DRUG NAME MECHANIS INDICATION/CONTR ADVERSE EFFECT NURSING RESPONSIBILITIES

M OF AINDICATION
ACTION
Generic Name: - Inhibits INDICATION: CNS: Dizziness, - Assess pain and limitation of
Diclofenac prostaglandin Management of Drowsiness, headache movement; note type, location and
synthesis. inflammatory disorders intensity before and 30-60 minutes
Brand Name: Suppression including; Rheumatoid CV: Hypertension after administration.
Cataflam of pain and Arthritis, Osteoarthritis, - Assess arthritic pain and limitation
inflammation. Ankylosing spondylitis. GI: GI bleeding of movement before and
CLASS Relief of mild to periodically during therapy.
Therapeutic: moderate pain of GU: Acute renal - Assess lesions prior to and
Nonopiod dysmenorrhea. Acute failure, Dysuria, periodically during therapy.
Analagesics, pain. Hematuria, Nephritis - Monitor BUN, serum, creatinine,
Nonsteroidal Anti- and electrolytes periodically during
Inflammatory Agents CONTRAINDICATION Derm: Exfoliative therapy.
: Hypersensitivity to dermatitis, eczema - Administer after meals, with food,
Dosage: diclofenac or other or an antacid containing aluminum
50 mg components of Hemat: Prolonged or magnesium to minimize gastric
formulation. Cross- bleeding time irritation.
Route: sensitivity may occur with - Instruct patient to take diclofenac
ORAL other NSAIDs including with afull glass of water and to
Aspirin. Active GI remain an upright position for 15-
bleeding/ ulcer disease. 30 minutes after administration.
- Advise patient to consult health
care professional if rash, itching,
visual disturbances, tinnitus, weight
gain, edema, black stools, persistent
headache or influenza.

Generic name: - Bind to INDICATIONS: Skin CNS: Seizures - Assess for infection (vital signs,
C bacteri and skin structure GI: appearance of wound, sputum,
EFRIAXONE al cell infections, bone and joint Pseudomembranous urine, and stool and WBC) at
 wall infections, urinary and colitis, Diarrhea, beginning of and throughout
Brand Name: membr gynecological infections Nausea, Vomiting therapy
ROCEPHI ane, including gonorrhea or DERM: Rashes, - Observe patient for signs and
N causing respiratory infections, Urticaria symptoms of anaphylaxis (rash,
cell intra- abdominal HEMAT: Bleeding, pruritus, laryngeal edema,
Therapeutic: death. infections. Perioperative blood dyscrasias, wheezing).
ANTI- Bacteri prophylaxis. hemolytic anemia - Monitor prothrombin time and
INFECTIVES cidal LOCAL: Pain at IM assess patient for bleeding.
action CONTRAINDICATION site, Phlebitis at IV site - Obtain specimens for culture and
Pharmacologic: against : Hypersensitivity to MISC: Allergic sensitivity before initiating therapy.
THIRD suscept cephalosporin. Serious reactions including First dose maybe given before
GENERATION ible hypersensitivity to anaphylaxis and serum receiving results.
CEPHALOSPORIN bacteri penicillin. sickness,.
a. Hypersensitivity to L- superinfection
Dosage: Similar arginine. Carnitine
0.5-1 g q 4 hours to that deficiency or inborn
of errors of metabolism.
Route: second
IM, IV generat
ion
cephal
osporin
but
have
activity
against
staphyl
ococci
is less,
wherea
s
activity
against
gram-
negativ
e
 pathog
ens is
greater,
even
for
organis
ms
resistan
t to
first
and
second
generat
ion
agents.

NCP

ASSESSMEN EXPLANATION OBJECTIVES NURSING RATIONALE EVALUATION

T OF THE INTERVENTIONS
PROBLEM
SUBJECTIVE The client is STO: Monitor - To have a Goal met. After 1-
: experiencing pain - Within 1- 2 hours of vital baseline 2 hours nursing
“Ang sakit ng due to the continuous nursing sign data. intervention;
sugat ko”as episiotomydone to intervention the patient - Monitored vital - Pain is a. The patient
verbalized by her after the CS will be able to; signs. subjective is able to
the patient. operation. Pain is a a. Verbalized the experience characteriz
Pain rated as typical sensory characteristics and - Assessed pain and must be e and the
8/10. experience that location of pain. including the described by location of
may be described b. Perform pain location, the client in pain.
OBJECTIVE: as the unpleasant management such as characteristics, order to plan b. The
BP: 120/80 awareness of a deep breathing onset, duration, effective patient is
PULSE: 110 noxious stimulus exercise. frequency, treatment. able to
bpm LTO: quality, - To prevent perform
RR: 24bpm - Within 24 to 48 hours of intensity or bleeding n deep
SPO2:90% continuous nursing severity and of the breathing
TEMP: 36.5 interventions the patient precipitating surgical exercises.
will be able to; factors. incision Goal not met.
NURSING the client’s made from After 24-48 hours
DIAGNOSIS: reported pain - Instruct the the of nursing
Acute pain will subside client to avoids operation. intervention;
related to post- the client’s strenuous a. The patient
operative reported pain exercise and - To promote still reports
surgical will subside activities. blood pain rated
Incision the client’s circulation as 8/10
reported pain and faster b. The patient
will subside healing of still can’t
a. Report pain subsides. the incision. be able to
b. Do activities and - Instruct the - To aid in the do
breastfeeding without client to have a strengthenin activities
intensive assistance. short walk g of having alone and
everyday as a a good still needs
form of immune intensive
exercise. system assistance.
against
infection.
- Advise the
client to eat - To prevent
plenty of further
nutritious foods infection.
and vegetables
and drink plenty
of water.
- The use of
noninvasive
pain relief
measures
- Instruct to clean can increase
and change the release
wound dressing of
at least once a endorphins
 day. and enhance
- Teach the use of the
non- therapeutic
pharmacologic effects of
techniques: pain relief
deep breathing medication.
technique.

13 AREAS OF ASSESSMENT

a) Psychosocial and Psychological Status

Patient X is a 25-year-old Female, married and Filipino. He is 25 years old which falls under the sixth stage of Erik Erikson’s Theory of
Psychosocial Development; Intimacy versus Isolation. This stage takes place during young adulthood between the ages of approximately 19 and
40 years old. Erik Erikson said that we must have a strong sense of self before we can develop successful intimate relationships. Adults who do
not develop a positive a positive self-concept in adolescence may experience feeling of loneliness and emotional isolation.
Patient X is married and currently has 2 kids with her husband. He is in a loving relationship as evidence by the frequent visitation of her
husband and kids in the ward.

b) Mental and Emotional Status

Patient X is conscious, alert and coherent. She is responsive to verbal, noise, light, touch and pain stimuli. She is oriented to time, date and
place. She speaks and acts according to her age. The patient is at the Formal Operational Stage of Jean Piaget’s Four Developmental Stages. She is
able to use symbols to relate to abstract concepts.
c) Environmental Status
Patient X is admitted at the OB Ward at Bed 38 Female side. The area is clean, well ventilated, and has proper lighting. The bedside table
is located on the left side of the bed and is easily accessible at hands reach.
d) Sensory Status

Visual Status Patient X’s vision is normal, was able to read a text message from her phone
without any trouble. Is able to distinguish different colors such as red, yellow,
blue and black.
Auditory Status Patient X does not use any hearing aid and was able to hear the words “book”
and “ballpen”
Olfactory Status Patient X can smell normal, was able to differentiate the smell of alcohol from
orange while eyes are closed.
Gustatory Status Patient X can taste fairly well as verbalized by the patient.
Tactile Patient X is able to distinguish the tip of the ball pen as pointed while pointing
on the touched part on both upper and lower extremities while eyes are closed.
Rated pain as 8/10, sharp, localized at the lower quadrant of the abdomen,
increases with movement.

e) Motor Status
Patient X’s movement is limited due to her surgical incision on the lower quadrant of her abdomen. Her significant other assists her to do
her activities of daily living due to his current situation. Confined in bed most of the time, still has difficulty moving and walking
f) Thermoregulatory Status
The patient’s axillary temperature during our rotation ranges from 36.5 to 37.1 degree Celsius which falls under normal value range of
36.5 – 37.5 which indicates he has fever.

Date Time Temperature

April 10, 2019 6 pm 36.8
10 pm 37.1
April 11, 2019 6 pm 36.5
10 pm 36.8
April 12, 2019 6 pm 36.6
10 pm 36.6

g) Respiratory Status
The patient’s respiratory status during our rotation ranges from 21– 24 cycles per minute and his oxygen saturation ranges from 89% -
91%, which falls below normal in some occasion while the respiratory rate is slightly higher than the normal range of 16-20 cycles per minute.

Date Time RR SpO2

April 10, 2019 6 pm 22 90%
10 pm 21 89%
April 11, 2019 6 pm 22 92%
10 pm 24 90%
April 12, 2019 6 pm 23 90%
10 pm 24 91%
 h) Circulatory Status
The patient’s circulatory rate during our rotation ranges from 90 – 110 beats per minute and his blood pressure ranges from 110/80 mmHg
– 130/80 mmHg. Her circulatory rate falls above the normal range values for adults of 60 -100 beats per minute. His blood pressure also falls
above the normal range of 110/80 mmHg – 130/80 mmHg. The capillary refill of the patient is within normal range.

Date Time BP CR Capillary Refill

April 10, 2019 6 pm 120/80 mmHg 100 2 seconds
10 pm 120/80 mmHg 90 2 seconds
April 11, 2019 6 pm 110/80 mmHg 110 2 seconds
10 pm 120/80 mmHg 90 2 seconds
April 12, 2019 6 pm 130/80 mmHg 95 2 seconds
10 pm 130/80 mmHg 96 2 seconds

i) Nutritional Status
Patient X is healthy in appearance with no nutritional abnormalities noted. Height is 5 feet and 4 inches, weight is 70 kilograms and has a
BMI of 26.5 which is slightly above the normal range of 18.5 – 24.9.

j)Elimination Status
The patient has not defecated for two days but has a urine output of 700 ml during our shift. Prior to admission, the patient bowel
movements and urination are normal.

k) Sleep, Rest, and Comfort Status

Patient claims that normally she sleeps six to eight hours a day. However, she only sleeps four to five during hospitalization due to his
operation. Pain scale of 8/10 is present as verbalized by the patient.

l) Fluid and Electrolyte Status

Patient has an ongoing IVF of 1000mL Plain Lactated Ringer’s Solution with a drop rate of 31 drops per minute to infuse for 12 hours.
Normally, she drinks 1 to 1.5 L per day.

m) Integumentary Status
Patient X’s is fair skinned, she has a surgical wound on her abdomen. There are no other lesions other than the surgical site. There are bulging or
inflammation at the IV site and around the surgical wound area. Nails and hair are well trimmed. Skin turgor is normal.

RESEARCH TASK

1. Many women have experience ovarian cyst. Most ovarian cysts present little or no discomfort and are harmless. The majority disappears
without treatment within a few months, but there are some cases that will progress into ovary complication such as ovarian cancer.
However, ovarian cysts especially those that have ruptured can cause serious symptoms.

Symptoms are manifested by the patient causing her to be admitted in the facility. Sudden and severe abdominal or pelvic pain
(sharp pain is being felt if the cyst is large and about to rupture.) Fever is also present with vomiting episode to the patient. Bloating and
heaviness of the abdomen is also one of the complaints of the patient (Fluid in an ovarian cyst can irritate the lining of your
abdomen, creating inflammation and inflammation can cause bloating.)

2. There are 2 commonly use diagnostic test for suspected ovarian cyst showing probable signs in addition to complete pelvic exam.
Transvaginal ultrasound (TVUS). A transvaginal ultrasound is an internal examination, the procedure involves the insertion of the
transducer into the vagina to produce incredibly detailed images of the organs in the pelvic region. CA- 125 blood testing is also to be
done to patients with high risk to measure the amount of the protein CA 125 (cancer antigen 125) in your blood. A CA 125 test may
be used to monitor certain cancers during and after treatment. CA 125 test may be used to look for early signs of ovarian
cancer.