INTERDISCIPLINARY PLAN

I. RECAPITULATION OF STAY:

A case of Ms. D.J.G, 35 y.o, married, living in 112 8 Apolarium St. Dulfo, Fatima Cebu
city was diagnosed with G5P5(5005) :Pregnancy unterine 38 weeks cephalic delivered,
Multiparity, Herpes Genitalis, primary low segment cesarean section, Bilateral Tubal ligation
term birth. Live baby girl. Patient was admitted at Visayas Community Medical Center last
February 25, 2011 for complaints of labor pain. Patient had her menarche at 13 years old with
regular monthly interval, lasting 5 days consuming 2 pads per day. Has history of
dysmenorrheal. First sexual contact at 15 years old with no vaginal discharges was noted.
Internal examination was done inside the labor room by her physician and was found out to
have a Herpes genitalia. Her physician ordered immediate cesarean section prior knowing her
condition. Delivered an alive baby girl. She undergone diagnostic test such as HbsAg,CBC,blood
test,urinalysis and immunology test on February 26, 2011. On February 28, 2011 the physician
ordered to encourage mobilization, deep breathing exercise and self perineal care. Her diet was
changed into Full Diet, with abdominal binder. On the same day, PO meds has been given, and
with vital signs of BP- 110/80 T- 36.5 R- 21 cpm P- 80bpm. On the next day, March 1 2011,
received patient lying on bed talking with her husband with the following vital signs of BP-
110/90 T-36.4 R-23 P- 82bpm. PO meds has been given as prescribed. Encourage mobilization,
deep breathing exercise and self perineal care On the Third day March 2,2011 the physician
done wound dressing, encourage mobilization, deep breathing exercise and self perineal care
Po meds has been given on that day. With the following vital signs of BP- 120/80 T-36.8 R-22 P-
80.Nursing care was given, client teaching was done, ready for discharge and on the fourth day
March 3,2011 at 8:30am she was discharged.



II. DISCHARGE DIAGNOSIS & MEDICAL HISTORY:

G5P5 (5005) pregnancy uterine 38 weeks cephalic delivered multiparity, herpes genitals
primary low segment cesarean section bilateral tubal ligation, term birth live baby girl.


III. MEDICAL STATUS:
Temp: 36.7 degrees Celsius
PR: 81 BPM
RR: 20 cpm
BP: 100/70 mmHg.



IV. LABORATORY X-RAY & DIAGNOSTIC TEST SUMMARY:
The patient had these following laboratory tests during the span of time she was in the
hospital:
Urinalysis (February 27, 2011)
Immunology / serology section (February 27, 2011)
Clinical chemistry section (February 27, 2011)
Clinical Chemistry section (February 27, 2011)
Hematology (February 27, 2011)

Abnormalities noted on the ff. tests:

Hematology Section (February 27, 2011)

Test name Result Reference range
WBC 17.61 High 4.1 10.9
-segmenters 89.50 High 47.0 80.0
-lymphocytes 6.10 Low 13.0 40.0
RBC 3.37 Low 4.0 5.2
Hemoglobin 10.13 Low 12.0 16.0
Hematocrit 30.4 Low 36.0 46.0
MCHC 36.60 High 31.0 36.0
RDW CV 18.5 High 11.0 16.0

WBC is high and means that the body is fighting an infection.
Low numbers of lymphocytes can increase your risk for infection.
Low RBC indicates low oxygen levels in the blood.
Low hemoglobin count is referred to as anemia.
Low hematocrit is referred to as being anemic.


Immunology/ Serology Section (February 27, 2011)

Ft4 10.76 L pmolL/ L 12.0 22.0
Test name Result Reference range
Ft4 10.76 Low 12.0 22.0



Clinical Chemistry Section (February 27, 2011)

Test name Result Reference range
Potassium 3.4 Low 3.5 5.3



V. FUCTIONAL STATUS:


VI. NUTRITIONAL STATUS:
Diet Full Diet
Height 160 cm
Weight 49 kg



VII. SENSORY & PHYSICAL IMPAIRMENT:




NO
IMPAIRMENT

TYPE OF
IMPAIRMENT

COMPLETE
LOSS

DESCRIBE
IMPAIRMENT

TYPES OF
PROSTHESIS
SIGHT
HEARING
SPEECH
PARALYSIS
BLADDER
INCONTENECE



VIII. PSYCHOSOCIAL STATUS:

Patient communicates by expressing herself to the health care provider, Able to
communicate well and responsive. She is oriented to time and place.

IX. SPECIAL TREATMENT OR PROCEDURES:
Ambulation
Deep breathing exercise
Perineal Care

ADLS

INDEPENDENT

REQUIRES ASSISTANCE

TYPE OF ASSISTANCE
AMBULATION
TRANSFERS
TOILETING
EATING
DRESSING
BATHING
GROOMING
COMMUNICATION

X. DENTAL STATUS:
YES NO UPPER LOWER
TEETH
DENTURES

Patients gums are not bleeding.

CONDITION OF TEETH & GUMS:

> The patient had a complete teeth both in the upper and lower and had no dentures attached
to her
> Patients gums are not bleeding.



XI. ACTIVITY POTENTIAL & REHABILITATION POTENTIAL:

Encourage ambulation
Eat foods that are nutritious and suitable for her condition to regain energy.
Tell patient to continue taking the medications as prescribed by the doctor.
Teach patient the importance of breastfeeding for her baby and the proper way of doing
it.
Encourage deep breathing exercise
Encourage to walk step by step
Encourage to eat vegetables

XII. COGNITIVE STATUS:

Patient is coherent, responsive and cooperative. She is oriented to time and place.
She was able to provide appropriate answers in every question asked.


XIII. DISCHARGE DRUG THERAPY:

MEDICATION

DOSAGE

FREQUENCY

REASON FOR MEDICATION


Cefuroxime

1 tab 500 mg

once a day

To treat for any infection

Mefenamic Acid

1 tab 500 mg

q6h as needed

For pain relief

Ferrous Sulfate
(Sorbifer)

1 tab 500 mg

once a day

To correct anemia



XIV. POST DIACHARGE PLAN:

CARE REQUIRED (INCLUDE TREATMENT & PROCEDURES)

M- Modification of Lifestyle
Encourage patient to do regular exercises for at least 15 minutes early in the morning.
Encourage ambulation
Instruct patient to refrain from performing heavy activities, instruct patient that she may
have to decrease her activities and may not be allowed to do any vigorous exercises.

E- Environment

Advise patient to ensure or maintain a clean and calm environment to prevent the risk for
infection.

T- Treatment
Instruct patient to take home medications religiously as prescribed by the doctor.

H- Health Teaching
Instruct patient to take a bath or shower everyday to maintain cleanliness of the body.
Encourage patient to have self-perineal care and do handwashing frequently.
Encourage patient to do deep breathing exercises.
Teach the patient the importance and the proper way of breastfeeding and new born care
and encourage newborn immunization.
Instruct patient to do breast care before breastfeeding
Encourage to wear a support bra to increase comfort

O- Outpatient
Encourage significant others as well as the patient to have follow-up check-up to her
attending physician

D- Diet
Instruct client to increase intake of nutritious foods such as foods that are rich in fiber and
protein.

S- Spiritual
Promote the importance of prayer and divine interventions.
Encourage patient to continue attending mass every Sunday.



XV. AID PROVIDED TO CLIENT / FAMILY IN ARRANGING POST DISCHARE SERVICES:
Instructed clients significant others / family to supervise client in daily activities.





Daub, Janelyn Gemang

317490

Dr. Alcantara, Clarita
CLIENT / PATIENTS
NAME
MEDICAL RECORD # ATTENDING PHYSICIAN