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Date Time

& Physicians Order


Patient is admitted under >Please admit patient under the service of the service of Dr. Derecho Dr. Derecho because the patient is in need of optimum health care. >Secure consent for case This particular diet is only given when patient can tolerate any food she desires that is nutritious, if >DAT this will not lead to any complications and if the client needs further monitoring for lab test. Vital signs are your baseline data to give indication of the state of health of an individual. Intravenous therapy may be used to correct electrolyte imbalances, to deliver medications, as fluid replacement to correct dehydration, etc. Isoxuprine HCl is given to prevent premature delivery. An Electronic Fetal Monitoring or EFM is used for monitoring both uterine contractions and the fetal heart rate. A baseline EFM is needed in order to know the state of the baby; whether the baby has tachycardia or bradycardia. It also detects early fetal distress resulting from fetal hypoxia and metabolic acidosis. This is to monitor the fetal well being. A complete blood count is used to determine presence of anemia, as well as a platelet count is used to estimate the clotting ability. Urine analysis is used to determine any presence of bacteria, pus, or proteinuria. To provide necessary

>Monitor VS q 4 and record please 06/19/2012 7:30 pm >Start D5LR 1L @ 120cc/hr

>Isoxsuprine HCl 1 tab q 8

>Baseline EFM

>Monitor FHT q 4 and record

>for CBC; U/A c/o OB sono

>AP aware >refer unusualities

COMPLETE BLOOD COUNT (June 20, 2012 at 1:45 am)

Parameter Hemoglobin

Normal Values 120.0 - 160.0 g/L

Result Increase L 115 Chronic Obstructive Pulmonary Disease (COPD) Failure of oxygenation due to Congestive Heart Failure (CHF) Polycythemia

Decrease Anemia Excessive fluid intake Severe or prolonged hemorrhage

Nursing Responsibilities Before: Explain to the patient the purpose of taking the blood specimen. Inform the patient who will perform the extraction of blood and the time it will be taken. Inform the patient that she may feel discomfort during


4.0 - 5.0 10^12/L

L 3.77

Severe diarrhea and dehydration Pulmonary fibrosis Polycythemia Macrocytic anemia

Anemia Leukemia

the insertion of the needle.


28.0 - 33.0 pg


Microcytic anemia

MCV MCHC WBC Neutrophil

82.0 - 98.0 fl 33.0 - 36.0 g/dl 4.8 - 10.8 10^9/L 40-70%

95.2 L 32.2 H 12.9 69

Macrocytic anemia Macrocytic anemia Infection Malignant disease Acute infection Leukemia

Microcytic anemia Severe hypochromic anemia ----- Viral infection Bone marrow disease Bone marrow suppression Aplastic anemia Immune deficiency diseases HIV infection Corticosteroids use Stress Use of medications During: Instruct the patient to relax and avoid extra it movements because




Viral or bacterial infection Hepatitis Viral infection Parasitic disease Sub acute infection Parasitic

might cause injury.

Monocyte Eosinophil

3.0 -9.0% 2.0 -8.0%

8 3

After: Apply pressure at the site

for 5 minutes. Label the specimen bottle and transport it to the laboratory. Observe the site for signs of bleeding and hematoma.


0.0 -0.5%

Acute leukemia

Allergic reaction Stress Allergy Parasitic disease Corticosteroids use

Hematocrit Platelet count

0.37 -0.45 % 150.0 - 400.0 10^9/L

L 0.36 194

Dehydration Erythrocytosis Rheumatoid arthritis Myeloproliferative disease

Acute massive blood loss Aplastic anemia Thrombocytopenic purpura Acute leukemia

URINALYSIS (June 20, 2012 at 9:17am)


Parameters Color Appearance Reaction Specific Gravity Protein Glucose

Normal Values Straw to dark yellow Clear 4.5 - 8.0 1.010 - 1.025 Negative Negative

Result yellowish clear 6.0 1.010 Negative Negative

Significance Normal Normal Normal Normal Normal Normal

Nursing Responsibilities Before: Instruct the patient

catch the midstream urine by first washing the perineal area then collecting discarding flow. only the the first midstream urine and

Chemical Characteristics

February 15, 2012 (3:34pm) WBC RBC Epithelial cells Cast Bacteria

Urine Flowcytometry 0-17 0-11 0-17 0-1 0-278 2 3 4 0 79 Normal Normal Normal Normal Normal

After: Label bottle the with specimen patient's

name, ward, room, and bed number.

Generic Name


Brand name Date Ordered Date Terminated Classification Dose Suggested Dose

Duvadilan 06/19/12 Vasodilator 10 to 20 mg 3 or 4 times daily

Mode of Action



Side Effects

Nursing Responsibilities

Stimulates skeletal beta receptors to produce vasodilation; stimulates cardiac function (increased contractility, heart rate, and cardiac output) and relaxes uterus. At higher doses, inhibits platelet aggregation and decreases blood viscosity. Peripheral and cerebral vascular insufficiency with spastic component showing symptoms: Dizziness Forgetfulness Confusion Visual, auditory and speech abnormalities Coldness and numbness of limbs Color changes and ischemic ulcers Raynaud disease Uterine hypermotility disorders Threatened abortion Premature labor Dysmenorrheal recent arterial hemorrhage, heart disease, severe anemia should not be administered immediately post partum and premature labor. Avoid parenteral administration to patients with hypotension, tachycardia, premature detachment of placenta or immediate postpartum. Transient flushing Hypotension Rashes Gastrointestinal (GI) disturbances Maternal pulmonary edema Fetal tachycardia Transient palpitations Dizziness 1.Assess patients condition before therapy. 2. Check vital signs 3.Monitor FHT 4..Monitor for possible drug induced adverse reactions: Hypotension Tachycardia Nausea

Vomiting Dizziness Severe rash 5.Provive safety by raising the siderails. 6. Monitor I & o 7. Monitor patients bowel sounds 8.Inform the patient about possible side effects , adverse symptoms to report

RISK FOR FETAL INJURY R/T POSSIBLE DELIVERY OF THE PREMATURE INFANT INTERVENTIONS CUES NEED NURSING GOALS OF & TIME DIAGNOSIS CARE S> Kumusta Risk for fetal injury After my 8 hours 1. Monitor VS akong baby?Ok lng H r/t possible delivery of nursing R: Serves as baseline data. ba siya ?as E of the premature intervention my Any deviation from the normal verbalized by the A infant patient will be may indicate infection, pain or patient. L able to maintain any complications. J T R: Preterm labor is her pregnancy as 2.Monitor FHT H defined as uterine evidenced by: R: Provides evidence of fetal U O >33 weeks 1/7 _ contractions well being. N days AOG P occurring after 20 a. absence of 3.Monitor uterine contraction E >admits tip E weeks of gestation uterine R: Provides evidence of >presence of R and before 37 contraction effective therapy. 2 vaginal spotting C completed weeks b. absence of 4.Provide safety for the client 0, >medication of E of gestation. Risk vaginal R: Safety measures should be isoxsuprine 1 tab P factors include spotting observed to prevent 2 q6 T multiple gestation, accidents/injuries that may 0 >WBC- 12.9 H I history of previous aggravate patients condition. 1 > Hgb-115 L O preterm labor of 5. Administer antibiotics as 2 >RBC-3.77 L N delivery, abdominal ordered surgery during R: To reduce/prevent further @ current pregnancy infection. , uterine anomaly, 6. Administer prescribed 7am history of cone medication such as isoxsuprine biopsy, maternal and regulation of IV flow rate age younger than R: such medication prevents 20 or older than preterm labor and stops age 35. contraction. 7. Encourage increase oral fluid intake Source: Pillitteri, R: to increase hydration. This Adele. Maternal aids to stop contraction. and child Health 8. Position patient in a nursing: Care of comfortable position (semithe Childbearing fowlers or left side-lying) and Childbearing R: Semi-fowlers position Family.5th ed. pp. promotes lung expansion; left 417-419 side-lying position prevents hypotension. 9. Maintain CBR w/o BRP as ordered R: Increased movement increases the need for O2 and it also stimulates contraction. 10.Provide a calm environment; adequate rest and sleep R: A calm environment is a

EVALUATION June 20, 2012 @ 3pm GOAL MET After my 8 hours of nursing intervention my patient was able to maintain her pregnancy as evidenced by: a. absence of uterine contraction b. absence of vaginal spotting