RAD RLE Guide -Written Requirements

Name of Student : Nicole Zschech C Leyson Section : BSNA9

Concept : Maternal RLE 1 Name ofClinical Instructor : Gil Platon Soriano

Patients Data:

Name: Rachel Saldivar Agapito Marital Status: Single

Gender: Female Occupation: Sales Agent
Birth Date: October 27, 1997 Nationality: Filipino
Birth Place: NA Religion: Roman Catholic
Age: 23 Source of Data: Mother
Address: 45 Lawaan, Talisay City, Cebu Date&Time of Admission: 4/26/20 at 7:03PM
Educational Level : NA Attending Physician: Dr. Yu
Diagnosis:Premature Rupture of Membrane

Chief Complaint: Watery Vaginal Discharge

LMP : 7/28/2019
AOG : 39 weeks (LMP)
EDC : 5/5/20
VITAL SIGNS:
BP: 90/60 Temperature: 36.5 Pulse Rate: 96 RR: 19 O2 Saturation: 98%
Weight: 63kg

Brief History Upon Admission:

- 5 hours PTI, patient noted soaked underwater, onset of watery vaginal discharges, associates with hypogastric pain
radiating to lumbosacral area, with uterine contraction every 30 minutes, condition persisted thus opted consult.

Admitting Diagnosis: Watery Vaginal Discharge

Students RLE Guide SY 21-22 Page 1
Anatomy & Physiology
(This will show a drawing of the organ affected related to the diagnosis of the patient.)

(FEMALE REPRODUCTIVE SYSTEM)

The organs of female reproductive system produce and sustain the female sex cells, transport these cells
to a site where they may be fertilized by sperm, provide 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 include the ovaries, Fallopian tube, uterus, vagina, uterus, vagina, accessory glands, and
external genital organs.

OVARIES
The primary female reproductive organs, or gonads, are the two ovaries. Each ovary is a solid, ovoid
structure about the size and shape of an almond, about 3.5 cm in length, 2 cm wide, and 1 cm thick. The ovaries are
located in shallow depressions, called ovarian fossae, one on each side of the uterus, in the lateral walls of the
pelvic cavity. They are held loosely in place by peritoneal ligaments. Female sex cells, or gametes, develop in the
ovaries by a form of meiosis called oogenesis. The sequence of events in oogenesis is similar to the sequence in
spermatogenesis, but the timing and final result are different. Early in fetal development, primitive germ cells in the
ovaries differentiate into oogonia. These divide rapidly to form thousands of cells, still called oogonia, which have a
full complement of 46 (23 pairs) chromosomes. Oogonia then enter a growth phase, enlarge, and become primary
oocytes. The diploid (46 chromosomes) primary oocytes replicate their DNA and begin the first meiotic division, but
the process stops in prophase and the cells remain in this suspended state until puberty. Many of the primary
oocytes degenerate before birth, but even with this decline, the two ovaries together contain approximately 700,000
oocytes at birth. This is the lifetime supply, and no more will develop. This is quite different than the male in which
spermatogonia and primary spermatocytes continue to be produced throughout the reproductive lifetime. By puberty
the number of primary oocytes has further declined to about 400,000.
An ovarian follicle consists of a developing oocyte surrounded by one or more layers of cells called follicular
cells. At the same time that the oocyte is progressing through meiosis, corresponding changes are taking place in
the follicular cells. Primordial follicles, which consist of a primary oocyte surrounded by a single layer of flattened
cells, develop in the fetus and are the stage that is present in the ovaries at birth and throughout childhood.
Beginning at puberty, follicle-stimulating hormone stimulates changes in the primordial follicles. The follicular cells
become cuboidal, the primary oocyte enlarges, and it is now a primary follicle. The follicles continue to grow under
the influence of follicle-stimulating hormone, and the follicular cells proliferate to form several layers of granulose
cells around the primary oocyte. Most of these primary follicles degenerate along with the primary oocytes within
 them, but usually one continues to develop each month. The granulosa cells start secreting estrogen and a cavity,
or antrum, forms within the follicle. When the antrum starts to develop, the follicle becomes a secondary follicle. The
granulose cells also secrete a glycoprotein substance that forms a clear membrane, the zona pellucida, around the
oocyte. After about 10 days of growth the follicle is a mature vesicular (graafian) follicle, which forms a "blister" on
the surface of the ovary and contains a secondary oocyte ready for ovulation.
.
FALLOPIAN TUBE
An The uterine tubes (or fallopian tubes, oviducts, salpinx) are muscular ‘J-shaped’ tubes, found in the
female reproductive tract. They lie in the upper border of the broad ligament, extending laterally from the uterus,
opening into the abdominal cavity, near the ovaries. The main function of the uterine tubes is to assist in the transfer
and transport of the ovum from the ovary, to the uterus. The ultra-structure of the uterine tubes facilitates the
movement of the female gamete: The inner mucosa is lined with ciliated columnar epithelial cells and peg cells
(non-ciliated secretory cells). They waft the ovum towards the uterus and supply it with nutrients. Smooth muscle
layer contracts to assist with transportation of the ova and sperm. Muscle is sensitive to sex steroids, and thus
peristalsis is greatest when oestrogen levels are high. There are 2 fallopian tubes present inside the female
reproductive and each has 4 inches. The lateral a end of a fallopian tube encloses an ovary,and the medial end
opens into the uterus. The end of the tube that encloses the ovary has fimbriae, fringe- like projections that create
currents in the fluid surrounding the ovary to pull the ovum into the fallopian. Because the ovum has no means of
self-locomotion(as do sperm),the structure of the fallopian tubeensures that the ovum will be kept moving toward the
uterus.
The smooth muscle layer of the tube contractsin peristaltic waves that help propel the ovum (or zygote, as
you will see in amoment). The lining (mucos) extensively tolded and is made of ciliated is The sweeping action of
the cilia also epithelial tissue. the ovum toward the uterus. Fertilization usually takes place in the fallopian tube. If
not fertilized,ovum dies within 24 to 48 an hours and disintegrates, either in the tube or the. If fertilized, the uterus.
ovum becomes a zygote and is into the uterus; this takes about 4 to 5 days swept. Sometimes the zygote will not
reach the uterus but will still continue to develop. This is called an ectopic pregnancy; ectopic means "in an
abnormal site." The developing embryo may become implanted in the fal- lopian tube, the ovary itself, or even
elsewhere in theabdominal cavity. An ectopic pregnancy usually does not progress very long, because these other
sites are not specialized to provide a placenta or to expand to accommodate the growth of a fetus, as the uterus is.
The spontaneous termination of an ectopic pregnancy is usually the result of bleeding in the mother, and sur-gery
may be necessary to prevent maternal death from circulatory shock. Occasionally and does go to ectopic pregnancy
full term and produces a healthy baby; such an event is a credit tothe adaptability of the human body and to the
advances of medical science.
UTERUS
The uterus is a hollow, pear-shaped, muscular organ located in the pelvic cavity between the bladder and
the rectum. The uterus plays a role in three important functions: menstruation, pregnancy, and parturition. The
uterus is composed of two parts, an upper portion called the corpus (body), and a lower, narrow part called the
cervix. The fundus is that portion of the corpus which rounds into a bulging prominence at about the level at which
the fallopian tubes enter the corpus. The wall of the uterine corpus is composed of the following microscopic layers:
1. Epithelial layer, which contains no blood vessels of lymphatics. 2. Basement layer, which is a sheet of
extracellular material that functions as a filtration barrier and boundary which helps to generate and maintain tissue
structure. 3. Lamina propria, which is composed of areolar connective tissue, contains blood vessels, nerves, and,
in some regions, glands. 4. Myometrium The uterus has thick wallsa nd a small, flat, triangular-shaped cavity. its
apex is directed downard and forms the internal os which opens into the cervical canal. Blood supply is received by
the uterus from the uterine arteries which are branches of the internal iliac arteries. Lymph nodes of the uterus
include: pelvic nodes (paracervical, parametrial, common iliac, internal iliac, external iliac, sacral and aortic. The
main lymphatic trunk is the utero-ovarian (infundibulo-pelvic), which drains into the iliac and sacral nodes.

VAGINA
The vagina is situated posterior to the bladder and anterior to the rectum. It extends upward and backward
from the vaginal orifice to the uterus. The vagina is a collapsible tube, capable of great distention, composed mostly
of smooth muscle lined with a mucous membrane of stratified squamous epithelium and connective tissue (stroma)
arranged in rugae, which is ridges, wrinkles, or folds of mucous membrane. A fold of mucous membrane, the hymen,
forms a border around its external opening in the virginal state. The regional lymph nodes are: Upper two thirds of
vagina: common iliac, internal iliac, hypogastric, external iliac, sacral promontory, pelvic, NOS Lower one-third of
vagina: superficial inguinal or femoral (unilateral or bilateral). The vagina has 3 main functions which includes
provides a passageway for blood and mucosal tissue from the uterus during a woman’s monthly period receives the
penis during sexual intercourse and holds the sperm until they pass into the uterus provides a passageway for
childbirth.

EXTERNAL GENITAL ORGANS

The external genitalia are the accessory structures of the female reproductive system that are external to
the vagina. They are also referred to as the vulva or pudendum. The external genitalia include the labia majora,
mons pubis, labia minora, clitoris, and glands within the vestibule. The clitoris is an erectile organ, similar to the
male penis, that responds to sexual stimulation. Posterior to the clitoris, the urethra, vagina, paraurethral glands and
greater vestibular glands open into the vestibule.
 MENSTRUAL CYCLE

The menstrual cycle is the monthly series of changes a woman's body goes through in preparation
for the possibility of pregnancy. Each month, one of the ovaries releases an egg — a process called
ovulation. At the same time, hormonal changes prepare the uterus for pregnancy. If ovulation takes place
and the egg isn't fertilized, the lining of the uterus sheds through the vagina. This is a menstrual period.
EMBRAYONIC STRUCTURE

 PLACENTA- A placenta is a female organ that develops during pregnancy stage which provides oxygen,
removes waste products from the baby’s blood and gives nutrients to the fetus.
 UMBILICAL CORD- The umbilical cord connects a fetus to the mother's placenta, supplying oxygen and
nutrient-rich blood while also eliminating waste.
 AMNIOTIC SAC (BAG OF WATER)- The double-walled fluid-filled sac that encloses and protects the fetus in
the womb splits during the birth process, releasing its fluid.
 AMNIOTIC FLUID- The protecting liquid retained by the amniotic sac of a gravid amniote is called amniotic
fluid. This fluid not only acts as a cushion for the growing fetus, but it also helps the mother and fetus
exchange nutrients, water, and metabolic products.
 UTERUS- The uterus, commonly known as the womb, is an inverted pear-shaped muscle organ positioned
between the bladder and the rectum in the female reproductive system. Its purpose is to feed and house a
fertilized egg until the fetus, or child, is ready to be born.
 CERVIX- The uterus's lowest portion, the cervix, connects the uterus to the vagina and creates a pathway
between the vaginal and uterine cavities.
 VAGINA-The vagina serves three purposes: It's where the penis is inserted during sexual intercourse. It's the
pathway (the birth canal) through which a baby leaves a woman's body during childbirth. It's the route
through which menstrual blood leaves the body during periods.
 DEFINITION OF DISEASE
PREMATURE RUPTURE MEMBRANE
Premature rupture of membranes (PROM) refers to a patient who is beyond 37 weeks' gestation
and has presented with rupture of membranes (ROM) prior to the onset of labor. Preterm premature
rupture of membranes (PPROM) is ROM prior to 37 weeks' gestation. Spontaneous preterm rupture of the
membranes (SPROM) is ROM after or with the onset of labor occurring prior to 37 weeks. Prolonged ROM
is any ROM that persists for more than 24 hours and prior to the onset of labor. At term, programmed cell
death and activation of catabolic enzymes, such as collagenase and mechanical forces, result in ruptured
membranes. Preterm PROM occurs probably due to the same mechanisms and premature activation of
these pathways. However, early PROM also appears to be linked to underlying pathologic processes, most
likely due to inflammation and/or infection of the membranes. Clinical factors associated with preterm
PROM include low socioeconomic status, low body mass index, tobacco use, preterm labor history,
urinary tract infection, vaginal bleeding at any time in pregnancy, cerclage, and amniocentesis.y during
childbirth. During periods, menstrual blood departs the body via this pathway.

`
Laboratory Test
Date Type of Patient’s Norma Significance / Interpretation
exam Result l
Value
s
4/27/2020
CBC (complete
blood count)
WBC COUNT 8. 50 4.4-11.0  NORMAL
3.75 4.5-5.1  LOW (sign of iron deficiency anemia) blood that
RBC COUNT consists RBCs.

HCT COUNT 11. 7 12.3-15.3  LOW (sign of iron deficiency anemia) blood
that consists RBCs.

HCT COUNT 14.7 35.9-44.6  (sign of iron deficiency anemia) blood that
consists RBCs.
MCV 92 80-90 NORMAL
MCH 31.1 27.5-33.2 NORMAL
MCHC 33.6 32.0-36.0 NORMAL
RDW 12.6 11.6-14.8 NORMAL
PLT 199 150-450 NORMAL
MPV 7.9 6.0-11.0 NORMAL

4/27/21 URINALYSIS COLOR: Pale yellow NORMAL

Yellow
CLARITY; Transparent a. A sign of hormonal changes, dehydration and vaginal
Hazy discharge. (a cloudy urine is a sign of hormonal changes
for pregnant women to support the fetus. )
b. If a pregnant woman is dehydrated during her
pregnancy, this may indicate dehydration due to frequent
nausea and vomiting.
Specific gravity: 1.005-1.025
1.015 NORMAL
PH 7.5
4.5-8.0
Albumin:
NEGATIVE NEGATIVE NORMAL
Ketone:
NEGATIVE NEGATIVE NORMAL
Blood:
NEGATIVE NEGATIVE NORMAL

Glucose:
NEGATIVE NEGATIVE NORMAL
Nitrite:
NEGATIVE NEGATIVE NORMAL
Bilirubin:
NEGATIVE NEGATIVE NORMAL
Urobilinojgen: NEGATIVE NORMAL
NORMAL 0.2-0.1 mg/dl NORMAL

WBC:0-3/HPF 0-3 HPF NORMAL

RBF:0-2/HPF 0-2/HPF NORMAL
Epithelial cells:
FEW FEW NORMAL
Mucus Threads: FEW NORMAL
FEW
 Bacteria: FEW NONE
Amorphous
phosphate: FEW NONE

Diagnostic Tests
Date Type of test Patient’s result Significance/ interpretation
9/18/2019 ULTRASOUND SCAN AOG: 6 2/7 weeks FIRST TRIMESTER

ULTRASOUND SCAN BPD: 8.81 cm AOG: 35 weeks 4 days

HC: 31.3cm AIG: 35 weeks 1 day
AC: 32.3 cm AOG: 35 weeks 1 day
FL: 6.82cm AOG: 36 weeks 1 day
AOG: 35 weeks
Average: 35 weeks 3 days
CONCLUSION:
Placenta: POSTERIOR HIGH Single , intrauterien pregnancy in cephalic position
LYING GRAD 2-3 with average ultrasound age of approximately 35
AMIOTIC FLUID: AF=13.2 cm weeks and 3 days of gestation .
LMP: 07/28/2019
FHB: 135 BPM Placenta: POSTERIOR HIGH LYING GRAD 2-3
EDD: 05/05/ 2020 AMIOTIC FLUID VOLUME:
EDD(LMP): 05/03?2020 ADEQUATE
EFW: 2765 grams

Students RLE Guide

SY 21-22 Page 2
Problem List

Number of Focus / Nursing Diagnosis

Priority

1 - The mother is at risk for infection that is related to premature rupture of membrane as
evidence by watery vaginal discharge.

2 - A hypogastric pain that is related to the uterine contractions.

3 - The lack of knowledge by the client.

 Drug Study
1. METRONIDAZOLE
2. TRANEXAMIC ACID
3. OXYTOCIN
4. TRADAMADOL
5. BISACODYL

DRUG STUDY NUMBER 1

Drug name Classification Mechanismof Indication Contraindication Adverse Nursing

action reaction responsibilities

Generic Name Therapeutic: Topical form: Before

CHEMICAL EENT:
lacrimation if
ANTIBACTERIAL EFFECT:
Metronidazole (optical) Inflammatory  Contraindicated in - Instruct patient to avoid us of
applied around

Unknown. May papules and patients hypersensitive topical gel around eyes.
pustules of to drug or its eyes which will
PHARMACOLIGIC
cause bactericidal
acne rosacea. ingredients, such as result into eye
CLASS: effect by interacting  For bacterial parabens,a dn other irritation.
NITROIMIDAZOLES
with bacterial DNA.
vaginosis. nitroimidazole Skin: transient During
Brand Name  Treatment fir derivatives. redness,
Drug is active anaerobic Use cautiously in
dryness, mild

FLAGYO - Advise patient to clean area
bacterial patients with history or
against many
infections. evidence of blood burning, thoroughly before use and to
dyscarsia and in those stinging, contact cleaning skin beofre applying
wait 15 to 20 minutes after
anaerobic gram
with hepatic dermatitis, drug to minimize risk of local
negative bacilli,
impairment. pruritus and irritation. Cosmetics may be
anaerobic gram  Use vaginal gel rash used 5 minute after
Vaginal form :
cautiously in patients medication has dried.
positive cocci,
with history of CNS
Gardnerella diseases. Oral form CNS:
ORDER may cause seizures and headache,dizzin After
500 mg IV drip q 8 hrs vaginalis, and peripheral neuropathy. ess, depression. - If
local reactions occur, advise
GI: cramps,
patient to apply drug less
Campylobacter. frequently or stop using it and
nausea, loose
Therapeutic effect:
notify prescriber. Advise to
stools, metalic avoid sexual intercourse while
Produces or bad taste in using vaginal preparation.
mouth,
Caution patient to avoid
bactericidal, alcohol while being treated
pain ,vomiting, with vaginal preparation.
antiprotozoal,
diarrhea.
amoebicidal, GU: cervicitis,
trichomonacidal vaginitis,
perineal and
effects. Produces
vulvovaginal
anti inflammatory, i itching, vaginal
mmune suppressive burning, vaginal
effects when applied discharge ,
pelvic
topically discomfort.
Skin: transient
redness,
dryness, mild
burning,
stinging.
DRUG STUD NUMBER 2
Drug name Classification Mechanism of Inidcation Contradiction Adverse Nursing
reaction
action responsibilit
ies

Generic Therapeutic Diminishes Treatment Contraindicatio Venous and Before: Obtain

Name: ns: arterial throm gynecologic,
class: cyclic Evidence of bosis or
Tranexamic dissolution
active thromboembol obstetric history.
acid Antifibrinolytic of excessi ve
thromboemboli i sm, cases of Assess current
Brand hemostati c retinal methods of birth
agent mentrual
Name c artery and control.During:
Lysteda bledding disease (DVT, retinal vein Assess for decrease
fibrin by pulmonary occlusions in B/P, increase in
Pharmacologi .
Order: plasmin, embolism, have been pulse rate,abdominal
Actual cal class: preserving cerebral thromb reported. orback pain, severe
dosage, rou and stabili osis); history Hypersensitivi headache ( may be
Sytemic of thrombosis, t y evidence of
te, zing
frequency hemostatic fibrin’s thromboemboli reaction hemorrhage).
Igran IVTT matrix sm,including occurs Question for change
retinal vein or rarely. in amount of
structure.
artery discharge during
Therapeuti occlusion; menses.
c thrombogenic Question andtreat
Effect: valvular headache
Prevents disease as appropriate.
formatio , cardiac After: Take
nof rhythm medication
fibrin clots disease, only during monthly
hyper- period (not meant to
coagulopathy treat menstrual
.Caution: symptoms). Stop
Concurrent medication and
useof report immediately
hormonal any eye symptoms
contraceptives, orchange in
women with vision.
acute Report if heavy
promyelocytic menstrualbleeding
symptomspersist or
leukemia worsen.
taking retinoic
acid for
remission
induction,
history of
allergies,
women with
subarachnoid
hemorrhage,
upper urinary
tract bleeding;
renal,cardiac,
cerebrovascula
r disease.
DRUG STUDY NUMBER 3
Drug name Classification Mechanism of Indication Contradiction Adverse Nursing
reaction responsibilities
action

Generic name:
Oxytoxin Brand Therapeutic Causes potent -To induce Contraindicate d CNS: BEFORE:
in patients subarachnoi Assess baselines
name:Pitoxin class: Oxytoxin andselective orstimulate
hypersensitive ) d for vit
Pharmacolo gic stimukatio n labor hemorrhage Deter
drug.
Order: class: of - To , seizures, mine
Contraindica coma. CV: frequ
Exogeneous uterine and reduce ted when ency,
arrhythmias
Actual dosage, vaginal delivery durat
hormones mammarygland pospartum ,
sn't advised hypertensio ion,
bleeding (placenta previa, n, PVCs. stren
vasa GI: gth
previa, nvasive nause of
cervical a, contr
vomit actio
ing. ns.
GU:
abruptiopl DURING:
acenta e, Monitor B/P,
tetanic pulse, respirations,
uterine fetalheart rate,
contractio
ns,
 route, smooty after carcinoma, genital postpartu intra
frequency her)es),when m uteri
muscles. expulsionof
10 units cephalopelvic hemorrha ne
oxytocinat placenta. disproportion is ge, pres
10 gtts/min - present, uterine sure,
orwhen ruptu contr
20 units Incomple te re, actio
delivery
oxytocinat or impaired ns
requires
30 gtts/min uterine (dur
invetiable conversion, asin
blood ation
transverse lie.
abortion. flow, ,
pelvic strength, frequency)
Contraindicate d hematoma q15mi
in fetal , n.
distress when increased Notify
delivery isn't afibrinoge physici
imminent, in nemia, an of
prematurity, in possibly contra
other obstetric related to ctions
emergencies, and postp that last longer
in patientswith artum than 1 min, occur
severe bleeding. more frequently
toxemia or Other: than every 2 min,
hypertonic uterine anaphy or
patterns. laxis, stop.
death fromoxytocinindu
Maintain ced w
e Use cautiously
CNS: careful
during first and
infant I&O; be
second stages of
brain alert to
labor because
damage, potentia
cervical laceration,
seizures. l
uterine rupture,
CV: water intoxication.
and maternal
bradycardi Check forblood
and fetal death
a, loss.
have been arrhythmi
reported. as, PVCs.
e Use EENT: After
cautiously, neonatal PATIENT/FAMIL
ifat all,
retinal Y TEACH ING
in
patients with hemorrha • Keep pt, family
invasive cervical ge. informed of labor
cancer and inthose Hepatic: progress.
with neonatal
previous cervical
jaundice.
oruterine
surgery (in Other:
cluding cesarean low Apgar
section), grand scores at 5
multiparity, uterine minutes,
sepsis, traumatic death.
delivery,
or
overdistende d
uterus.
DRUG STUD NMBE 4

Drug name Classification Mechanism Indication Contradiction Adverse Nursing

of action reaction responsibilities

CNS: Before: Assess onset,

Generic Therapeutic class: Unknown. Thought Moderat e - dizziness, type,
name:Tramadol Analgesics to to constraindica tee in headache, location, duration of
Pharmacolo gic bind to opiod moderat ely patients hypertensive somnolence, pain. Assess drug
Brand name: class: Synthetic receptors and severe chronic to deug or opoids vertigo, history, esp.
Dolcet centrally active inhibit pain in patients seizures, carbamazepine,
analgesics reuptake for with severe renal anxiety, analgesics, CNS
norepinerph one impairement, asthenia, depressants, MAOIs.
Order: and breastfeedin g CNS Review past medical
Actual dosage, ro serotonin. women, suicidal stimulation, history, esp. epilepsy,
ute, frequency 1 patients, and in those confusion, seizures. Assess
amp IVTT with acute intoxication coordination renal/hepatic function
q8h 1 tab TID PO from alcohol, hynltics, disturbance, lab values.
cebtrally acting euphoria, During: Monitor pulse,
analgesics, opids, or malaise, B/P,
psychotropic drugs nervousness, renal/hepatic function.
- sleep Assist with ambulation if
Constraindic ated on disorder. CV: dizziness, vertigo
patients with significant vasodilation. occurs. Dry crackers,
respiratory depression EENT: visual cola may relieve
or acute or disturbances. nausea.
severe bronchial GI: Palpate bladder for
asthma or constipation, urinary retention.
hypercapnia in nausea, Monitor daily pattern of
unmonitored settings vomiting, bowel activity, stool
or where abdominal consistency. Sips of
resuscitative equipment pain, tepid water may relieve
isn’t anorexia, dry mouth. Assess for
available. diarrhea, dry clinical improvement,
mouth, rec ord onset of relief of
dyspepsia, pain.
flatulence. After:
GU: May cause dependence.
menopausal Avo id alcohol,
symptoms, OTC medications
proteinuria, (analgesics, seda tives).
urinary May
frequency, cause drowsiness
urine , dizziness, blurred
retention. vision.
Musculoskel Avoid
etal: tasks requiring
hypertonia. alertness,
Respiratory: motor skills until
respiratory response to drug is
depression. established.
Skin: Inform physician if
diaphoresis, severe constipatIon,
pruritus, difficulty breathin g,
rash. excessive sedation,
seizures, muscle
weakness, tremors,
chest pain, palpitations
occur
DRUG SUDY NUMBER 5

Drug name Classification Mechanis m Indication Contraciction Adverse Nursing

reaction
of responsibiliti
action es
Therapeutic
class: Laxative Direct effect on Treatment of
Genicname: Abdominal pain, Long-term Before:
Pharmacologic colonic Smooth constipation,
appendici use may Observe for
class: GI musculatur e Colonic
tis,intestinal result in evidenceof
Biisacodyl stimulants by stimulating evacuation
obstruction, laxative constipation
intramural nerve before
Brand name: nausea, dependence, .
plexi. examinations
undiagnosed rectal chronic Assess
Dulcolax Therapeuti c or procedures
bleeding,vomiting, constipati on, pattern of
Effect: Promotes
pregnancy, loss of bowelactivity,
fluid and ion
lactation. normal bowel stool
Order: Actual accumulati on in
function. consistency.
colon, increasing
dosage,route, Cautions: Chronic use During :
peristalsis,
Excessive use may or overdose Encourage
frequency 2 producing laxative
lead to fluid, may result adequatefluid
effect.
tab if no BM electrolyte in electrolyte intake. Assess
imbalance. or metabolic bowel sounds for
disturbances peristalsis. Monitor
(hypokalemia daily pattern of
, bowel
hypocalcemia activity, stool
, metabolic consistency; record
acidosis, time of
alkalosis), evacuation.
persistent Assess for
diarr hea, abdominal
vomiting, disturbances.
muscle Monitorserum
weakness, electrolytes in
malabsorptio
those exposed to
n, weight
prolonged,
loss
frequent,or
excessive use of
medication.
After:
Institute measures
topromote
defecation:
increase fluid
intake,exercise,
high fiber diet. Do
not take antacids,
milk, or other
medication within 1
hrof taking
medication
(decreased
effectiven
NRSING CARE PLAN

Defining Nursing Scientific analysis Goal of care Intervention Rationale

chracteristi diagnosis
c
s
After 8 hours Independent
Subjective Risk for infection is defined of nursing -Elevations in vital signs
:Watery as at risk for being invaded intervention, Assess for signs of accompany infection;
Risk for the patient
vaginal bypathogenic organisms. infection and fluctuations, or changes in
will be able
infection
discharge to: monitor the vital symptoms, suggest
related to -introducing
The sac (amniotic signs. alterations in client status.
prematur various to
Objective: membrane) surrounding restrict the Demonstrate -Cleaning removes
e rupture spread of
Patient your correct perineal urinary/fecal contaminants.
of illness and
notedsoaked baby breaks (ruptures) before lower the cleaning after
Changing pad removes
membran riskof
underwear, week 37 of voiding and moist medium that favors
e as consequence
onset of pregnancy. Once the s. defecation, and bacterial growth.
evidenced Determine
watery sac breaks, you have frequent changing -It Allows early
by watery how to
vaginal an prevent or of peri pads. identification and
vaginal lessen the
discharges, increased risk for infection. It Observe treatment; promotes
discharge danger of
associated raises the risk for infection. perineum/incision resolution of infection.
with infection (infections LONG TERM: for other signs of -It helps prevent cross
After 2 infection (e.g.,
hypogastric of the amniotic fluid contamination.
weeksof
pain and membrane). nursing redness,
-Identifies factors that
intervention, edema, ecchymosi place client in high- risk.
radiatingto
the patient
lumbosacral One of the common will be able s, discharge and -Right medication and
to: approximation
area, with complications dosage reduce more risks
-Achieve
uterine associated with timely [REEDA scale]). and complications;
healing Note subinvolutio n and promotes efficacy.
contraction pretermrupture of
, free
of uterus, extreme
every 30 labor is uterine tenderness. -Oral antibiotics may be
of additional
minutes, chorioamnionitis. complications. 4. Instruct the continued after discharge.
condition The condition occurs proper disposal of Failure to
persisted when bacteria infect the contaminated complete medication may
thusopted chorion, amnion, and linens, dressings, lead to relapse.
consult. amniotic fluid around the and peripads.
fetus. Maintain isolation,
Physical if indicated. 5.
examinati
Sources: Review prenatal,
on
https://www.chusj.org/ intrapartal, and
BP: postpartal record
https://www.urmc.rochester.ed
90/60
HR: 96 u/ https://www.healthline.com/ Dependent
RR: 19 Nurse’s Pocket Guide: Administer right
Temp:
36.5O2 Diagnoses, Prioritized medications and its
Sat: 98% Interventions, and Rationales, dosage as
Weight: 63
Marilynn E. Doenges, page no. prescribed by the
kg
538, Edition 13. physician.
Instruct in proper
medication use
(e.g., with or
without meals, take
entire course
of antibiotic, as
prescribed)
FDAR SY 21-22 Page 3
Date Focu Time DAR
s
4/26/2020 Hypogastric 07:05 pm D: The patient is awake, conscious, face
pain related to
uterine grimacing. Complained hypogastric pain
contractions
radiating to lumbosacral area, with uterine
contraction every 30 minutes.
Vital Signs: BP: 90/60; HR: 96; RR: 19;
Temp: 36.5; O2 Sat: 98%; Weight: 63 kg

A: Encourage the pt to do deep breathing

exercise and relaxation techniques.
Perform a comprehensive assessment of
pain. Provide nonpharmacologic
pain management. Provide pharmacologic
pain management as ordered. Provide
health teachings based on the
patient’s condition.

R: Patient verbalized that pain was

minimized and relieved.
Discharge Planning Page 4
Date Focus Time DAR

04/29/2020 Discharge 07:00 PM D: With discharge order from attending

Instructions physician Dr. Yu A ctivity: The client is
instructed not to do light exercises and
avoid heavy chores orwork and also, to
avoid heavy works especially lifting
and straining heavy things that may
shock the pt’s body physically. The
following are specific suggestions by
the physician:
-Bed rest: The client may need to stay
in bed all the time. The client will be
allowed to get up briefly to go to the
bathroom. -Pelvic rest: This means that
the client should not put anything in
your vagina, such as tampons. Do not
have sex. -Temperature monitoring:
The client may need to
check your temperature each day to
make sure you do not have a fever. A
fever may be a sign of infection.
M edication: The client knows the
name, action, purpose, dose, route of
administration and side effects of each
drug she is taking. The client is
instructed to report or contact the
physician if adverse reactions are
present.
-Celecoxib 200 mg 1 cap BID x 1
week
-Cefuroxime 500 mg 1tab BID x 7
days
E nvironment: The client knows the
importance of having a clean,
comfortable and healthy environment
free from any actual or potential
hazards. This can contribute to the
client’s improvement of her health
condition. Homemaking services; and
emotional and economic support
systems are in place. T reatment: The
client and family will know the purpose
and action of any treatment. Take
home medications are vital for the
improvement of the client’s condition.
 H ealth Teaching: Observe strict
perineal care daily to avoid
contamination of perineal area. Make
sure that you are sanitized and clean
when taking care of your baby to
ensure your baby’s safety. Sitz Bath:
sitting in a tub of warm water for 15
minutes, two to three times per day,
will help relieve the discomfort. Do
deep breathing exercise and relaxation
techniques.
O utpatient Referral: Follow up at APS
clinic on May 6, 2020 D iet: Drink plenty
of liquids. Eat foods that have
protein such as milk, cheese, meat,
and fish. Eat fruits and vegetables.
Avoid alcohol and caffeine.
R: Out of the room per wheelchair with
improved condition

Bibliography (a summary of all the resources used)

Dayal, S. (2021, July 21). Premature rupture of membranes. StatPearls [Internet]. Retrieved
September 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK532888/.

MediLexicon International. (n.d.). Leaking amniotic fluid: Signs and what to do. Medical News Today.
Retrieved September 22, 2021, from https://www.medicalnewstoday.com/articles/322878.

The Children's Hospital of Philadelphia. (2014, August 24). Premature rupture of membranes
(prom)/preterm premature rupture of membranes (PPROM). Children's Hospital of Philadelphia.
Retrieved September 22, 2021, from https://www.chop.edu/conditions-diseases/premature-rupture
membranes-prompreterm-premature-rupture-membranes-pprom.

Dayal, S. (2021, July 21). Premature rupture of membranes. StatPearls [Internet]. Retrieved
September 22, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK532888/.

http://training.seer.cancer.gov/linksor/