as
Lungs anteroposterior 4cm; the anteroposterior and transverse
(cardio- diameter in the patient. diameter of the thorax increases, which
pulmo) enlarges chest wall circumference.
Breast > Venous congestion is Not Performed Not Performed > Venous congestion is noted with
Not Performed
noted with prominence prominence of veins. Montgomery
of veins. tubercles are prominent. Breast size is
> Montgomery tubercles increased and nodular. Breast are more
are prominent. Breast sensitive to touch.
size is increased and Colostrum is excreted especially in the
nodular. thirdtrimester. Hyperpigmentation of
> Breast are more nipples is normal.
sensitive to touch.
> Colostrum is excreted
especially in the third
trimester.
> Hyperpigmentation of
nipples is evident.
Heart Not Performed Not Performed > Normal > Normally no murmurs are heard but for
Not Performed
sinus pregnant patients soft systolic murmurs
rhythm are commonly audible during pregnancy
Soft systolic secondary to the increased blood
murmurs volume.
are noted
Abdomen >Upon inspection, striae > Not Performed Not Performed > Striae and linea-nigra are normal. The
Uterus
and linea-nigra are feels firm size of the abdomen mqy indicate
present. Increased size gestational age and the shape of the
of the abdomen due to uterus may suggest fetal presentation
and position in later pregnancy.

10
 the indication of upon > The uterus is normally feels firm in
gestational age. palpation. pregnant patients. Normally Contraction
may last 40-60 seconds and occur every
5-6 minutes.
Fetal > FHT: 133 (4-12-22 – Not Performed Not Performed > Fetal heart rate normally ranges from
Not Performed
Heart 4am) 120 to 160 beats/min. During the third
trimester, the fetal heart rate should
accelerate with fetal movement.
Genito- > IE: IE at 6:55pm Not Performed Not Performed > External Genitalia: Normal findings
Not Performed
Urinary Cervix close, no blood include enlarged labia and clitoris,
on gloved finger parous relaxation of the introitus, and
scars from an episiotomy or perineal
lacerations (in multiparous women).
There should be no discomfort or
discharge with examination. No
cystocele or rectocele.
> Internal Genitalia: Cervix should look
pink, smooth, and healthy. With
pregnancy, the Cervix may appear
bluish (Chadwick sign). In multiparous
women, the cervical opening has a slit-
like appearance known as "fish mouth."
A small amount of whitish vaginal
discharge (leukorrhea) is normal. The
cervix may be palpated in the posterior
vaginal vault. It should be long, thick,
and closed.Cervical length should be
approximately 2.3-3 cm. Positive Hegar
sign (Softening of the lower uterine
segment) should be present.

11
 > No masses should be palpable.
Discomfort with examination is due to
stretching of the round ligaments
throughout the pregnancy.
Anus and > Mucosa is pink and Not Performed Not Performed > Mucosa should be pink and intact. No
Not Performed
Rectum intact. masses, varicosities, lesions, tears, or
> No masses, discharge present. Hemorrhoids or
varicosities, lesions, varicose veins may be present.
tears or discharge is Hemorrhoids usually get bigger and
noted. more uncomfortable during pregnancy.
Bleeding and infection may occur.
Musculos > Subpubic arch is Not Performed Not Performed > The subpubic arch should be greater
Not Performed
keletal greater than 90 than 90 degrees.
degrees. > Lateral walls should be straight or
divergent.
> Ischial spines are small, not
prominent. Interspinous diameter is at
least 10.5 cm
Reference: Health Assessment in Nursing/ Janet R. Weber, Jane H. Kelley. Sixth edition. | Philadelphia: Wolters Kluwer, [2018]

12
 GORDON’S FUNCTIONAL HEALTH PATTERN

HEALTH PATIENT’S ANSWER JUSTIFICATION

PATTERN

Health • The patient Constipation is fairly common in

Perception/ stated that her pregnancy, defined as having fewer
Health health is not than three bowel movements per
Management healthy due to week and/or having difficulty passing
experiencing stool when you do go. While
constipation. constipation during pregnancy isn't
Her bowel harmful to the baby, it might be
movements are unpleasant for you.( Miller, 2021)
2-3 times a
week.
The high blood pressure runs in
• The patient families, and this is a risk factor for
reported a having high blood pressure. If you
family history of have one or more close family
hypertension on members who have high blood
both the mother pressure before the age of 60, you
and father side. have a twofold chance of developing it
yourself. (CDC, n.d)
• The patient
stated she
experienced Morning sickness, often known as
severe morning pregnant nausea and vomiting, is a
sickness in her common ailment. It affects over 70%
3rd and 4th of pregnancies and typically begins
month term. around week 6 of pregnancy and lasts
for weeks or months. During the
second trimester, symptoms normally
improve (weeks 13 to 27; the middle 3
months of pregnancy). (Cleveland
Clinic, n.d)

Nutritional- • The patient Excessive caffeine consumption, as

Metabolic stated that she well as the use of alcohol, cigarettes,
has no and khat during pregnancy, might
restrictions on have negative health consequences
her diet other for the fetus. Pregnant women are
than alcohol and also advised to refrain from
caffeine. The consuming alcohol, khat, or tobacco.
patient also eats (Alamneh n.d)
some fruit every
meal.

13
 • The patient
stated that she
drinks alcohol
occasionally
before her
pregnancy.

Elimination • The patient Constipation is fairly common in

stated that she pregnancy, defined as having fewer
had a problem than three bowel movements per
with defecating, week and/or having difficulty passing
bowel stool when you do go. While
movements constipation during pregnancy isn't
every 2-3 days, harmful to the baby, it might be
feeling bloated, unpleasant for you.(Miller, 2021)
and frequent
urination. Bladder control issues can occur
throughout pregnancy as well as after
childbirth. Pelvic organ prolapse,
weaker pelvic floor muscles, and
injured pelvic nerves are all possible
causes of bladder control problems.
Kegel exercises are frequently
prescribed to strengthen pelvic
muscles and regain bladder control.
(Cleveland Clinic, 2020)

Activity- • The patient On most, if not all, days of the week,

Exercise reported that most pregnant women should engage
she sometimes in at least 30 minutes of moderate-
walks every intensity exercise. For beginners,
morning, twice a walking is an excellent kind of
week. exercise. It provides moderate aerobic
conditioning while putting the least
• The patient amount of strain on your joints.
reported that (MayoClinic, 2021)
she
independently
performed her
ADL's.

Cognitive- • The patient can The patient was oriented to date,time

Perceptual identify the time, and place on the day of the interview.
place and date. The patient was able to hear well
without any problem.

14
 • The patient has A number between +/-.025 to +/-2.00
no hearing is considered mild, a number between
problem. +/-2.25 to +/- 5.00 is considered
moderate, and a number greater than
+/- 5.00 is considered severe. Eye
• She stated that prescriptions can change over time.
she has a +2.0 Visual acuity, or sharpness of vision,
or +3.0 glasses may decrease gradually over time,
grade. caused by aging or other eye
conditions such as astigmatism or
amblyopia (lazy eye). (Willans K.,
2022)

Sleep-Rest • The patient The first and most serious cause of

reported that her sleep disorders during pregnancy is
bedtime routine the fetus's growing growth, which
is around 9 pm makes it difficult to find a comfortable
and she wakes resting posture. If you've always slept
up at 6:00 am, on your back or stomach, you could
but she also find it difficult to adjust to sleeping on
stated she your side (as doctors recommend).
wakes up at Additionally, as your pregnancy
midnight at advances and you gain weight,
12:00 am. shifting about in bed becomes more
• The patient difficult. (Hirsch, L,. (2016)
reported that
she does have
difficulties
sleeping due to
her position.
She usually
sleeps on her
left side, then
changes to the
right side if she
experiences
pain.
• The patient
stated that at
night her lower
back hurts,
especially when
tired.

Self- • The patient Introversion is a personality type

Perception describes characterized by traits such as

15
 herself as an reserve, passivity, thoughtfulness,
introvert as well and a preference to keep emotional
as having low states private. (Guy-Evans, O., 2021)
self-esteem due
to her height. Low self-esteem is when someone
lacks confidence about who they are
and what they can do. They often feel
• She also incompetent, unloved, or inadequate.
describes People who struggle with low self-
herself as esteem are consistently afraid about
someone making mistakes or letting other
dependent on people down. (Brennan, D., 2020)
her mother as When your children reach early
she is the only adulthood, it's critical that you
child. acknowledge that your job as a parent
transforms from protector to coach
and mentor. As a result, married
young adults may require your
assistance in this area as well. Even
though they are married, today's
culture places greater demands on
marriage than past generations. Your
flexibility and input are critical in
helping them mature before becoming
parents. (Cuppy, C., 2022)

Role- • The patient Study after study shows that money is

Relationship reported that the second reason people get
she lives at her divorced and the #1 reason couples
parents' house, fight. It’s a normal phenomenon, but it
her family and doesn’t have to be. In fact, talking
friends are about money early on can help bridge
supportive, and those gaps and prevent
she describes disagreements down the road.
her relationship (Moore, H., 2019)
with her
husband and in-
laws as good.

• The patient also

stated
sometimes they
experienced
problems with
her husband

16
 due to money
problems.

Sexually- • The patient had On average, the menarche age for

Reproductive her menarche at girls in the U.S. is around 12 or 13
11 years old. years. The standard age range for
• Her 1st menarche is between 11 and 15.
pregnancy was However, young women can also
planned. experience early menarche (i.e.,
• She is sexually before 11 years) or delayed menarche
active and she (i.e., after 16 years). (Adereyko, O.,
stated that she MD., 2020)
initiates it with
her husband. Preconception health and health care
• The client used focus on things you can do before and
a contraceptive between pregnancies to increase the
(condom) once chances of having a healthy baby. For
before her some women, getting their body ready
pregnancy. for pregnancy takes a few months. For
• The patient other women, it might take longer.
verbalized that (CDC, 2020)
she is straight.
Linda De Villers, sex therapist and
author of Love Skills, urges married
couples to engage in open discussion
about sexual performance. Talk about
sexual limits, signs of pleasure,
arousal, distaste, anxiety, discomfort
or nervousness should rule, both in
and out of the bedroom, if couples
expect to establish a base for fulfilling
physical intimacy. So in the early
stages after marriage, when trial and
error rules, a willingness for couples to
be honest creates a solid foundation
for sexual intimacy and pleasure in
years to come. (Meier, K., 2021)

Condoms are the only way to protect

against sexually transmitted diseases
(STDs), such as HIV and herpes. As a
barrier method of birth control,
condoms stop sperm from reaching
eggs.(Cleveland clinic, 2020)

17
Coping/ • The patient Also known as emotional eating,
Stress stated that she stress-eating involves using food as a
Tolerance relieves her coping mechanism to help you feel
stress by eating better. (Lindberg, S., 2021)
her favorite
foods and Television really goes both ways. It
talking to her can be used to reduce your anxiety if
mother. you use it as a distraction and
• She also stated relaxation tool, but it can also increase
that she liked your anxiety if you watch what most
watching people watch and spend too much
Korean dramas time directly in front of the TV when
to relieve her you should be exercising or engaging
stress but in other activities. (Abraham, M.,
stopped when 2020)
she was
pregnant to
avoid sleeping
late.

Value-Belief • The patient’s The patient wasn’t religious before she

religious was pregnant due to the busyness of
affiliation is work but opened herself again to God
Roman Catholic. when she became pregnant.
• The patient
verbalized not
being religious
due to busy
work.
• The patient
stated that they
have religious
statues at home.
• She stated that
she prays more
frequently when
she became
pregnant,
repentance -
asking for
guidance, as
well as praying
for the safety of
her child and
herself.

18
 CHAPTER IV

REVIEW OF ANATOMY AND PHYSIOLOGY

Anatomy of Female Reproductive System

The organs of the female reproductive system produce and sustain the

female sex cells (egg cells or ova), transport these cells to a site where they may

be fertilized by sperm, provide a favorable environment for the developing fetus,

move the fetus to the outside at the end of the development period, and produce

the female sex hormones. The female reproductive system includes the ovaries,

Fallopian tubes, uterus, vagina, accessory glands, and external genital organs

(Introduction to the Reproductive System | SEER Training, 2022) .

19
External

• Labia majora: The labia majora (“large lips”) enclose and protect the other

external reproductive organs. During puberty, hair growth occurs on the skin

of the labia majora, which also contain sweat and oil- secreting glands.

• Labia minora: The labia minora (“small lips”) can have a variety of sizes and

shapes. They lie just inside the labia majora, and surround the openings to

the vagina (the canal that joins the lower part of the uterus to the outside of

the body) and urethra (the tube that carries urine from the bladder to the

outside of the body). This skin is very delicate and can become easily

irritated and swollen.

• Bartholin’s glands: These glands are located next to the vaginal opening on

each side and produce a fluid (mucus) secretion.

• Clitoris: The two labia minora meet at the clitoris, a small, sensitive

protrusion that is comparable to the penis in males. The clitoris is covered

by a fold of skin, called the prepuce, which is similar to the foreskin at the

end of the penis. Like the penis, the clitoris is very sensitive to stimulation

and can become erect

20
Internal

• Vagina: The vagina is a canal that joins the cervix (the lower part of uterus)

to the outside of the body. It also is known as the birth canal.

• Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home

to a developing fetus. The uterus is divided into two parts: the cervix, which

is the lower part that opens into the vagina, and the main body of the uterus,

called the corpus. The corpus can easily expand to hold a developing baby.

A canal through the cervix allows sperm to enter and menstrual blood to

exit.

• Ovaries: The ovaries are small, oval-shaped glands that are located on

either side of the uterus. The ovaries produce eggs and hormones.

• Fallopian tubes: These are narrow tubes that are attached to the upper part

of the uterus and serve as pathways for the ova (egg cells) to travel from

the ovaries to the uterus. Fertilization of an egg by a sperm normally occurs

in the fallopian tubes. The fertilized egg then moves to the uterus, where it

implants to the uterine lining.

21
PATHOPHYSIOLOGY

22
 LABORATORY RESULTS

BLOOD TESTS RESULTS NORMAL VALUES

Platelet Count 365 150-400x109/L

MPV (Mean Platelet Volume) 10.30 6.5-12.0fL

Hemoglobin 122 110-160g/L
Hematocrit 0.37 0.37-0.47
RBC COUNT 4.21 3.50-5.00x1012/L
MCV (Mean Corpuscular Volume) 88 80-100fL
MCH (Mean Corpuscular Hemoglobin) 29 27-24pg
MCHC (Mean Cell Hemoglobin 32.90 32-36g/dl
Concentration)

RDW (Red Cell Distribution Width) 13.60 11-16%

WBC 8.58 4-10 x 109/L
URINALYSIS RESULTS NORMAL VALUES
Color Pale yellow Pale Yellow/Amber
Specific Gravity 1.010 1.005-1.025
ph 6.5 4.6-7.5
Glucose Negative Negative
Protein Negative Negative
RBC Negative Negative

23
 CHAPTER V

DIAGNOSTIC PROCEDURES

INDICATION
DIAGNOSTIC RATIONALE
ABNORMAL NORMAL
TEST
RESULTS RESULTS
Physical Physical • Cloudy urine occurs
when the urine is hazy
Urinalysis • Hazy • Pale Yellow which is not normal, clear,
Color light yellow. Cloudy urine
Chemical Chemical is generally harmless but
frequent and repetitive
• 1+ • Negative cloudy urine could be a
Leukocytes Sugar, sign of a medical
• 3.20 Protein, condition.
Urobilinogen Blood, • Clumps of WBCs are
• Many Bilirubin, typically observed when
Mucus Ketone, there is inflammation or
Threads Nitrate bacterial infections of the
• Few • 6.5 pH renal and urinary tract.
Bacteria • 1.010 The clumping is due to
Specific increased mucus in the
Gravity urine.
• An excess amount of
mucus may indicate a
Cells urinary tract infection (UTI)
or other medical condition.
• 2.00 Pus
• Normal urine
Cells
contains some
• 0.00 RBC
urobilinogen. If there is
little or no urobilinogen in
urine, it can mean your
liver isn't working
correctly. Too much
urobilinogen in urine can
indicate a liver disease
such as hepatitis or
cirrhosis.
• 365.00 Normal
Platelet
Complete count
Blood Count • 10.30 MPV

24
 • 122.00
Hemoglobin
• 0.37
Hematocrit
• 4.21 RBC
Count
• 88.00 MCV
• 29.00 MCH
• 32.90
MCHC
• 13.60 RDW
• 8.58 WBC
Count
HBsAg Negative Normal

O Positive Normal
Blood Typing Reverse Typing
• Positive A
& B Cells

25
 CHAPTER VI
NURSING CARE PLAN
OLIGOHYDRAMNIOS
1. Acute pain related to muscle contractions and surgical injury due to cesarean birth as evidenced by verbalization of
moderate pain scale 6 out of 10
2. Disturbed Maternal-Fetal dyad as evidenced by compromised fetal well-being secondary to oligohydramnios as
evidenced by premature birth, small for gestational age fetus, and bradycardia
3. Risk for Infection related to invasive procedure
4. Anxiety related to unfamiliar experience regarding pregnancy as evidenced by verbalization of concerns
5. Self-care deficit related to physical limitations due to surgical injury as evidenced by inability to perform activities of daily
living such as bathing, dressing, and toileting activities as normal.
NCP #1
ASSESSMENT DIAGNOSIS and OBJECTIVES NURSING RATIONALE EVALUATION
INFERENCE INTERVENTION
Subjective Acute pain related General INDEPENDENT After 8 hours of
Cues: to muscle objective: • Assess patient’s vital • To establish nursing
contractions and signs such as Temp, baseline data and interventions,
“Sakit After 8 hours of PR, RR, BP. to assist in
surgical injury due goals partially
sakong intervention, creating an
to cesarean birth met:
tiyan banda patient will be accurate
as evidenced by
ma’am.” able: diagnosis.
verbalization of
“Kaganina • > To maintain • Patient was
ma’am 9 good hygiene able to cite

26
 out of 10, moderate pain and physical • Every time patient • Developments normal
pero karon scale 6 out of 10 comfort. complains about from earlier physiological
6 out of 10 • > To promote pain, conduct pain reports should be effects of
nalang.” optimal activity: assessment. noted. Monitor CS.
Background/ exercise, rest, any worsening of • Patient
Inference: sleep. the patient’s case verbalized
or severity of lesser pain
Objective • > To recognize
Cesarean Birth pain. and gave a
Cues the physiologic pain scale of
responses of 2 out of 10.
> Facial
the body to
Grimace
disease
• To promote rest
> Guarding Post-CS effects to conditions— • Provide quiet and and comfort.
behavior mother e.g. pathologic, conducive
such as Physiological and physiologic, environment e.g. turn
putting Psychological and on air-con or provide
hands in changes such as compensatory. pillows and blankets.
abdomen intensified muscle
area contractions, • To prevent
• Maintain post-cs care infection.
surgical injury, Specific
to surgical site.
possibly a bladder Objectives:
• Deep breathing
VS (POST- distension.
After 8 hours of promotes healthy
CS • Encourage deep
intervention, blood flow,
10:45AM) breathing exercises
patient will be: releases toxins
like Pursed-lip
Ø > BP: from the body,
133/74 • Able to Breathing and
Result in pain Diaphragmatic and aids in
mmHg recognize
physiologic Breathing getting restorative
Ø >Temp: sleep.
NDA

27
Ø > HR: 70 Miovech, S. M., al effects of • To gain
cpm Knapp, H., CS. cooperation and
(normal) • Able to • Provide patient and for easier
Borucki, L.,
Ø >RR: 14 verbalize family education on achievement of
Roncoli, M.,
(normal) feelings of normal physiological goal of faster
Arnold, L., & effects of CS to
Brooten, D. relief from recovery.
pain. understand better
(1994, January). and adherence to
Major concerns of taking medicines on
women after time, importance of
cesarean eating healthy food.
delivery. Journal • To recharge body
of obstetric, in general and to
• Advise patient to get
gynecologic, and reduce activity
enough rest and
neonatal nursing : intolerance to
sleep at least 8
JOGNN. avoid distress.
hours.
Retrieved April
16, 2022, from
https://www.ncbi.
nlm.nih.gov/pmc/ • Ketorolac is
DEPENDENT
articles/PMC3694 effective in
506/ • Administer reducing
prescribed analgesic postoperative
medications such as pain and narcotic
Ketorolac and use in patients
Tramadol who have
undergone
cesarean
delivery.

28
 • Tramadol mg can
provide adequate
postoperative
analgesia without
respiratory
depression in
patients after
Cesarean
delivery.

29
 NCP #2
ASSESSMENT DIAGNOSIS and OBJECTIVES NURSING RATIONALE EVALUATION
INFERENCE INTERVENTION
SUBJECTIVE Disturbed General INDEPENDENT: After 8 hours of
CUES: Maternal-Fetal Objectives: nursing
• Obtain history • Lack of
> Patient dyad related to interventions,
Ø To promote about prenatal prenatal care
verbalized, compromised goals met.
safety by screening and can place both
“Medyo fetal well-being preventing Patient had
amount of timing fetus and
nagasakit secondary to accidents, positive
oligohydramnios of care. mother at risk. response to
ang akoang injuries, or
lower back, as evidenced by other trauma teaching and
premature birth, • May reveal interventions
ma’am” and preventing
small for the spread of • Review vaginal. presence of provided and
> Patient gestational age infection. cervical, or rectal sexually attained
verbalized, cultures and transmitted
fetus, and progress
“Naa koy ma serology results. infections
bradycardia towards desired
feel na Specific (STIs) or outcomes.
contractions Objectives: identify active
pero dili sya After 8 hours of or carrier state
Inference/
kayo nursing of hepatitis or
Background
significant, interventions, HIV.
Knowledge
usahay lang the client will
jod tapos be able to:
gamay lang Uteroplacental Ø Verbalize • Weigh client and • Underweight
dili sakit jud” insufficiency, compare current clients are at
understanding risk for
OBJECTIVE atresia, renal of individual weight with pre-
CUES: gravid weight. anemia,
risk factors or
inadequate

30
 VS (POST- genesis, amniotic condition(s) protein and
CS rupture that may calorie intake,
10:45AM) impact vitamin or
pregnancy. mineral
Ø > BP: 133/74 Ø Engage in deficiencies,
mmHg necessary
Ø >Temp: NDA and
alterations in
Ø > HR: 70 gestational
lifestyle and
cpm Oligohydramnios daily activities hypertension
(normal) (fluid volume less to manage
Ø >RR: 14 <500ml) risks. • Note the condition • A rigid or
(normal) Ø Participate of cervix. Monitor unripe cervix
Ø screening for signs of will not dilate,
Ø >FHT: 133 procedures as amnionitis. Note impending
Ø PU 34 indicated. fetal
elevated
weeks, Ø Identify signs descent/labor
G1P0 temperature or
and symptoms progress.
Ø >Cervix Less space or WBC; odor and
requiring Development
close, no compresed fetus medical color of vaginal
blood on discharge. of amnionitis
evaluation or
gloved finger is directly
intervention.
upon internal related to
examination length of
during active labor, so that
phase of Developmental delivery
labor should occur
abnormalities
Ø >(+) Fetal within 24
movement hours after
Ø >Bradycardia rupture of
noted on membranes.
FHT

31
Ø > Infant
small for • Following
gestational • Monitor fetal heart
delivery,
age response to
Premature birth preoperative narcotics
Ø > Weight: via cesarean normally
2.14 lbs., 4 medications or
section regional reduce FHR
oz.
anesthesia. variability and
Ø > Length: 45
cm necessitate
Ø > Head naloxone
circumferenc (Narcan)
e: 31 cm administration
Ø > Chest Disturbed to reverse
circumferenc Maternal-Fetal narcotic-
e: 37 cm dyad as induced
Ø > Abdominal evidenced by respiratory.
circumferenc compromised
e: 26 cm
fetal well-being
due to reduced • Bowel fullness
amniotic fluid • Review bowel may hinder
volume as habits and uterine activity
evidenced by regularity of and interfere
premature birth, evacuation. with the fetal
small for descent.
gestational age
fetus, and
bradycardia.
• Family stress
is amplified in

32
Reference: • Assess perceived a high-risk
impact of pregnancy,
Dulay, A. T. (2020,
complication on where concern
October 5).
client and family focus on the
Oligohydramnios. members. health of both
MSD Manual Encourage
Professional Edition;
the client and
verbalization of the fetus.
MSD Manuals. concerns.
https://www.msdm
anuals.com/professi • To create new
onal/gynecology- tissue and to
and- meet
• Develop dietary
obstetrics/abnormal increased
plan with client
ities-of- that provides maternal
pregnancy/oligohyd necessary metabolic
ramnios nutrients. needs.
.

• To create new
COLLABORATIVE: tissue and to
meet
• Develop dietary increased
plan with client maternal
that provides metabolic
necessary needs.
nutrients.

• For ongoing
support and

33
• Refer to assessment of
community medical
service agencies. problem,
financial
status, coping
behaviors, and
financial
stressors.

34
 NCP #3
ASSESSMENT DIAGNOSIS and OBJECTIVES NURSING RATIONALE EVALUATION
INFERENCE INTERVENTION
SUBJECTIVE Risk for Infection General INDEPENDENT: After 8 hours of
CUES: related to invasive Objectives: nursing
• Assess the client’s • Rupture of
> Patient procedure as interventions,
Ø To promote vital signs for signs membranes
states she evidenced by goals partially
safety by and symptoms of occurring 24
feels weak cesarean incision hours before the met. Patient had
preventing infection. (Temp:
but overall surgery may positive
Inference/ accidents, >40 °C; PR >100
good. result in response to and
Background injuries, or bpm; RR >18 bpm;
chorioamnionitis involvement to
Knowledge other trauma BP >120/80 mmHg)
before surgical interventions,
and preventing
OBJECTIVE intervention and teaching, and
the spread of impair wound
CUES: actions
Cesarean Birth infection. healing. performed.
Ø > Facial
Specific • Observe for
grimace due • Surgical site
Objectives: localized signs of
to acute infection is
pain at the infection at the
After 8 hours of manifested as
incision site. surgical incision
nursing site. wound infection,
Ø > Guarding intervention, endometritis, or
behavior the patient will urinary tract
such as Post-CS effects to be able to: infection.
putting mother e.g
hands on Physiological andØ Verbalize • Encourage early • Early
abdomen psychological understanding ambulation after mobilization is
area. of individual cesarean birth. often part of a
changes such as
intensified muscle causative risk surgical bundle
factors.

35
contractions, Ø Identify “fast track” or
surgical injury, interventions “enhanced
possibly a bladder to prevent or recovery after
distention reduce risk of surgery”.
infections.
Ø Demonstrate • Instruct client and • In order to know
techniques family about when to seek
and lifestyle techniques to medication.
changes to protect the skin’s
promote safe integrity and
environment. prevent the spread
Ø Achieve timely of infection.
Pain
wound
healing; be • Observe client for
free of • Possible signs
the following:
purulent of developing
ü Changes in skin
drainage or systemic
color and warmth
erythema; be infection.
at incision site.
afebrile. ü Changes in
mental status,
Risk for Infection skin warmth and
color, heart and
respiratory rate.
ü Changes in color
and/or odor of
Miovech, S. M.,
secretions
Knapp, H., Borucki,
L., Roncoli, M.,
Arnold, L., &amp; • Discuss the
Brooten, D. (1994, importance of not • Inappropriate
January). Major taking antibiotics use can lead

36
concerns of women or using “leftover” to
after cesarean drugs unless development
delivery. Journal of specifically of drug-
obstetric, instructed by resistant
gynecologic, and healthcare strains or
neonatal nursing : provider. secondary
JOGNN. Retrieved infections.
April 16, 2022, from
https://www.ncbi.nl DEPENDENT:
m.nih.gov/pmc/artic • Evaluate the
• Obtain blood, results of blood
les/PMC3694506/
vaginal, and and wound
placental cultures, cultures before
as indicated. the initiation of
antibiotics to
help determine
the infecting
organisms and
degree of
involvement.

COLLABORATIVE:
• Cleanse incisions • To reduce the
and and insertion potential for
sites per facility catheter-related
protocol with bloodstream
appropriate infections, and
antimicrobial to prevent the
topical or solution. growth of
bacteria.

37
 NCP #4
ASSESSMENT DIAGNOSIS and OBJECTIVES NURSING RATIONALE EVALUATION
INFERENCE INTERVENTION
SUBJECTIVE Anxiety related to General INDEPENDENT: After 8 hours of
CUES: unfamiliar Objectives: • The greater the nursing
• Assess psychological client perceives
Ø > Patient experience interventions,
Ø To identify response to events the threat, the
verbalized, regarding goals met.
and and availability of greater her
“Ginakulbaa pregnancy as accept support systems. Patient had
n lang ko evidenced by anxiety level. positive
interrelate
kay first verbalization of dness of response to and
time man concerns • Provides a involvement to
emotions • Determine stress
gud nako.” database to build interventions,
and level and learning
Ø > Patient on to provide teaching, and
organic needs.
verbalized, information that
Inference/ illness. actions
“Naa pajod will decrease
Background anxiety. performed.
koy
complication Knowledge: Specific
, so murag Uteroplacental Objectives:
mas doble • Consider cultural • Women who have
insufficiency, After 8 hours of a cesarean birth
ang influences or
atresia, renal nursing might be
kakulba.” expectations.
genesis, amniotic intervention, stigmatized
rupture the patient, the because they are
OBJECTIVE seen as having
client will be
CUES: avoided
able to:
something
Ø > Patient difficult.
Ø Verbalize
appear calm
awareness

38
but slightly Oligohydramnios of feelings • Know whether the • If the procedure is
agitated. (fluid volume less of anxiety. procedure is planned unplanned, the
<500ml) Ø Appear or not. client or couple
relaxed usually has
and report limited
that physiological or
anxiety is psychological
reduced to preparation time.
a
Less space or manageab • Note and validate
expressions of fear, • Validation helps
compresed fetus le level. the nurse and the
Ø Identify distress, or feelings
of helplessness. client deal
healthy realistically with
ways to fear.
deal with
and
express • Remain with client, • Therapeutic
Developmental and stay calm. Speak communication
anxiety.
abnormalities Ø Use slowly and convey helps to reduce
resources/ empathy. interpersonal
support transmission
systems anxiety and
effectively. shows care for
the client or
couple.

Premature birth • Focuses on the

• Reinforce positive
via cesarean likelihood of a
aspects of maternal
section and fetal condition. desirable
outcome and
helps bring

39
 perceived or
actual threats into
perspective.

• Helps to
Anxiety related to • Let the client or distinguish
actual threat of couple verbalize their negative feelings
maternal and fetal inner thoughts and and concerns and
well-being as feelings. provides a
evidenced by chance to cope
verbalization of with uncertain or
concerns unresolved
regarding present feelings of grief.
condition
• Support or redirect • Improves
expressed coping fundamental and
mechanisms. automatic coping
mechanisms,
increases self-
confidence and
Reference: acceptance and
reduces anxiety.
Dulay, A. T.
(2020, October • The client may
5). • Allow the client to
discuss and have twisted
Oligohydramnios. thoughts of past
MSD Manual elaborate past
childbirth delivery or
Professional unrealistic
experiences or
Edition; perceptions of
expectations, as
appropriate. abnormality of

40
MSD Manuals. cesarean birth
that will increase
anxiety.

• Allows the client

• Provide patient’s or couple to
privacy. process
information,
organize
resources, and
cope effectively.

• Guide the client • Familiarization

through preoperative with preoperative
nursing care. nursing care can
significantly
reduce the client’s
anxiety, heart
rate, respiratory
rate, and blood
pressure.

41
 NCP #5
ASSESSMENT DIAGNOSIS and OBJECTIVES NURSING RATIONALE EVALUATION
INFERENCE INTERVENTION
Subjective Self-care deficit General INDEPENDENT After 8 hours of
Cues: related to physical objective: • Assess patient’s • Use of nursing
limitations due to ability to perform observation of interventions,
Client After 8 hours of ADLs through function provides
cesarean incision goal met,
verbalized, intervention, observation. Noting complementary
as evidenced by patient was able
“Wala pa ko patient will be specific deficits and assessment data
inability to to verbalize
nakailis able: causes. for goal and
perform activities importance of
sugod gaina intervention
of daily living • To hygienic
ug di pa planning.
such as bathing, maintain practices,
kaadto’g cr
dressing, and good identify
para • Give tepid sponge
toileting activities hygiene • Since the patient alternative ways
maligo.” bathe cannot bathe
as normal and to take care of
Objective physical independently, self, and asked
Cues comfort. TSB is an for assistance in
Background/ alternative way to performing
• To
> Inability to clean patient’s ADLs when
Inference: promote
dress body.
optimal needed.
independen Cesarean Birth
activity:
tly • Encourage client and
exercise • Proper hygiene is
family member to the most
> Inability to , rest, provide TSB every important way to
bathe and sleep. day and other
groom self Post-CS effects to prevent
Specific hygienic practices occurrence of
independen mother e.g. like handwashing,
Objectives: infection and
tly physical changes toothbrushing, promote comfort.

42
> Inability to such as surgical After 8 hours of putting deodorant,
perform injury intervention, combing, nail cutting
toileting patient will be: while in bed.
tasks
independen • Provide health
tly • Emphasizing this
• Verbalize teaching on the
Pain causing health teaching
importance importance of the
> Inability to physical limitation helps patient to
of hygienic following:
ambulate such as practices be reminded of
Tootbrushing,
independen performing ADLs • Identify necessary actions
Handwashing,
tly alternative Combing, Nail on a regular basis
action to Cutting, TSB, of her recovery
Miovech, S. M., perform Passive Exercises. period.
Knapp, H., ADLs.
Borucki, L., • Depend on
Roncoli, M., a guardian • Provide positive
• Positive
or watcher reinforcement for
Arnold, L., &amp; reinforcement
to ask for every
Brooten, D. accomplishment enhances self-
(1994, January). assistance
made. esteem and
in
Major concerns of encourages
performing
women after ADLs for repetition of
cesarean the mean desirable
delivery. Journal time of behaviors.
of obstetric, recovery
gynecologic, and period.
neonatal nursing : • To prevent
• Instruct patient to get
JOGNN. enough rest. fatigability and
Retrieved April have enough
16, 2022, from

43
https://www.ncbi. energy to perform
nlm.nih.gov/pmc/ ADLs.
articles/PMC3694
506/

44
 CHAPTER VII
DRUG STUDY
DRUG Generic CLASSIFI MECHANISM INDICATIONS DRUG FORM ADVERSE NURSING RESPONSIBILITIES
(Brand) CATION OF ACTION & DOSAGE REACTION

1.DEXAMET Corticoste Antenatal - > Accelerates RECOMMENDED CNS: • If insomnia occur, make
HASONE roids steroids maturation of 4 to 20 insomnia, sure the patients room is
(Decadron) (dexamethaso fetal lungs mg/day psychotic quiet, dark, relaxing, and
ne or - > Improves given in a behavior, at a comfortable
betamethason survival in single daily depressio temperature.
e) can cross preterm dose or in 2 n, vertigo,
• Raise the side rails for the
the placenta to to 4 divided paresthesi possible occurrence of
delivered
mature the doses; High a, seizure.
neonates.
fetal lung and dose: 0.4 to seizures. • If vertigo occur, inform the
brain. In the 0.8 patient to lie down and not
lung, antenatal mg/kg/day to move so as not to
steroids can (usually not accumulate injuries or
decrease the to exceed 40 pain.
fetal lung fluid mg/day). • For the occurrence of
through paresthesia, simply
activation of changing the client
ENaCs, induce ACTUAL
position or moving around
the production can relieve temporary
6mg q12hrs paresthesia.
of surfactant
via IM • Watch for depression or
proteins and
psychotic episodes,
lipid synthesis,
especially in high-dose
and alter therapy.
preterm

45
responses to
oxidative • Monitor vital signs
CV: HF, specifically the blood
stress
HTN, pressure for possibility of
edema, HPN
arrhythmia • If patient experienced
s, edema, help her by raising
thromboe the affected limb higher
mbolism. than her heart.
• Monitor s/s for
arrhythmias, HF and
thromboembolism then
inform attending physician.

GI: GI • If GI irritation occur,

irritation, encourage patient to eat
increased mild foods, such as rice,
appetite , dry toast or crackers,
bananas, and applesauce.
nausea,
Try eating several small
vomiting. meals instead of two or
three large ones
• Tell patient to avoid foods
and smells that trigger
nausea and position the
patient upright while eating
and for 1 to 2 hours post-
meal

46
 GU: • Monitor urine output and
increased get sample for urine test
urine specifically the presence of
glucose and increased
glucose
calcium level. Then
and immediately inform the
calcium physician.
levels.

Metabolic: • If hypokalemia occur,

hypokale initiate physician order for
mia, oral or intravenous
hyperglyc potassium.
emia, • Monitor sugar level for
carbohydr possible occurrence of
ate hyperglycemia.
• Encourage client to weight
intoleranc
herself every morning to
e,
monitor any possible
hyperchol weight gain.
esterolemi
a,
hypocalce
mia,

47
 weight
gain.

Musculosk • For the occurrence of

eletal: muscle weakness and
muscle myopathy, Assist patient
weakness, for muscle exercises.
osteoporo
sis,
tendon
rupture,
myopathy.

Skin:
hirsutism, • Inspect patient's skin for
delayed petechiae.
wound • To prevent atrophy in
healing, injection site Z-track
acne, method must be done.
various
skin
eruptions,
atrophy at
IM
injection

48
 site, thin
fragile
skin.

49
DRUG Generic CLASSIFI MECHANISM INDICATIONS DRUG FORM ADVERSE NURSING RESPONSIBILITIES
(Brand) CATION OF ACTION & DOSAGE REACTION

2.CEFUROXI Cephalos- Inhibits cell- - >Antibacterial RECOMMENDED CV:

ME (Zinacef) porin wall synthesis,- >To prevent Reconstitute phlebitis, - > Monitor for any sign of
Antibiotics promoting post- each 750-mg thrombop phlebitis and
osmotic hlebitis. thrombophlebitis such as
operative site vial with 8
instability; visible red “streaking“ on the
infections mL and each
usually skin along the vein.Inform
1.5-g vial attending physician
bactericidal. with 16 mL immediately.
Ceftriaxone of sterile
selectively and water for
irreversibly injection. GI:
inhibits diarrhea, - > If diarrhea occur,
ACTUAL
bacterial cell ,nausea, encourage the patient to
wall synthesis 750mg IVTT anorexia, take at least 1500ml to
by binding to Q8hrs ANST vomiting. 2000ml of fluid plus 200ml
transpeptidase for each loose stool.
s, also called - If vomiting happen, Offer ice
transamidases, chips since it helps moisten
which are mucous membranes.
penicillin-
binding
proteins Hematolo - > Drug may increase INR
(PBPs) that gic: and risk of bleeding. Monitor
catalyze the hemolytic patient.
cross-linking of anemia,thr
the ombocyto
peptidoglycan penia,

50
polymers transient
forming the neutropen -
bacterial cell ia, -
wall. eosinophil -
ia. -
-
-
Skin: - > Perform a skin test first to
erythemat determine allergy status of
ous
the patient
rashes,
- If rashes occur, inform the
urticaria, ,
physician immediately.
temperatu
- Monitor vital sign for
re possible elevation of
elevation. temperature.

51
DRUG Generic CLASSIFI MECHANISM INDICATIONS DRUG FORM ADVERSE NURSING RESPONSIBILITIES
(Brand) CATION OF ACTION & DOSAGE REACTION

3.KETOROLA Non May inhibit - > For pain RECOMMENDED CNS: - > If headache occur, assist
C (Toradol) Steroidal prostaglandin reliever Adults headache, patient to rest in a quiet,
Anti synthesis to younger than dizziness, dark room until the
Inflammat produce anti- drowsines headache is gone. Close the
age 65 and
ory Drud inflammatory, eyes and try to relax or go to
adolescents s.
(NSAID’S) analgesic, and sleep.
age 17 and - If drowsiness and dizziness
antipyretic older: 30 mg felt, educate patient to lie
effects. IM or IV down and not to move so as
Although every 6 not to accumulate injuries or
ketorolac is hours for pain .
non-selective maximum of
and inhibits 5 days.
both COX-1
and COX-2 CV: - > Monitor vital sign
enzymes, it's ACTUAL edema, especially the BP to
clinical efficacy HTN. determine if there is HPN
50mg IVTT occur.
is derived from
Q8hrs PRN - If patient experienced
it's COX-2
for severe edema, help her by raising
inhibition. The
pain the affected limb higher than
COX-2
enzyme is her heart.
inducible and
is responsible
for converting GI:
arachidonic dyspepsia - > If GI irritation occur,
acid to , GI pain, encourage patient to avoid

52
prostaglandins nausea, foods that trigger indigestion
that mediate constipati such as fatty and fried food.
inflammation on, Eating five or six small
and pain. By vomiting. meals a day instead of three
blocking this large meals.
pathway, - > For prevention of
constipation, encourage
ketorolac
client to increase fluid intake
achieves
if not contraindicated and
analgesia and increase fiber rich food such
reduces as grains.
inflammation. - > Tell patient to avoid foods
and smells that trigger
nausea and position the
patient upright while eating
and for 1 to 2 hours post-
meal

GU: renal > Monitor urine output for

impairmen any signs of renal
t. impairment.
Hematolo - Monitor patient for any
gic: hematologic problem and
anemia, immediately inform the
decreased physician.
platelet
adhesion,
prolonged

53
 bleeding
time,
purpura.

Skin:
- > If pruritus occurs,
diaphoresi
Encourage patient gentle
s, pruritus, rubbing rather than
rash. scratching and keep finger
nails short.

- Observe for any unusual

rashes for possible drug
allergic reaction and
immediately inform the
physician.

54
DRUG Generic CLASSIFIC MECHANISM INDICATIONS DRUG FORM ADVERSE NURSING RESPONSIBILITIES
(Brand) ATION OF ACTION & DOSAGE REACTION

4. Ranitidine H2-receptor Ranitidine is - > Ranitidine RECOMMENDED CV: - > Report any rhythm
hydrochloride blockers a competitive has been Up to 50 mg Arrhythmi disturbances or symptoms of
(Zantac) inhibitor of as. increased arrhythmias,
used to treat via IM or IV
histamine inj over 2 including palpitations, chest
and prevent
H2-receptors. discomfort, shortness of
ulcers in the minutes or
The breath, fainting, and
stomach and 25 mg/hour fatigue/weakness.
reversible intestines. It via -
inhibition of intermittent
also was - > Assess patient for
H2-receptors IV infusion. GI: abdominal pain. Note:
used to treat
in gastric Dose may constipati presence of blood in emesis,
parietal cells conditions in
be repeated on, stool, or gastric aspirate.
results in a which the
6-8 hourly. diarrhea, - Advise patient to report all
reduction in stomach adverse reactions,
ACTUAL
nausea.
both gastric produces too especially abdominal pain,
acid volume much acid, 50 mg IVTT blood in the stool or emesis,
and such as E80 coffee-ground emesis, or
concentration Zollinger- black tarry stools.
. Ellison -
- High doses (100 mg or
syndrome. Hepatic: more) or prolonged IV
Ranitidine jaundice. therapy (5 days longer) may
was also increase ALT (Alanine
used to treat aminotransferase level).
gastroesoph -
ageal reflux

55
disease CNS: - > Assess dizziness and
(GERD) and headache, drowsiness that might affect
other malaise, gait, balance, and other
conditions in vertigo. functional activities. Report
balance problems and
which acid EENT: functional limitations to the
backs up blurred physician and caution the
from the version patient and family/caregivers
stomach into to guard against falls and
the trauma.
esophagus, -
- > Advise patient to avoid
causing
Other: alcohol, cigarette, and foods
heartburn. that may cause an increase
anaphylax
is, in GI irritation.
angioede - Monitor IM injection site for
ma, pain, swelling, and irritation.
burning Report prolonged or
excessive injection site
and
reactions to the physician.
itching at
injection
site.

56
DRUG Generic CLASSIFIC MECHANISM INDICATIONS DRUG ADVERSE NURSING
(Brand) ATION OF ACTION FORM & REACTION RESPONSIBILITIES
DOSAGE

5.Metoclopra Antiemetic Stimulates - > To prevent RECOMMENDED CV: - > Monitor BP carefully
mide hydro- agent and motility of or reduce 10 mg as a bradycardi during IV administration.
chloride Dopamine upper GI a, - > Monitor patient for fever,
postoperative single dose.
D2 tract, supraventri CNS symptoms, irregular
(Reglan) nausea and
antagonist increases cular pulse, cardiac arrythmias, or
vomiting, to abnormal BP, which may
lower facilitate ACTUAL tachycardi
indicate Neuroleptic
esophageal small-bowel a,
10 mg IVTT malignant syndrome (NMS).
sphincter hypotensio
intubation. E80 - > Monitor other changes in
tone, and n, transient mood and behavior,
Relieve
blocks HTN, HF. including euphoria,
dopamine heartburn
confusion, malaise,
receptors at and speed
nervousness, and anxiety.
the the healing Notify physician if these
chemorecept of ulcers and changes become
or zone. sores in the problematic.
esophagus in - > Drug may cause tardive
people who dyskinesia, parkinsonian
have symptoms, and motor
restlessness. Monitor patient
gastroesoph
for involuntary movements
ageal reflux of face tongue, and
disease extremities, which may
(GERD). indicate tardive dyskinesia.
-

57
 CNS: - > Monitor patient for
anxiety, dizziness, headache, or
drowsiness nervousness after
, dystonic metoclopramide is stop; this
reactions, may indicate withdrawal
fatigue, syndrome.
lassitude, - > Advise patient they may
experience these side
restlessnes
effects: Drowsiness,
s, seizure, dizziness (do not perform
suicidal other tasks that require
ideation, alertness); restlessness,
akathisia, anxiety, depression,
confusion, headache, insomnia
depression (reversible); nausea,
, dizziness, diarrhea.
extrapyram - > Report involuntary
idal movement of the face, eyes,
symptoms, or limbs, severe depression,
fever, severe diarrhea.
- > Do not use alcohol, sleep
hallucinatio
remedies, sedatives; serious
ns,
sedation could occur.
headache, -
insomnia, -
tardive
dyskinesia.

58
 -
GU: - > Monitor bowel sound.
incontinenc - Informed patient that it can
e, urinary cause frequent urination.
frequency.

Skin: rash, - > Instruct patient to report

urticaria persistent or serious
adverse reactions promptly
such as anaphylaxis
reaction.
-
Other - > Health teach and instruct
prolactin the client to avoid
secretion, engorgement, wear a
gynecoma supportive bra, hand-
express before feeds, and
stia,
massage and care for
ameno- breasts.
rrhea - > Informed patient delayed
menstruation may occur if
taking this drug.
-

59
DRUG Generic CLASSIFIC MECHANISM INDICATIONS DRUG FORM ADVERSE NURSING
(Brand) ATION OF ACTION & DOSAGE REACTION RESPONSIBILITIES

6. Tramadol Opioid Tramadol - > Tramadol RECOMMENDED CNS: - > Reassess patient’s
hydrochloride analgesic modulates is used to 50-100 mg 4- Dizziness, level of pain at least 30
(Ultram) the relieve headache, minutes after
6 hourly via
descending somnolence, administration.
moderate to slow IV over
pain vertigo, - Monitor patients at risk
moderately 2-3 minutes,
pathways seizures, for seizure threshold.
severe pain, IM, or SC inj. - Monitor patient for drug
within the including Max: 600 mg anxiety,
dependence.
central daily. asthenia, CNS
pain after -
nervous stimulation, -
surgery. ACTUAL
system confusion,
through the 50 mg IVTT coordination
binding of disturbance,
parent and euphoria,
M1 malaise,
metabolite to nervousness,
μ-opioid sleep disorder,
receptors fever,
and the weak paresthesia,
inhibition of tremor,
the reuptake agitation,
of apathy.
-
norepinephri -
ne and - > Monitor CV and
serotonin. CV: respiratory status,
vasodilation, especially within first 24
HTN, to 74 hours of therapy

60
 peripheral initiation and after
edema. dosage increases; adjust
dosage accordingly.
Withhold dose and notify
prescriber if respirations
are shallow or rate is
below 12 breaths/minute.
-
-
Respiratory: - > Explain assessment
bronchitis, and monitoring process
to patient and family.
respiratory
Instruct them to
depression. immediately report
difficulty of breathing or
other signs or symptoms
of a potential adverse
opioid-related reaction.
-
GI: - > Monitor bowel and
constipation, bladder function.
nausea, Anticipate need for
vomiting, stimulant laxative.
- Advise patient that drug
abdominal
may cause constipation.
pain, anorexia,
-
diarrhea, dry -
mouth, -
dyspepsia, -
flatulence. -

61
 GU:
menopausal
symptoms,
proteinuria,
urinary
frequency,
urine
retention,
pelvic pain,
UTI. - > Instruct client to
Musculoskelet promote passive or
al: hypertonia, minimal exercise.
- Instruct to report any
arthralgia,
signs of pain in
neck pain, Musculoskeletal.
myalgia. -
- Caution ambulatory
patient to be careful
EENT: visual when rising and walking.
disturbance, - Instruct client to report
nasopharyngiti any adverse reaction
s, pharyngitis, such nasopharyngitis,
rhinitis, pharyngitis, rhinitis,
sinusitis. sinusitis.
-
- > Instruct patient to
report persistent or
serious adverse
reactions promptly such
as anaphylaxis reaction.

62
 Skin: - Monitor patient for
diaphoresis, dizziness, headache, or
pruritis, rash. nervousness after
metoclopramide is stop;
Other: chills, this may indicate
withdrawal withdrawal syndrome.
syndrome, -
accidental
injury.

63
 CHAPTER VIII
DISCHARGE PLANNING

PLANNING RATIONALE

Medication • Instruct the patient and • To ensure that the

significant others that all condition of the patient
medications should be will stay healthy as long
complied as prescribed as possible.
by the physician

• Educate the patient

about the given drugs; its • This can help a patient
brand name, generic decide to go ahead with
name, adverse effects, any procedures by being
and function. conscious of potential
adverse effects. Knowing
what adverse effects can
arise, allows a patient to
deal with potential
problems appropriately.

• Inform the patient and

• In order to keep the
significant others to
amount of medicine in
strictly follow the
the patient's system,
schedule of medication
medications or treatment
and dosage as
must be given at
prescribed by the
specified periods. Taking
physician. Note dosage,
a dose too soon may
route, frequency, action,
lead to too high levels of
contraindication and side
the medication, and
effects of drugs to
skipping a dose or
prevent misuse, abuse
waiting too long between
and to achieve
doses may reduce the
therapeutic level of
amount of the drug and
therapy. Advice the
prevent it from
relative to continue the
functioning properly.
prescribed home
Noting the dosage, route,
frequency will provide

64
 medication to ensure accuracy in giving those
optimum recovery. medications and to check
for unusualities.
Exercise • Gentle activity will help • After your 6-8-week
you recover from your postnatal check, you
caesarean section (c- should be able to
section) such as belly gradually increase the
breathing and seated amount of exercise you
kegel’s exercise. do.
Treatment • Instruct patient to have • Rest is important for the
complete bed rest. patient’s recovery. Allow
the patient to slowly
return to normal activities
and do more as he feels
stronger. This is also to
provide optimal comfort
for the patient.

• Instruct patient to • This is to keep a record

monitor blood pressure. of his blood pressure and
bring the record to his
follow up visits.

• Instruct patient to avoid • Nicotine in cigarettes

smoking. causes low birth weight
and other medical
problems.

• The vitamins should

• Take prenatal vitamins contain at least 4,000
as directed. micrograms of folic acid.
Folic acid helps prevent
birth defects such as
spina bifida.

65
 • Control diabetes or other • Diabetes can cause
medical conditions. problems for the baby,
such as too much weight
gain. It is advised to
manage blood sugar
levels next pregnancy.

Hygiene • Encourage patient or • This will keep the patient

significant others to free from infections and
maintain a clean decrease stress.
environment. • It is important to be
• Maintain good hygiene gentle with the skin in the
by taking a daily bath weeks after a C-section.
such as tepid sponge The decision to
bath submerge the body in
water depends on the
status of the incision site.
In general, most people
can take a bath about 3–
4 weeks after a C-section
— although the patient
may be able to take a
bath sooner, depending
on the circumstances
• Practicing proper
hygiene will keep your
body healthy while
preventing infections and
diseases.
Outpatient • Instruct the patient to • For health status
continue to follow up monitoring.
check-up with the doctor
as per advised.
Diet • Eat meals at home. • For a healthier choice.
Restaurant meals may
have a higher salt
content.

• Limit salt and sugar

intake. and eat healthy

66
 food such as vegetables • This aims to keep you
(lettuce, green beans, healthy and provides the
green leafy vegetables), energy you need.
fruits (tomatoes, apples,
bananas, oranges), and
meat.
• Drink enough and not
too much fluid as
prescribed by doctor, at • To maintain hydration,
least 8 glasses of water more liquid can help
a day. prevent dehydration and
high blood pressure.
Spiritual • Encourage prayers • This aims to strengthen
within their faith tradition their faith and tend to
for the patient to express have a more positive
her thoughts and outlook in life. This will
feelings according to her give the patient a sense
beliefs. of peace, hope,
wholeness and balance
among the physical,
emotional, social
and spiritual aspects of
our lives.

67
 CHAPTER IX

BIBLIOGRAPHY

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Dulay, A., (2020). Oligohydramnios.

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Dalmacion G., et al (2018). Handheld ultrasound to avert maternal and neonatal

deaths in 2 regions of the Philippines: an iBuntis® intervention study.

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Willacy, H. (2021). Oligohydramnios epidemiology.

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Friedman, P. and Ogunyemi, D. (2018). Prevalence and Epidemiology.

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3F,fetu s%2C%20you%20may %20have%20oligohydramnios.

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Edition; MSD Manuals.

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Karp. J.K, (2020). Direct Antiglobulin Testing.

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Sweha, A. & Hacker, T. (1999). Interpretation of the Electronic Fetal Heart Rate

During Labor. https://www.aafp.org/afp/1999/0501/p2487.html

Girault, A. et al. (2020). Reducing neonatal morbidity by discontinuing oxytocin

during the active phase of first stage of labor: a multicenter randomized

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4-020- 03331-x

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WebMD (n.d) Ranitidine Hcl - Uses, Side Effects, and More. .

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liquid-

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inger %2DEllison%20syndrome)

Anderson, O & Wearne, M.J,. (n.d) Informed Consent for Elective Surgery—What

Is Best Practice? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1791005/

Ndrugs (2021). Planil generic. Price of planil. Uses, dosage, side effects.

https://www.ndrugs.com/?s=planil

Goodman, P. (2019, May 1). What Causes Pain with Urination after c Section? -

New Kids Center. New Kids Center. https://www.newkidscenter.org/pain-when-

urinating-after-c-section-

1.html?msclkid=c9450caec51b11ecb7687d4a48b82483

Themes, U. (2016, November 26). 12. Postpartum Assessment and Nursing Care.

Nurse Key. https://nursekey.com/12-postpartum-assessment-and-nursing-

care/?msclkid=866005d9c52b11ec8d5e2d120ed34a89

editor. (2022, February 15). C-Section Complications. American Pregnancy

Association. https://americanpregnancy.org/healthy-pregnancy/labor-and-

birth/c- section-

complications/?msclkid=d4ac57bbc52011ecbcc0968dd53773be

Drugs.com. (2021, August 5). Dextrose 5% in Water (D5W).

https://www.drugs.com/dextrose-5-in-

water.html?msclkid=c3af45cdc52211ec89faf3d620250cd8

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Glezer, A., MD. (2021, June 30). Oxytocin and Postpartum Mood. Mind Body

Pregnancy. https://www.mindbodypregnancy.com/articles/oxytocin-postpartum-

mood?msclkid=b04d307fc52611ec87e10e55d58abed1

Drugbank. (2022, April 22). Cefuroxime: Uses, Interactions, Mechanism of Action

| DrugBank Online. https://go.drugbank.com/drugs/DB01112

Achwal, A. (2020, November 5). How to Sleep After Cesarean Delivery. FirstCry

Parenting.https://parenting.firstcry.com/articles/sleeping-position-after-c-

section- how-to-sleep-after-

cesarean/?msclkid=ae159dc4c52911ec81804d699958823d

Whitlock, J. (2021, September 6). Why You Must Pass Gas After Surgery. Verywell

Health. https://www.verywellhealth.com/passing-gas-after-surgery-

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Home, A. (2019, June 29). Diet after cesarean delivery - foods to eat and avoid.

‫أﺣﻠﻰ ھﺎوم‬ .https://www.a7la-home.com/en/diet-after-cesarean-delivery-foods-

eaten- avoided?msclkid=ee8800e4c52e11ec8645d7c87422daa0

Drugs.com. (2020, December 1). Cefixime.

https://www.drugs.com/pro/cefixime.html

Cloudy Urine: Causes, Treatment, & What Does It Mean. (2021, 28 september).

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%20clumps%20of%20WBCs%20are,increased%20mucus%20in%20the%

20urine.

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73
 CHAPTER X

APPENDIX

DATE & DOCTOR'S ORDER JUSTIFICATION

TIME

04/11/2022 • To labor room and EFM Tracing • The patient was forwarded to the labor room and EFM tracing
6:50pm as ordered by the doctor. EFM tracing is to monitor and
assess fetal well-being during labor.

• May have DAT • DAT is used to see if red blood cells (RBCs) have been coated
with immunoglobulin, complement, or both in vivo.
8:41pm

04/12/2022 • Relay EFM Tracing results at • The doctor ordered Dexamethasone 6mg IM Q'12 Monitor
1:10am 3am blood pressure 2 - 3 times daily, and observe for signs of
• Give Dexamethasone 6 mg IM adverse reactions. Relay EFM Tracing results. To enable
now then every 12 hours × 4 physicians to order, the nurse must assess preterm clients
doses thoroughly and relay pertinent information appropriately.

5:50am • Start sidedrip 500cc D5Water + • The patient was in Labor room with IVF Start sidedrip 500cc
10 units of oxytocin at 8-10 D5Water + 10 units of oxytocin at 8-10 mgtts/min, the doctor
mgtts/min ordered to discontinue drips because fetal and maternal
• Discontinue drips once with the problems such as neonatal acidosis and postpartum
fetal bradycardia, fetal hemorrhage have been linked to it.
tachycardia or absence of
variability

74
 • Schedule for STAT CS • The patient was PV 34 weeks Cephalic not in labor
9:15am • Inform Dr. Allen Garcia Oligohydramnios G1P1 so the doctor ordered a schedule for
Anesthesia STAT CS. Ensure that the patient is fully hydrated and ensure
• Inform Dr. Domingo Pedia that the side rails are up, and the woman is covered with a
• Secure consent for B.O blanket.
• Secure consent for Operation
• May give Planil, amp now
• May give Ranitidine, amp now • The patient was scheduled for STAT CS, so the doctor was
ordered to inform Dr. Allen Garcia for Anesthesia and Dr.
Domeigo for Pedia for the operation, to secure consent for
operation. The nurse informs the medical staff to be involved
in the operation, prepares the consent, and consent should
begin with a brief explanation of the planned operation,
including the anaesthetic involved.

• The doctor ordered Ranitidine and Planil ampule,

Ranitidine medication is used to treat stomach and intestine
ulcers and keep them from returning after they have healed
and Planil It's also used to treat arthritis by reducing
inflammation, edema, stiffness, and joint discomfort, as well
as to manage lupus erythematosus symptoms (lupus; SLE).

4/12/22 • To UA
10:00 am • UTI may be acquired due to the urinary catheter they had to
place for the delivery. Couple that with an epidural block for
anesthesia which causes the urinary tract to go to sleep, and
you have all the conditions for infection.

75
 • Vital signs every 15 minutes
until stable then every 4 hrs. • The patient is closely observed and assessed because it is a
critical time to prevent the dangers of hemorrhage and
hypovolemic shock. Aside from that there are risks associated
with any type of abdominal surgery such as infection,
hemorrhage, injury to organs, adhesions, and reaction to
medications.

• MONITOR I&O
• Monitoring is an important clinical care process that provides
the means to determine the progress of the disease and the
beneficial as well as detrimental effects of treatment.
Monitoring of intake helps caregivers ensure that the patient
has proper intake of fluid and other nutrients. Monitoring of
output helps determine whether there is adequate output of
urine as well as normal defecation.

IVF: • Dextrose 5% in water is used to treat low blood sugar

(hypoglycemia), insulin shock, or dehydration (fluid loss).
• D5W SIV CC + 10 vi oxytocin at Dextrose 5% in water is also given for nutritional support to
120cc/h patients who are unable to eat because of illness, injury, or
other medical condition. Oxytocin is also a neuropeptide
• CCFVF: made in the hypothalamus, a regulatory center in the brain. It
is involved in labor and breastfeeding. It helps with uterine
• D5W, L + 20 vi oxytocin at contractions and with milk letdown. It has been studied for its
120cc/h role in maternal child attachment and more generally social
relationships in all mammals.

76
 • D5W, L + 10 vi oxytocin at 8h

10:20 am Meds: 1. Cefuroxime is a cephalosporin indicated for the treatment of

a variety of infections. Prophylactic antibiotic therapy is
1. Cefuroxime 75g IV Q8 ANST accepted for prevention of post-cesarean infection in certain
2. Ketotolac 30mg IVTT Q'8 risk groups.
ANST 2. Patient was done with the surgery there was an order from
3. Tramadol 50mg IVTT Q'8 PRN the doctor, Ketotolac 30mg IVTT Q'8 ANST
for severe pain 3. Tramadol 50mg IVTT Q'8 PRN for severe pain, Monitor signs
4. Ranitidine Ranitidine 50mg of allergic reactions and educate the patient about the drugs
IVTT Q'8 ×2 more dosages 4. The doctor ordered Ranitidine 50mg IVTT Q'8 ×2 more
dosages, monitored signs of hypersensitivity reactions and
advised patients to avoid alcohol and foods that may cause
an increase in GI irritation.

• Flat on bed until 6pm • After the patient's surgery, the doctor ordered the patient to
stay in the bed until 6pm. The nurse observes the patient's
Vital signs and lets the patient rest.

• We can keep the uterus contracted via fundal massage.

• Keep uterus well-contracted; Fundal massage or uterine massage refers to a massage
apply via placenta given to the uterus to reduce bleeding from the genital tract
soon after delivery. This massage is used to reduce post-
delivery hemorrhage, pain, and cramping. It is performed
every 10-15 minutes in the first-hour post-delivery and every
30 minutes during the second hour, post which it is given
every 4-8 hours until the patient is discharged.

77
 • Monitoring is an important clinical care process that provides
• Input and output and succeed the means to determine the progress of the disease and the
beneficial as well as detrimental effects of treatment.
Monitoring of intake help care givers ensure that the patient
has proper intake of fluid and other nutrients. Monitoring of
output helps determine whether there is adequate output of
urine as well as normal defecation.

• Keep warm & thermoregulated • The healthcare team should try to ensure that you stay
comfortably warm all the time. They should do several things
to keep you warm, starting before your operation and
continuing until you are comfortably warm back on the ward.
They should monitor your temperature, and use a special
warming blanket or mattress to help stop you getting too cold.

• Refer accordingly • Referring a patient to another provider is a common practice

that helps ensure patients receive the care they need.
Referrals can sometimes be ideal — or even necessary — to
smooth out the overall patient experience and reduce care
gaps.

4/12/22
10:45 am • Monitor input and output • Monitoring is an important clinical care process that provides
the means to determine the progress of the disease and the
beneficial as well as detrimental effects of treatment.
Monitoring of intake help care givers ensure that the patient
has proper intake of fluid and other nutrients. Monitoring of

78
 output helps determine whether there is adequate output of
urine as well as normal defecation.

• Give Cefin at 7pm tonight • Cefine is an antibiotic medicine that works by killing the
infection-causing bacteria in your body. It is effective for
bacterial infections of the lungs, throat, and urinary tract
among others.

• Soft diet once w/ flatus • The body accumulates gas after childbirth. New mothers
should be careful not to eat food items that cause gas and
constipation. If you can't pass gas soon after surgery, it may
mean that a post-operative ileus, or gastric delay, is
happening. A post-operative ileus or POI is when there's a
slowdown in your body's ability to digest food.

79
 INFANT’S DATA
Weight _5_ Lbs. _4_oz. Length _45 cm Sex _Male_ Attending Physician: _Dra. Domingo_
Head Circum. _31_cm Chest Circum. _27_cm Abdominal Circum. _26_cm
Eye Treatment: _Tobramycin eye ointment OU_ Applied by: _Cedeño_ Cord Clamp by _ Cedeño_
Abnormalities ____________________________________________________________________________
Medications _Vit K IM 6MG_
Remarks _Received an alive baby body from a G1P1 mother p CS c HS 8 and 9

80
 RECOVERY ROOM RECORD
SURNAME FIRST NAME MIDDLE ROOM HOSPITAL # DATE

CERVANTES SHENA CALIBAY EXT 2-C 22-00004561 04/12/2022

ATTENDING PHYSICIAN ANESTHETIST AGE/SEX RECOVERY TIME ARRIVED TIME

SCORE DISCHARGED
DR. GAGWIS, RHODORA DR. GARCIA, ALLENE 26 Y.O. F

OBSERVATION
TIME 45 50 50 00 05 10 15 20 25 30 35 40 45 50
10 10 10 10 10 10 10 10 10 10 10 10 10 10

BP 133/74 138/80 125/76 121/81 127/79 121/80 118/87 124/77 121/79 181/76 129/80 130/79 130/78 132/83

PULSE 70 72 71 69 68 64 67 65 61 64 69 62 62 65

RESPIRATORY 14 13 14 13 15 14 15 14 16 17 14 18 13 17

SPO2 99% 99% 99% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

RECOVERY SCORE
ACTIVITY 1 1 1 1 1 1 1 1 1 1 1 1 1 1

81
RESPIRATORY 2 2 2 2 2 2 2 2 2 2 2 2 2 2

CIRCULATION 2 2 2 2 2 2 2 2 2 2 2 2 2 2

CONSCIOUSNESS 2 2 2 2 2 2 2 2 2 2 2 2 2 2

COLOR 2 2 2 2 2 2 2 2 2 2 2 2 2 2

TOTOAL SCORE 9 9 9 9 9 9 9 9 9 9 9 9 9 9

82
 VITAL SIGNS MONITORING SHEET
Name: _Cervantes, Shena_ Physician: _Dra. Gagwis, Rhodora_ Room: _______
Age/Sex: _26 y.o./F_ Chief Complaint: _Oligohydramnios_
BP Temp CR RR O2 NOD
Date Time mm/Hg °C bpm cpm Sat FHT Initials
4/11/22 2:30 100/60 36 91 20 98% 143 ER
pm
LABOR ROOM
4/11/22 7:30 161
pm
8:00 110/70 36 85 19 144
pm
9:00 149
pm
10:00 141
pm

83
 11:00 110/60 36 88 20 143
pm
9/12/22 12:00 110/70 36 84 19 136
am
1:00 144
am
2:00 142
am
3:00 139
am
4:00 110/70 36 83 19 133
am
5:00 137
am
6:00 132
am
7:00 138
am

84
8:00
am
POST-OP

85